Persius/imr-appeals huggingface dataset:
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested Afirma gene expression classifier and BRAF testing for evaluation of her medical condition.  Findings: Three physician reviewers found that while fine needle aspiration (FNA) biopsy of a suspicious thyroid nodule is typically an accurate means of assessing whether the nodule is benign or malignant, approximately 15% of FNA biopsy results are considered to be indeterminate (Alexander, et al). Until recently, the only method to establish whether the nodule was thyroid cancer was via surgical excision (Miller, et al). The Afirma Thyroid FNA analysis utilizes a gene expression classifier in order to help determine the likelihood of malignancy of nodules with indeterminate cytology on FNA biopsy, thereby decreasing the need for unnecessary surgeries (Duick, et al). Thus, the Afirma gene expression classifier and BRAF testing was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.  Final Result: All three reviewers determined that the testing at issue was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned.  Credentials/Qualifications:  All three physician reviewers are board certified in internal medicine with sub-specialty certification in endocrinology and metabolism 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: Upheld

The patient is a 56-year-old female who was found to have decreased bone density in 2002. She has been treated with Actonel and Fosamax for over a year. She then started on Forteo and has been taking Forteo for approximately one year. She claims she was unable to tolerate prior medications and that her bone mineral density worsened. Her Health Plan has denied authorization for Forteo.The patients initial diagnosis of osteoporosis in March 2002 is not supported by the patient's bone mineral density. In addition, one cannot compare changes in bone mineral density results from equipment from different companies. This patients bone mineral density has been tested on different equipment. The small changes in the patients bone mineral density from 2003 to 2004 are statistically insignificant. She does not have severe bone loss and her bone mineral density has been continually average for her age. Furthermore, she has no fractures. Moreover, there is no objective evidence establishing how the patient was intolerant of bisphosphonates or that she has attempted alternative bisphosphonates. Based upon this information a prescription of Forteo is not supported. Therefore, I have determined that the requested medication is not medically necessary for the treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned

A 25-year-old female enrollee has requested for an acute hospitalization for treatment of her endometriosis.  Findings:  The physician reviewer found that the surgeon noted extensive intra-abdominal/pelvic lesions at that time which biopsy identified as endometriosis. According to the enrollee, she had a 13-year history of pelvic pain and also had gastrointestinal symptoms and respiratory symptoms during menstruation. The enrollee indicates that her symptoms worsened after September 2006. She consulted with a specialist within the Health Plan who reportedly offered partial laser excision of the endometriosis.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Canadian crutches for treatment of the enrollee, who has a history of ankle pain. Findings:  The physician reviewer found that submitted documentation fails to demonstrate the medical necessity of the requested equipment. The records document chronic ankle and foot pain. The physical examination was unremarkable, and the patient reported that he had an x-ray which was negative for a fracture. There is no documentation of a more recent injury or abnormal x-ray or laboratory studies.  Chronic foot and ankle pain can be a common problem among adults. Often, the cause can be suggested by the location of pain and physical findings on examination.  In this case, there is no documentation to suggest the etiology of the pain.  It is possible it is arthritic, inflammatory or a tendinopathy. The treatment of tendinopathies of the ankle varies depending on the location of injury. Common treatment includes analgesics, rest and an arch support or heel wedge or custom foot orthosis. The Canadian crutch is a combination of an underarm crutch and an elbow crutch. In this case, there is no documentation to support that the patient has been treated with conservative care and requires crutches to support non-weight bearing status. Therefore, the requested Canadian crutches are not medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested equipment 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 internal 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: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Stelara 45 mg/0.5 mL. Medical literature describe ustekinumab (brand name Stelara) as a human monoclonal antibody that binds with high specificity and affinity to the P40 subunit of both interleukin 12 (IL-12) and interleukin 23 (IL-23), thereby suppressing IL-12 and IL-23 mediated inflammation associated with psoriasis. Researchers note that for systemic medications for psoriasis, ustekinumab and secukinumab had the lowest rate of adverse events for several of the system organ classes, with a statistically significant decreased rate ratio (incidence rate ratio less than 1), whereas cyclosporine and infliximab had the highest, with an increased rate ratio (incidence rate ratio equal or greater than 5). In this case, the patient has a history of psoriasis and has tried and failed topical steroids, Protopic and salicylic acid. As the patient was noted to have elevated liver function tests, methotrexate and cyclosporine, which are metabolized by the liver and may cause liver toxicity, are not recommended. Given that current medical literature supports the use of ustekinumab in this clinical setting, the requested medication is medically indicated. Therefore, Stelara 45 mg/0.5 mL 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 dermatology 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

