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

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for mammaplasty augmentation surgery with prosthetic implant.The World Professional Association for Transgender Health (WPATH) lists feminizing mammoplasty as a treatment for gender dysphoria. The WPATHs Position Statement on Medical Necessity of Treatment (2016) states that non-genital surgical procedures are often of greater practical significance in a patients daily life than reconstruction of the genitals. The WPATH states that these reconstructive procedures are not optional in any meaningful sense, but are understood to be medically necessary for the treatment of the diagnosed condition. The WPATH has identified the criteria for breast augmentation (implants/lipofilling) in male-to-female patients as, 1. Persistent, well-documented gender dysphoria; 2. Capacity to make a fully informed decision and to consent for treatment; 3. Age of majority in a given country (if younger, follow the SOC for children and adolescents); 4. If significant medical or mental health concerns are present, they must be reasonably well controlled.` (WPATH 2016).In this case, the patient's therapist attested to the then 51-year-old patients diagnosis of gender dysphoria, her capability of making appropriate decisions and consenting to treatment, and the lack of psychological contraindications to the breast augmentation procedure. Both the patient's internist and her therapist attested to the medical necessity of feminizing mammoplasty for the patient. Under these circumstances, the mammaplasty augmentation surgery with prosthetic implant at issue was medically necessary to treat the patients condition.Final Result: The reviewer determined that the services at issue were medically necessary to treat the patients condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in psychiatry 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:  An enrollee has requested Harvoni for 12 weeks for treatment of his hepatitis C.  Findings:  Two physician reviewers found that according to the most recent joint guidelines issued by the American Association for the Study of Liver Diseases and the Infectious Diseases Society of America, all patients with chronic hepatitis C, regardless of fibrosis, should be treated except those with limited life expectancy less than 12 months due to non-liver-related conditions.  In treatment-naive patients with hepatitis C, genotype 1 infection, therapy with Harvoni for 12 weeks is recommended.  It is advantageous to treat patients before they progress to cirrhosis.  Based on evidence of safety and efficacy in the published literature, Harvoni for 12 weeks is medically indicated for the treatment of this patient.  Final Result:  Two reviewers 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 three reviewers are board certified in internal medicine with sub-specialty certification in gastroenterology and are actively practicing. All three reviewers are experts 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 parent of an enrollee has requested authorization and coverage for Symbicort 80 mcg-4.5 mcg. Findings:  The physician reviewer found that Symbicort is a combination medication, using both budesonide (inhaled corticosteroid) and formoterol (long-acting beta agonist). This combination has been well-studied, and studies have shown that for patients experiencing an acute exacerbation despite routine use of an inhaled corticosteroid controller medication, addition of budesonide/formoterol is more effective in controlling bronchospasm than simply increasing the dose of inhaled corticosteroid. The combination is so effective that some advocate for its use as maintenance as well as reliever therapy. In this patients case, he is limited by age and developmental ability to only a few of the recommended options. He is also limited by the fact that he already uses an inhaled corticosteroid as a controller medication. He has been successfully treated with Symbicort as a reliever medication in the past. The current medical evidence supports the requested medication in this clinical setting. Therefore, Symbicort 80 mcg-4.5 mcg 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 pediatrics with sub-specialty certification in pediatric critical care 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 62-year-old female enrollee has requested Protopic 0.03% for the treatment of her lid retraction prior to surgery. Findings:  The physician reviewer found that the prescribed use of Protopic for this patient was not medically indicated. There is no evidence in the medical literature that the use of Protopic prior to eyelid surgery in an attempt to loosen the skin is as good as or better than alternative medications or no medication at all. Since there is no literature suggesting that loosening the skin before eyelid surgery is beneficial to the outcome of surgery, the pre-operative use of Protopic for this non-FDA supported indication in this patient was not medically warranted.
Appeal type: Experimental/Investigational
Decision: Upheld

