Persius/imr-appeals huggingface dataset:
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested panitumumab (Vectibix) injection therapy for treatment of the enrollees metastatic colon cancer.  Findings: The physician reviewer found that as noted in the medical literature, cetuximab and Vectibix are monoclonal antibodies directed against the epithelial growth factor receptor (EGFR) protein on the surface of colon adenocarcinomas. Both medications have been demonstrated to be effective and safe in treating patients with colorectal cancer and are approved by the U.S. Food and Drug Administration (FDA) for use in metastatic colorectal cancer. Cetuximab is approved in combination with FOLFIRI as first-line treatment. FOLFIRI is an active regimen that has shown efficacy in stage IV colorectal cancer in combination with cetuximab or Vectibix (Peeters, et al; Van Cutsem, et al). Vectibix is indicated as a single agent after progression on fluoropyrimidines, oxaliplatin, or irinotecan-based therapies or in combination with FOLFOX as a first-line therapy. Peeters and colleagues reported increased progression-free survival in patients treated with FOLFIRI and Vectibix compared with FOLFIRI alone. Similarly, the PICCOLO trial also showed improved response and progression-free survival with Vectibix and irinotecan versus irinotecan alone in KRAS wild type tumors (Seymour, et al). Further, Van Cutsem and colleagues noted that in patients with markedly chemotherapy refractory disease, Vectibix and best supportive care was superior in terms of progression free survival with minimal toxicities when compared to best supportive care alone. For these reasons, the requested Vectibix is medically necessary for treatment of this patients metastatic colon cancer.Final Result: The reviewer determined that the requested medication is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in internal medicine with sub-specialty certification in oncology and hematology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Urgent Care
Decision: Upheld

A 58-year-old female enrollee has requested services she received in Singapore for treatment of her low back pain.   Findings:  The physician reviewer found that review of the submitted clinical documentation fails to demonstrate that a prudent layperson would have sought immediate medical attention on the date in question. Based upon the documentation provided, the patients symptoms were not of sufficient severity to lead a prudent layperson to believe that he or she required treatment on an emergent basis. According to Mattu and Goyal, patients with lumbar motor radiculopathy may require early surgical treatment and the most important determining factor is the presence of significant weakness. If the weakness is substantial, delaying surgery could result in a permanent deficit. Thus, urgent magnetic resonance imaging (MRI) is needed to ensure optimal outcomes. In this case, there are no records provided for review demonstrating an MRI or physical exam findings to determine if this was an urgent or emergent case. Thus, there is no clinical evidence that shows the patient was experiencing significant symptomatology such that the absence of immediate medical attention could reasonably be expected to result in placing the patients health in serious jeopardy; serious impairment to bodily functions; or serious dysfunction of any bodily organ or part. All told, given the lack of medical documentation provided for review the patients symptoms did not meet prudent layperson criteria for emergency care.
Appeal type: Experimental/Investigational
Decision: Upheld

A 39-year-old female enrollee requested authorization and coverage for transcranial magnetic stimulation.  Findings:  Two physician reviewers found that the patient has major depressive disorder.  Her symptoms include low energy, depressed mood and excessive sleep.  The submitted documentation noted a decline in work and interpersonal functioning.  Her prior medications have included Pristiq, Geodon, Prozac, Paxil, Effexor, Abilify and Zoloft.  The patient has not had a trial of electroconvulsive therapy due to concern regarding memory loss.  She has requested authorization and coverage for transcranial magnetic stimulation therapy which the health plan denied as investigational.  The peer-reviewed literature addressing the topic of antidepressant treatment consists of varying reports on the efficacy and potential side effect profile of repetitive transcranial magnetic stimulation.  Gross and colleagues provided an updated meta-analysis of studies related to this treatment modality.  The authors concluded that although results suggest that repetitive transcranial magnetic stimulation has significant antidepressant effects, larger multicenter studies are needed to confirm these trends.  Lam and colleagues concluded that for patients with treatment-resistant depression, repetitive transcranial magnetic stimulation appears to provide significant benefits in short-term treatment studies. However, the relatively low response and remission rates, the short durations of treatment, and the relative lack of systematic follow-up studies suggest that further studies are needed before repetitive transcranial magnetic stimulation can be considered as a first-line monotherapy treatment for treatment-resistant depression. In this patients case, transcranial magnetic stimulation is not likely to be superior over other available treatment alternatives.
Appeal type: Medical Necessity
Decision: Overturned