Nature of Statutory Criteria/Case Summary: An enrollees parent has requested authorization and coverage for Xeljanz 5 mg twice daily. The treatment of patients with alopecia areata is largely based on provider preference as there is lack of standard therapies approved by the U.S. Food and Drug Administration (FDA) for this indication. This patients provider has recommended treatment with Xeljanz, which is a JAK inhibitor. In addition, per clinical notes reviewed from the provider, the patient has tried and failed treatment with topical steroids, intralesional Kenalog, topical anthralin, topical tofacitinib, and topical minoxidil. There are several large case series reported in the literature demonstrating improvement of alopecia with Xeljanz treatment (Ibrahim, et al.; Liu, et al.). Since this patients morphea is currently controlled, continued treatment with methotrexate is not indicated. Considering that the patient has failed treatment with topical steroids, treatment with Xeljanz is appropriate. Therefore, the requested Xeljanz 5 mg twice daily is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Findings: Three of the three physician reviewers found the requested Xeljanz 5 mg twice daily 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. Credentials/Qualifications: Physician reviewer 1 is board certified in dermatology and is actively practicing. Physician reviewer 2 is board certified in dermatology and is actively practicing. Physician reviewer 3 is board certified in dermatology and is 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: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for skilled nursing facility services. There is a paucity of evidence in current medical literature supporting significant rehabilitation interventions, outside of obtaining compensatory skills, following significant lower limb fractures. Researchers reported little evidence for rehabilitation interventions during the immobilization period after conservative orthopedic management and no evidence for stretching, manual therapy or exercise compared to usual care following the immobilization period.  Researchers found that a supervised exercise program and advice did not confer additional benefits in activity limitation or quality of life compared with advice alone for patients with isolated and uncomplicated ankle fracture. The authors further noted that their findings did not support the routine use of supervised exercise programs after removal of immobilization for patients with isolated and uncomplicated ankle fracture. In this case, the patient has undergone rehabilitation but continues to have limited functions due to morbid obesity, marginal functional status at baseline, and weight bearing restrictions on his left leg. He remains dependent for transfers and is non-ambulatory, requiring total assistance for his lower body self-care. Given that the records do not reflect ongoing goals or other medical, nursing, or rehabilitation needs until his weight bearing status is liberalized, the requested services are not medically indicated. Therefore, skilled nursing facility services are not medically necessary for the treatment of this patient.Final Result: The reviewer determined that the 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 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 61-year-old man with coronary artery disease. He underwent percutaneous transluminal coronary angioplasty in 1992. He received 100 chelating treatments. In 1993, he complained of effort angina. In August 2003, after complaints of chest pain, a nuclear stress test was performed. The patient was able to exercise 10 minutes and 27 seconds and achieve a maximum heart rate of 137 bpm. He reported a slight pressure sensation with exercise. The test was positive by EKG and nuclear criteria. Thereafter, his physician prescribed and administered 33 enhanced external counterpulsation (EECP) treatments. The Health Plan has denied reimbursement for the EECP treatments at issue on the basis they were not medically necessary for treatment of the patients medical condition.Analysis and Findings:In 1999, the Centers for Medicare and Medicaid Services (CMS) approved EECP as a reasonable and necessary treatment for certain Medicare beneficiaries suffering from stable angina pectoris refractory to medical and/or surgical therapy. The CMS approval provides coverage for EECP to Medicare patients who have been diagnosed with disabling angina (class III or class IV, Canadian Cardiovascular Society Classification or equivalent classification) who, in the opinion of a cardiologist or cardiothoracic surgeon, are not readily amenable to surgical intervention. The information provided in this case does not include documentation of medical or surgical management for the patients angina pectoris. In addition, objective testing indicates the patient does not meet medical necessity criteria for treatment. Therefore, there is no evidence demonstrating EECP was medically necessary for this patient.Based upon the information set forth above, I have determined that the treatments at issue were 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:  An enrollee has requested a hospital grade electric breast pump for treatment of her medical condition.  