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

A 57-year-old female enrollee has requested endoscopy sinus surgery (septoplasty/SMR/maxillary crest reconstruction, bilateral concha bullosa reconstruction with limited ethmoidectomy with possible balloon sinusotomy of the maxillary sinus) for treatment of her obstructive sleep apnea. Findings:  The physician reviewer found that the submitted documentation demonstrates the patient presents with the primary problem of sleep apnea and nasal obstruction. Based on the medical records examined, the nasal valve is not contributing to the patients symptomatology. The CT scan shows that the source of the problem is the septum/turbinates and concha bullosa. Therefore, the patient meets accepted clinical indications for septoplasty and concha bullosa reduction. The minimal maxillary/ethmoid findings seen on the CT scan are not contributing to this patients symptoms and therefore the ethmoidectomy and sinusotomy are not medically necessary. As such, a portion of the requested services are medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld

A 43-year-old female enrollee has requested gastric bypass revision for the treatment of her obesity. Findings:  The physician reviewer found that upon review of the submitted clinical information, there is no evidence of any technical failure of the original gastric bypass operation. Inadequate weight loss is not an uncommon finding after a gastric bypass procedure. A revision of gastric bypass in this setting will involve creation of a smaller stomach pouch and/or reducing the size of the gastrojejunostomy anastomosis. Both of these operative steps will result in worsening of the patients reflux. Further, in the absence of any technical complications such as a gastro-gastric fistula there is no scientific evidence as to the long-term success of a second gastric bypass in a patient for whom the first operation has not been successful.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Revlimid (lenalidomide) 25 mg capsule, in a cycle of 1 capsule by mouth daily for 21 days, then off for 7 days, for a six month period. Findings:  The physician reviewer found that treatment of multiple myeloma support the use of Revlimid for high risk patients for up to two years based on improved progression free survival and decreased end organ damage. In this case, the patient has a diagnosis of smoldering multiple myeloma that is high risk based on bone marrow findings. He has so far received five cycles of Revlimid and remains on close observation. In this clinical setting, the requested medication is medically indicated. Therefore, Revlimid (lenalidomide) 25 mg capsule, in a cycle of 1 capsule by mouth daily for 21 days, then off for 7 days, for a six-month period is medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested services are 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 certifications in medical 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: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary:  An enrollee has requested the wearable cardioverter defibrillator (LifeVest) for treatment of his medical condition.  Findings:  The physician reviewer found that based on the records provided for review, the patient has a newly recognized tachycardia mediated cardiomyopathy. In this circumstance there is potential for recovery of left ventricular function over time with cardioversions and medical therapy. There was no clinical indication for immediate placement of a defibrillator such as sustained or inducible ventricular tachycardia, syncope or aborted sudden cardiac arrest. Placement of a prophylactic defibrillator is not recommended until a period of more than 90 days where continued left ventricular dysfunction ejection fraction of less than or equal to 35% is documented to persist in spite of appropriate treatment. A prophylactic defibrillator (wearable or implantable) before this time has not been demonstrated to improve outcome. Medical studies assessing efficacy of prophylactic defibrillators early after diagnosis of myocardial infarction and reduced ejection fraction of less than or equal to 35% before ventricular function has had a chance to recover have not demonstrated improved outcome. Also, studies evaluating wearable defibrillators during periods of increased risk where criteria for implantable defibrillators have not yet been met are largely comprised of registry data without adequate control groups. At this time prophylactic wearable external defibrillator would be indicated only if accepted criteria for an implantable defibrillator were met and an implantable defibrillator could not be placed, needed to be significantly delayed due to infection or required explantation. Therefore the medical necessity for the wearable cardioverter defibrillator has not yet been demonstrated by existing scientific literature at this time in this clinical setting. Final Result: The reviewer determined that the services at issue were 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 cardiovascular disease 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 parents of a nine-year-old male enrollee have requested for neurofeedback for treatment of his autism. Findings:  The physician reviewer found that neurofeedback is not currently within standards of good medical practice for the treatment of mild traumatic brain injury within the organized medical community. The current practice guidelines for mild traumatic brain injury do not include neurofeedback treatment. As such, the clinical utility of neurofeedback has not been established in this setting.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for an increase in dosage of fentanyl from 175 mcg to fentanyl 250 mcg for treatment of her fibromyalgia, neuropathy, and bilateral sacroiliac joint dysfunction. Findings:  The physician reviewer found that in this clinical setting, the recommendation to maintain the patients pain medications at 175 mcg is well supported by the medical literature. Dose escalation is not a long term plan but a short term plan for the treatment of tolerance. The stepwise World Health Organization (WHO) ladder for pain relief is considered the reasonable approach to pain control in the palliative setting. However, in this case, there is no medical evidence based rationale given for the increase in dosage by the provider. There must be a risk and benefit analysis in order to justify the requested increase in dose of fentanyl from 175 mcg to fentanyl 250 mcg. It is unclear what the plan is for any unseen future pain results the patient would experience while already on over 600 morphine milligram equivalents (MME)/day. In addition, according to the records, this patient may have built a tolerance to this medication therapy since the start of the narcotics. The patients pain scores have remained the same despite increases in the amount of opioid she is taking. Her pain level was 4/10 when she was taking 330 MME/day and was also 4/10 on 495 MME/day. There was no documentation to show that her pain levels had improved and there were no changed objective functions noted with this 165 MME/day increase. As such, the objective goals, with this high of a dose of opioid, have not been established. There were no records to show that all non-pharmacological therapies have been performed or even addressed. There were no mention of behavior therapy despite much research to support its use. Final Result: The reviewer determined that the requested medication dosage 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: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested Viekira Pak for treatment of her hepatitis C.  Findings:  The physician reviewer 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 due to non-liver-related comorbid conditions.  Per the guidelines, treatment-naive genotype 1a patients should be treated with Viekira Pak and ribavirin for 12 weeks. This recommendation is based on multiple high-quality clinical trials.  For these reasons, the requested treatment with Viekira Pak is medically necessary for the treatment of this patients hepatitis C infection. 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 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