A 33-year-old female enrollee has requested gastric bypass surgery for treatment of her morbid obesity status post vertical band gastroplasty. Findings:  The physician reviewer found that this patient meets all of the National Institutes of Health (NIH) criteria for bariatric surgery. She is status post vertical banded gastroplasty which was developed as an early bariatric procedure. The patient is having complications of GERD, dysphagia from the fixed band and remains morbidly obese. She meets all consensus guidelines for primary treatment and would benefit from revision of the vertical banded gastroplasty to gastric bypass to definitively treat the GERD, morbid obesity, and the complications of the vertical banded gastroplasty such as esophagitis from ongoing GERD. For these reasons, the requested gastric bypass surgery is supported as medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Vemlidy for treatment of the enrollees chronic hepatitis B virus.Findings:  The physician reviewer found that guidelines for the treatment of hepatitis B from the American Association for the Study of Liver Disease (AASLD) recommend Baraclude and tenofovir compared with alternatives for the treatment of chronic hepatitis B. In comparison with Viread, which the patient is taking, the Vemlidy formulation of tenofovir is effective for hepatitis B, but is associated with lower incidence of side effects such as osteopenia and renal disease. Final Result: The reviewer determined that the requested medication is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in in internal medicine with sub-specialty certification in gastroenterology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

An 18-year-old female enrollee has requested breast reconstructive surgery for one breast for treatment of her breast asymmetry.  Findings:  The physician reviewer found that lack of breast development creating significant asymmetry can be considered abnormal. The medical record documents that the patient has significant breast asymmetry. A detailed analysis of correctable causes is given by an endocrinology work-up, and an MRI confirmed the presence of breast asymmetry. The patient is documented to have a congenital or developmental anomaly. Significant lack of breast development is a function of an abnormal process. This has been documented to have been present over a number of years and has not resolved. Surgical intervention can help to create a normal appearance to the extent possible. However, an evaluation by a plastic surgeon is needed to determine whether the patients condition is cosmetic. Therefore, the patient needs to be thoroughly evaluated by a plastic surgeon in order to determine if there is a clinical indication for the requested surgery and whether the requested procedure is cosmetic or reconstructive.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested Opana ER for treatment of her medical condition. Findings: The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the medication at issue.  In the documentation available for review, non-opioid treatment options have not been exhausted.  The records do not document behavior therapy, despite research to support its use.  In addition, the records indicate that tolerance has taken place.  However, the providers long-term plan for treating tolerance has not been documented.  Dose escalation is not a long-term plan, but a short term plan for the treatment of tolerance.  The medical evidence suggests that opioid rotation or the use of long-acting opioids does not decrease pain tolerance or addiction any better than their counterparts.  The current medical evidence does not support the medication at issue in this clinical setting.  All told, Opana ER was not and is not medically indicated for the treatment of this patient.  Final Result: The reviewer determined that the medication at issue was not and is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.  Credentials/Qualifications: The reviewer is board certified in anesthesiology with sub-specialty certification in pain medicine and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

A 55-year-old female enrollee has requested authorization for acute inpatient psychiatric services for treatment of her amphetamine dependence and psychosis.  Findings:  The physician reviewer found that the clinical record does not support the need for continued acute inpatient psychiatric care.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a male enrollee requested or one 60-minute session of occupational therapy per week; one 60-minute session of speech therapy per week; and one 60-minute session of physical therapy per week for medical treatment of the enrollees autism spectrum disorder.  Findings:  The physician reviewer found that in this case, the continuation of PT, OT and ST are medically necessary for treatment of the patients autism. However, there is a lack of medical literature supporting the benefit of a single 60-minute session of OT, PT, and ST compared to two 30-minute sessions. A developmentally impaired autistic three-year-old likely has a short attention span, so two 30-minute sessions would be advantageous in this clinical setting. As such, it is not medically necessary for this patient to receive one 60-minute therapy sessions of PT, OT and ST rather than two 30-minute therapy sessions. Therefore, based on the medical literature cited above and the documentation submitted for review, two thirty-minute sessions per week of occupational therapy, speech therapy and physical therapy are medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested bariatric surgery for treatment of her medical condition.  Findings:  The physician reviewer found that review of the submitted documentation fails to establish the medical necessity of the requested surgery. In this case, the patient presents with weight regain status post gastric bypass procedure. Revision surgery is indicated for documented complications of the original procedure that require surgical intervention to correct. Based on the clinical records submitted for review, there is no documented complication of the original procedure that requires surgical intervention to correct. For the reasons provided, the request for bariatric surgery is not medically necessary for treatment of the patients medical condition.  Final Result: The reviewer determined that the requested surgery is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.  Credentials/Qualifications: The reviewer is board certified in general surgery and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Trokendi. Long-acting topiramate (Trokendi) is U.S. Food and Drug Administration (FDA) approved for migraine therapy. Moreover, data suggests that Trokendi offers a lower side effect profile than immediate release topiramate. This patient has chronic migraine as well as Lupus. She was treated with immediate release topiramate, which provided a good result with regard to her headaches. However, she is experiencing tingling with topiramate, which caused her providers to recommend Trokendi. It is within the current standard of care to provide A study finds that Trokendi to patients who respond to the therapeutic effect for migraine, but have significant side effects with immediate release topiramate. Given this support, the requested Trokendi is medically necessary for treatment of this patients migraines. Final Result: The reviewer determined that the requested medication is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in neurology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