A 76-year-old male enrollee has requested stereotactic radiosurgery (CyberKnife) for treatment of his high grade prostate cancer.  Findings:  Three physician reviewers found that while CyberKnife is a treatment option, it is not standard therapy for prostate cancer. In a report from King and colleagues, the authors acknowledge that their results are not mature enough. In addition, short follow-up is also an issue with the study by Madsen and colleagues which treated patients with hypofractionated radiation, though not with CyberKnife. Despite these shortcomings, the studies demonstrate that hypofractionated radiation is effective with respect to biochemical control (Katz, et al). However, none of the studies referenced above discusses the use of CyberKnife/SBRT as a boost treatment.  In fact, the paucity of studies suggests that such an approach has not been investigated. Furthermore, there is no literature for the use of SBRT as palliative therapy (i.e. treating the prostate in the setting of metastatic disease).All told, IMRT as a boost treatment is likely no less effective, and perhaps yields a lower risk of late toxicity due to the fractional dose delivery when compared to CyberKnife. As such, there is no compelling clinical rationale for this patient to be treated with CyberKnife and there is no proven benefit of CyberKnife treatment over standard prostate radiation therapy options including IMRT or 3D-conformal radiotherapy.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary:  An enrollee has requested tramadol for treatment of her chronic pain syndrome.  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested medication quantity.  Tramadol is considered a mild synthetic opioid.  This patient has non-malignant chronic pain, which will often worsen or recur as a result of opioid rebound.  The current standard of care for chronic pain is treatment in a multidisciplinary practice to include physical therapy, massage therapy, cognitive behavioral therapy, and injections to help reduce pain.  Baron and McDonald reported that chronic opiates might contribute to pain sensitization via opioid-induced hyperalgesia, decreasing patient pain threshold and potentially masking resolution of a preexisting pain condition.  In this retrospective study, the majority of patients undergoing detoxification of high-dose opiates for chronic pain reported a significant decrease in pain at the end of the study, further supporting the theory of opioid-induced hyperalgesia.  Chronic opiates may also cause adverse outcomes.  Ballantyne and Mao reported that prolonged use of high-dose opiates might induce tolerance, abnormal pain sensitivity, and hormonal effects.  The current medical evidence does not support the requested medication quantity in this clinical setting.  All told, the requested tramadol is not medically indicated for the treatment of this patient.  Final Result: The reviewer determined that the requested medication quantity 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: Experimental/Investigational
Decision: Overturned

Findings:  The physician reviewer found that An enrollee has requested authorization and coverage for Ubrelvy 100 mg (10 tablets/30 days concurrently with Aimovig). Calcitonin gene-related peptide (CGRP) plays a crucial role in migraine pathophysiology and has been established as an important target for both preventive and acute treatments. Aimovig is an injectable monoclonal antibody targeting the CGRP receptor and approved by the FDA for the prevention of migraine. Ubrelvy is an oral CGRP inhibitor indicated for the acute treatment of migraine with or without aura in adults. The efficacy of Ubrelvy for the acute treatment of migraine has been demonstrated in two randomized, double-blind, placebo-controlled trials (Edvinsson, et al.; Mullin, et al.). In both studies, the percentage of patients achieving headache pain freedom two hours post dose was significantly greater among patients receiving Ubrelvy compared to treated with placebo. This patients records document a history of migraines that have not responded to multiple oral abortive and preventative medications. Given the current support demonstrating that the combination of the two classes of treatments are effective for acute migraine attacks as well as for migraine prevention, the requested treatment with Ubrelvy in combination with Aimovig is appropriate. For these reasons, the requested Ubrelvy 100 mg (10 tablets/30 days concurrently with Aimovig) is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Findings:  Two of the three physician reviewers found the requested Ubrelvy 100 mg (10 tablets/30 days concurrently with Aimovig) is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the requested medication is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Upheld

A 39-year-old female enrollee requested magnetic resonance imaging (MRI) of the cervical spine (CPT code 72141) for medical evaluation of the enrollees neck and thoracic pain.  Findings:  The physician reviewer found that review of the submitted documentation and relevant literature fails to demonstrate the medical necessity of the diagnostic study at issue. The documentation submitted for review indicates that the patient previously underwent an MRI of the neck. The clinical documentation failed to provide evidence of significant progressive neurological deficits that would warrant an additional study. Further, the documentation failed to provide evidence of conservative treatment prior to the imaging study. The peer-reviewed literature supports ongoing conservative treatment in this clinical setting. As there is no indication that the patient had undergone any type of treatment or sustained injury since the previous MRI, the need for an additional MRI is not clinically indicated. As such, the diagnostic study was not medically necessary for evaluation of the patients medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned

A 21-year-old male enrollee requested measurement of serum concentration of infliximab and antibodies to infliximab as well as continued measurement of serum concentration of infliximab and antibodies to infliximab for medical evaluation of the enrollees Crohns colitis.  Findings:  Two physician reviewers found that the services at issue were and are likely to be more efficacious than other modalities.  The medical evidence supports the services at issue in this clinical setting.  The services were and are indicated for the evaluation and treatment of this patient.  This patient is currently on Remicade 15mg/kg, which is a high dose.  Thus, measurement of serum concentration of infliximab and antibodies to infliximab and continued measurement of serum concentration of infliximab and antibodies to infliximab were and are likely to be superior over other methods of evaluating this patient.
Appeal type: Experimental/Investigational
Decision: Overturned