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Orthovisc injection series of left knee. Findings:  The physician reviewer found that Evidence from systematic reviews and randomized controlled trials indicate that although viscosupplementation may relieve knee pain in some patients with osteoarthritis, data has not established which patients will benefit. Guidelines from the American Academy of Orthopedic Surgeons (AAOS) indicate that the data on safety and efficacy of viscosupplementation remain inconclusive. As such, the AAOS does not currently recommend viscosupplementation as routine treatment for osteoarthritis of the knees. Viscosupplementation is reserved for patients with a history of lasting benefit from prior injections and in cases where the remaining options are limited. In this case, various conservative options have been attempted, including weeks of physical therapy and a corticosteroid injection without substantial benefit. The only other alternative is a total knee arthroplasty. As such, the provider has recommended treatment with viscosupplementation for pain relief and to delay the patients need for total knee arthroplasty. Given this support, the requested Orthovisc injection series of left knee is medically necessary for treatment of this patient.Final Result: The reviewer determined that the requested services are 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 orthopedic 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: An enrollee has requested authorization and coverage for Humalog and Lantus in the pen form for treatment of the enrollees type 2 diabetes. Findings:  The physician reviewer found that The there is sufficient support for the requested medications in this clinical setting. The most recent American Diabetes Association standards of diabetes care state that a patient-centered approach should be used to guide the choice of pharmacologic agents. Considerations include efficacy, hypoglycemia risk, history of atherosclerotic cardiovascular disease, impact on weight, potential side effects, renal effects, delivery method (oral versus subcutaneous), cost, and patient preferences. In a study which included 13,428 patients by Ayyagari and colleagues, the authors noted adherence and pen use have beneficial effects on patients real-world outcomes, with the most favorable effects attributable to adherent pen use. This patients diabetes is poorly controlled. Allowing the patient to self-administer his required insulin via insulin pens is medically necessary to optimize his diabetes control and outcomes, and prevent diabetes-related morbidity and hypoglycemia. All told, Humalog and Lantus in the pen form are medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested medications are 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 23-year-old male enrollee has requested Orthovisc injections for treatment of his advanced osteoarthritis to the right knee status post arthroscopy. Findings:  The physician reviewer found the submitted documentation and relevant literature fails to demonstrate the medical necessity of the requested services. There is a lack of adequate randomized, controlled studies in the peer-reviewed literature demonstrating the clinical effect from hyaluronate injections. Rutjes and colleagues assessed the efficacy of viscosupplementation for adults with symptomatic knee osteoarthritis. This study concluded after review of a total of 89 trials involving 12,667 adults that in patients with knee osteoarthritis, viscosupplementation is associated with a small and clinically irrelevant benefit and that there is an increased risk of serious adverse effects (Rutjes et al). Furthermore, several studies evaluating repeated treatment protocols document adverse events including inflammatory changes within the knee joint and in some cases requiring arthrocentesis after multiple injections. Based on the medical literature cited above, the requested services are not medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned

A female enrollee requested Harvoni for medical treatment of her hepatitis C.  Findings:  Three physician reviewers found that according to the most recent guidelines issued by the American Association for the Study of Liver Diseases and 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 comorbid conditions.  For treatment-naive patients, a 12 week course of Harvoni is recommended.  Based on published evidence of safety and efficacy, the requested medication Harvoni is medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Otezla. This patients symptoms of psoriasis have persisted for several years with worsening over the last two years. The patient is also being treated for androgenetic alopecia. His psoriasis primarily involves the scalp and feet. He was treated with excimer laser for the scalp, which responded. However, the patients feet have been refractory to excimer laser. Ketoconazole cream was added to the patients regimen given the unresponsiveness of his plantar disease. The patients provider has recommended treatment with Otezla. Otezla is a phosphodiesterase 4 inhibitor that reduces the inflammatory process associated with psoriasis. In a recent article by Kt and colleagues, methotrexate is as effective and well tolerated as Otezla in the treatment of palmoplantar psoriasis. On review of this patients records, he has not failed an adequate trial and there is no reported contraindication to treatment with methotrexate. All told, the requested Otezla is not medically necessary for treatment of this patient. Final Result: The reviewer determined that the requested medication 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 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: Medical Necessity
Decision: Overturned