Findings:  The physician reviewer found that upon review of the submitted documents as well as the relevant literature, a hospital grade electric pump is medically necessary in ensuring that this patient is able to feed her infant. The American College of Obstetricians and Gynecologists Committee (ACOG) have weighed in on this issue as it relates to breast pumps and advocating for removal of barriers to the process of breast feeding. There is growing support for delivery of breast pumps as part of womens preventative health services. It is prevailing opinion that there should be a mechanism to support and help achieve the successful process of providing human breast milk to infants during the first year of life. Also, the majority of womens and infant care organizations agree that all efforts to assist the infant and nursing mother through the process should be supported. Major medical association guidelines do not require that the nursing mother show a need for a breast pump; but instead, these associations base their recommendations on the more global process of supplying a newborn breastmilk in whatever means that can be best achieved. For these reasons, the requested hospital grade electric breast pump is medically necessary to ensure the patient is able to nurse her infant.  Final Result: The reviewer determined that the requested device 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 obstetrics and gynecology 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 Forteo for treatment of her medical condition.  Findings:  The physician reviewer found that the submitted documentation supports the medical necessity of the requested medication.  Osteoporosis is an increasingly widespread condition, and fractures are the most dangerous aspect of osteoporosis.  Until recently, pharmacological options for the treatment of osteoporosis have been limited to antiresorptive agents, including the oral bisphosphonates.  While these can be effective medications, antiresorptive agents can be difficult for patients to tolerate and can lead to severe gastroesophageal reflux disease.  Further, the antiresorptive agents, including both the bisphosphonates and newer antiresorptive agents, such as Prolia, may lead to dangerous outcomes, including osteonecrosis of the jaw.  Newer treatment agents have become available over the past few years, including Forteo.  This patient has experienced gastrointestinal distress while on bisphosphonates.  Further, her multiple dental procedures put her at risk for osteonecrosis of the jaw.  All told, Forteo is medically indicated 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 internal medicine with sub-specialty certification in endocrinology, diabetes and metabolism 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 49-year-old female has requested compression stockings for treatment of varicose veins. Findings:  The physician reviewer found that the patients medical records do not reflect swelling, abnormal pulses, varicosities, stasis ulcers, or other circulatory abnormalities. Rather, the records generally document normal extremities. As such, compression stockings are not clinically indicated.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for air ambulance transportation services. Findings:  The physician reviewer found that Parastomal hernias are a known complication following urinary diversion. Most patients are asymptomatic or have minimal symptoms. In a few patients, acute surgical intervention is required involving both the urinary and gastrointestinal systems. Oftentimes specialists from surgery and urology are required to safely perform the surgical procedure. This patient met the criteria for urgent transfer per the evaluating provider. He was accepted by the tertiary care center where the initial procedure was performed. The urgent transfer via air ambulance was consistent with the recommendations in the current medical literature. All told, the air ambulance transportation services provided were medically necessary for treatment of this patient. Final Result: The reviewer determined that the services at issue were 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 urology 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 a 12-week course of Harvoni for treatment of his hepatitis C.  Findings:  Three physician reviewers found that the current medical evidence supports the requested medication in this clinical setting.  The records document cirrhosis, and Harvoni has been demonstrated to be effective for patients with cirrhosis.  This patient meets American Association for the Study of Liver Diseases and Infectious Diseases Society of America guidelines for immediate treatment with highest priority.  Therefore, the requested 12-week course of Harvoni is medically indicated for the treatment of this patient.  Final Result:  Three 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: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested breast tomosynthesis for evaluation of her breast cancer screening. Findings: Three physician reviewers found that breast tomosynthesis was likely to be more beneficial for this patient than any available standard modalities. Medical studies have shown that the addition of three dimensional (3D) digital breast tomosynthesis (DBT) reduces false positives and increases cancer detection when compared to two dimensional full field digital mammography (FFDM, 2D) alone. Recall rates are reduced by 15-17%: 3D allows for separation of structures to differentiate architectural distortion from masses and overlapping fibroglandular tissue (asymmetries). Studies have also shown that there has been an increase in cancer detection by 33-53%: cancer detection increased from 6 cancers/1000 women screened with 2D to 8 cancers/1000 women screened with 3D. Three dimensional DBT allows better characterization of possible masses, spiculation, and architectural distortion. In sum, there is sufficient evidence supporting the use of tomosynthesis for this patients routine breast cancer screening.  Final Result: All three reviewers determined that the service at issue was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: All three reviewers are board certified in diagnostic radiology 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.