The patient is a 53-year-old female who reportedly has had gastroesophageal reflux disease for many years. It has been reported the patient has been tried on Aciphex, Protonix, and Prilosec. The patient indicates Nexium has been an effective treatment for her condition.  The Health Plan has denied authorization and coverage for Nexium on the basis the submitted documentation does not demonstrate it is medically necessary.Review of the submitted information reveals detailed information regarding the patients clinical history is lacking. There are no progress notes or medical records to show in detail the medications the patient has reportedly tried and failed. Additionally, it is not known how long the patient was tried on these medications. Furthermore, the patients endoscopy results have not been submitted. As such, the submitted documentation does not demonstrate Nexium is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld

Findings:  The physician reviewer found that The patient has requested authorization and coverage for OneTouch Verio test strips (six to seven test strips daily/30 day supply). Heinemann and colleagues report that self-monitoring of blood glucose (SMBG) allows patients with diabetes to monitor glycemic control. Schnell and colleagues note that the benefits of SMBG in management of type 2 diabetes are supported by randomized and prospective clinical trials, published reviews, meta-analyses, and guidelines. Gribovschi explains that SMBG before and after meals with a glucometer is an important adjunct for achieving and maintaining optimal glycemic control. The use of insulin may support the need for more frequent testing. In this case, the patients medications include oral antidiabetic drugs, rather than insulin, and the prescription directs testing with one strip two times daily, rather than the six to seven times as the patient has requested.  Therefore, OneTouch Verio test strips (six to seven test strips daily/30 day supply) are not medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested supplies are not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for the medication Ajovy. The American Headache Society (AHS) notes that treatment with monoclonal antibodies to calcitonin gene-related peptide (CGRP) may be indicated for patients with chronic migraines with an inability to tolerate topiramate. The AHS recommends that clinicians and patients reassess the benefits of CGRP monoclonal antibody therapy after three to six months and continue treatment if benefits can be documented, such as a reduction in mean monthly headache days of 50% or more relative to the pretreatment baseline. The U.S. Food and Drug Administration (FDA) has approved the use of Ajovy, a CGRP antagonist, for the preventive treatment of migraines in adults. In this case, the patient has a history of chronic migraines that did not respond to topiramate and metoprolol. Given that the patient fits AHS criteria for treatment with CGRP monoclonal antibody therapy, the requested medication is medically indicated. Therefore, Ajovy is medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested medication is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in neurology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld

A 49-year-old male enrollee has requested a C-Leg prosthesis and microprocessor knee and related components for the treatment of his above the knee amputation. Findings:  Two physician reviewers found that this patient is requesting the C-Leg microprocessor component for alleviation of right knee arthritis.  He has had his current prosthesis for over three years, during which time his left stump has atrophied, thus causing a poor fit of his socket. The old, ill-fitting prosthesis is likely the cause of the patients difficulties, and replacement with a well fitted prosthesis will likely alleviate these problems. The biomechanical ramifications of his ill-fitting sockets can be contributing to his low back pain, instability, and right knee degenerative joint disease. There is no evidence in the literature that a microprocessor knee will reduce progression of osteoarthritis in the contralateral limb. There has been no consistent evidence that the C-Leg component will improve gait and function.
Appeal type: Experimental/Investigational
Decision: Upheld

A 37-year-old male enrollee has requested pain management related services for the treatment of pain and muscle spasms. Findings: Three physician reviewers found that the literature pertaining to the use of Botox injections for management of chronic myofascial pain is not conclusive. There is no evidence the patient exhausted the conservative modalities available in this setting. Findings:  Three physician reviewers found that
Appeal type: Medical Necessity
Decision: Upheld

A 60-year-old male enrollee has requested for a duodenal switch procedure for treatment of his obesity. Findings:  The physician reviewer found that many articles have shown that a mostly restrictive procedure is not sufficient to maintain weight loss for certain individuals.  The patient did not complete an alcohol abuse program.  All told, the medical necessity of a duodenal switch has not been established at this time.