A 20-year-old male enrollee has requested a magnetic resonance imaging (MRI) scan of the knee for an evaluation of his left knee pain. Findings:  The physician reviewer found that the accuracy and utility of knee MRI for the diagnosis of intra-articular pathology is well documented.  This patient has ongoing knee pain despite physical therapy and other conservative measures.  The incidence of his knee locking up may be indicative of loose bodies in his knee, and other issues which may only be revealed non-invasively through an MRI. Therefore, an MRI of his knee is indicated and appropriate to further evaluate his condition.
Appeal type: Experimental/Investigational
Decision: Upheld

A twenty-seven year-old female who has degenerative disc disease is requesting authorization of multi-level artificial disc replacement surgery.  Reviewers Findings:  The three reviewing physicians found that artificial disc replacement has only recently been FDA approved. The procedure is of unproven efficacy. Long-term results are unknown and the procedures risks, long-term viability, and complications are unclear.  The reviewing physicians found that the Health Plan denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld

An 18-year-old female enrollee has requested residential treatment for treatment of her eating disorder.  Findings:  The physician reviewer found that the patients diagnosis at admission was eating disorder, not otherwise specified. Laboratory testing on the dates in question were reported to be within normal limits.  There was no history of binging or purging, and exercise was reported to be four times per week. There was no history of use of diet pills or laxatives. There were no major comorbidity issues.  The patient rated her depression 4 out of 10 and noted a positive response to mood stabilizers. She was also described as motivated for treatment.  In this case, the patient does not meet American Psychiatric Association guidelines for residential level of care. Consistent with American Psychiatric Association treatment guidelines, the patient was a candidate for intensive outpatient services, such as full day partial hospitalization.  All told, residential treatment services from the said dates forward were not and are not medically indicated for this patient.
Appeal type: Medical Necessity
Decision: Upheld

A 40-year-old female enrollee has requested Positron Emission Tomography (PET) scan for treatment of her Lupus, syncope, asthma, fibromyalgia, and hypertension. Findings:  The physician reviewer found that as reported in the relevant medical literature, PET or PET with CT attenuation, is utilized in patients with known malignancy, to determine optimal site for biopsy, establish the extent of disease, and a patients response to treatment. As noted by the American College of Radiology, the only scientific data that support the use of PET scanning in a patient without an established neoplasm is in the evaluation of the solitary pulmonary nodule. Other uses for this type of imaging have shown promise, as in inflammatory disease or fever of unknown origin, but its role remains uncertain. PET scans appear to have a very high negative predictive value in ruling out inflammatory causes of fever. However, because of its limited availability, it is too early to determine if PET scans will prove to be a useful diagnostic tool in the evaluation of these patients. Certainly there is no current literature supporting PET scan as a screening examination for malignancy. Likely this would produce unnecessary workups relative to PET scans high sensitivity, but likely low specificity particularly with the normal imaging already preformed. As such, PET is not recommended for other diagnostic uses, and is not covered for screening in patients without specific signs and symptoms of disease. For these reasons, the medical necessity of the requested PET scan has not been established in this clinical setting.
Appeal type: Experimental/Investigational
Decision: Upheld

A 55-year-old female has requested coverage for past ChemoFx Assay for evaluation of her adenocarcinoma.  Findings:  Three physician reviewers found that the patient has been diagnosed with peritoneal carcinomatosis. She had a suboptimal debulking surgery two years ago. She had specimens submitted to ChemoFX for analysis which demonstrated the tumor to be sensitive to carboplatin and paclitaxel. The patient was started on this regimen for a planned 6-8 cycles. In vitro drug testing on patients tumor cells prior to administration of chemotherapy is currently supported by a paucity of peer-reviewed medical literature. The most thorough evaluation of these technologies was performed by the American Society of Clinical Oncology (ASCO) in 2004. In their review of this technology, the ASCO panel concluded that such in vitro drug testing should be limited to clinical trials. The paclitaxel/platinum combination has proven to be better than single agent platinum therapy in several clinical trials of ovarian cancer and is now considered the standard of care (Parmar, et al). Appendiceal adenocarcinomas can be quite aggressive and also cause peritoneal carcinomatosis presentations. Retrospective analyses of these tumors showed reasonable five year survival rates with extensive debulking and intraperitoneal chemotherapy. However, the use of ChemoFX assay in the selection of chemotherapy regimens is not supported as superior to standard chemotherapy regimens. Further, the Physicians Data Query of the National Cancer Institute does not recommend the ChemoFX assay to direct therapy.