A 37-year-old female enrollee has requested reimbursement for Botox injections. The Health Plan has denied this request indicating that the Botox injections at issue are considered experimental for treatment of the enrollees lateral pterygoid muscle dystonia. Findings:  Two physician reviewers found that the medical record indicates the patient has responded to Botox for this disorder.  Dystonia, including oral-buccal dystonia, typically does not respond to medication. There is data to support Botox for treatment of this patients condition. It is unlikely that any other available treatments will benefit the patients condition than Botox.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested resumption of physical therapy and occupational therapy in a skilled nursing facility (SNF for treatment of the enrollees medical condition status post resection for pituitary macroadenoma.  Findings: The physician reviewer found that SNF or skilled rehabilitation services are services that must be performed by or under the supervision of a professional for a condition that required inpatient hospital services or that arose while receiving care in a SNF and are required on a daily basis. This patients documentation does not support that this patient requires SNF services with ongoing physical therapy and occupational therapy. Overall, there is a lack of evidence that the patient requires such SNF services as intravenous or enteral feeding that comprises at least 26% of daily calorie requirements and provides at least 501 milliliters of fluid per day, tracheotomy aspiration, suprapubic catheter care, treatment of a stage 3 or greater decubitus ulcer, institution of a bowel/bladder training program, colostomy care or other SNF service. While the patient would benefit from continued therapy the records do not demonstrate that he requires these services on a daily basis or that the services could only be provided while he is an inpatient in a SNF. The patient has made progress in therapy but is not expected to make measurable gains within a reasonable and predictable period of time given his prior physical therapy and occupational therapy notes, which reveal that the patient has made gradual progress in therapy. The patient does not require skilled therapy on a daily basis to prevent deterioration with mobility, or activities of daily living, or to prevent a deterioration in his condition. In addition, the patient does not require skilled therapy to establish a safe and effective maintenance program. Speech therapy noted that the patient was tolerating a soft diet without aspiration and he was planned to follow-up with a provider regarding feeding tube dependence. Without clear skilled nursing needs the patient does not require SNF services to establish a safe and effective maintenance program. Therefore, this patients current needs can be met at a lower level of care. For these reasons, the request for authorization and coverage for resumption of physical therapy and occupational therapy in a SNF is not medically necessary.Final Result: The reviewer determined that requested services are 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 physical medicine and rehabilitation with sub-specialty certification in neuromuscular 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

The patient is a 36-year-old woman who indicated she was bitten by a tick in 1998.  There is no record that she had Erythema migrans (the skin rash that is classical for early Lyme disease). She is noted by her provider to have had some of her symptoms since she was a teenager. The patient reports a variety of symptoms including nausea, fatigue, nerve pain, flu-like symptoms, poor memory, vertigo, confusion, limited sleep, joint and muscle pain, low temperatures, headache and pruritis.  Reported physical examinations and vital signs are unremarkable.There is no evidence in the record that the patient has Lyme disease. A single IgM Western Blot result is provided. This test was performed in April 2005 and is negative by CDC criteria.  No Babesia test results have been provided. The patients provider noted Lyme results as  equivocal in January 2005 and in a clinic note two weeks later noted +/- results for both Lyme and Babesia. The only abnormal test reported is the CD8/CD57 lymphocyte ratio. This is of uncertain significance and does not suggest Lyme disease. The patient has been treated with oral antibiotics including Zithromax, Cipro, Levaquin, Flagyl, Hydroxycholoquin, Ketek, and Tinidazole and with IV Rocephin. A request for reimbursement for previous antibiotic treatment as well as prospective authorization for an additional 12 weeks of IV Rocephin therapy. The Health Plan has denied this request indicating there is no evidence that the use of IV Rocephin beyond the initial four-week period is medically necessary.The evidence provided in this record does not establish a diagnosis of Lyme disease.   The CDC approach (screening test followed by Western Blot studies) remains the accepted route to a serological confirmation of Lyme disease. In this case, there is a negative IgM Western Blot.  The record does not include evidence of a IgG Western Blot or a screening test.   There is also no Babesia test data in the record. The patient has already received months of treatment with oral antibiotics and a month of IV Rocephin.   Because the diagnosis of Lyme disease was not substantiated the therapy at issue was/is not medically necessary. Even if there was convincing evidence of Lyme disease, there is no peer-reviewed data supporting more than 30 days of IV antibiotic treatment for Lyme disease in any form. Therefore, I have determined the therapy at issue was/is not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Experimental/Investigational
Decision: Overturned

An enrollee has requested authorization and coverage for intraoperative radiation therapyFindings:  Two of the three physician reviewers found Intraoperative radiation therapy is considered a standard treatment in this patients case. Accelerated partial breast irradiation is considered an acceptable treatment for patients with early stage breast cancer meeting stringent criteria. Accelerated partial breast irradiation may be delivered using external beam radiotherapy, brachytherapy, or intraoperative radiation therapy. The trial noted equivalent four-year local control rates between intraoperative radiation therapy and external beam whole breast radiotherapy, and colleagues noted that toxicity was lower in the intraoperative radiotherapy group than in the external beam radiation therapy group. In sum, intraoperative radiation therapy is likely to be more effective than other treatment options. Final Result: The reviewers determined that the requested services are likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: Physician reviewers 1, 2 and 3 are board certified in radiation oncology and are actively practicing. The reviewers are experts 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: Overturned

A 57-year-old female enrollee requested authorization for an MRI of the left breast for evaluation of possible spiculated density in the medial aspect of the left breast.Reviewers' Findings:Two of the three physician reviewers found that as noted by the society of breast surgeons, breast MRI is medically appropriate to further evaluate suspicious findings after a complete mammogram and ultrasound evaluation. The patient had a complete evaluation by mammography and ultrasound which remained indeterminate and therefore breast MRI was medically indicated.