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

A 54-year-old female enrollee has requested Nutropin for treatment of her panhypopituitarism, chronic adrenal insufficiency, hypothyroidism, hyponatremia, growth hormone (GH) deficiency, and diabetes insipidus.  Findings:  The physician reviewer found that based on the documentation provided, this patient requires GH therapy, and Nutropin is supported as medically necessary. The American Association of Clinical Endocrinologists (AACE) noted the deleterious effects of GH deficiency in patient health and the benefits of replacement. The guidelines indicate that in the presence of organic disease (pituitary tumor followed pituitary resection surgery), the patient needs documentation of three pituitary hormone deficiencies and low IGF-1 with no stimulation test needed to establish the diagnosis of GH deficiency. The records indicate the patient has a low IGF-1 and has four noted pituitary deficiencies including thyroid, adrenal, gonadal, and antidiuretic hormone deficiencies. In this clinical setting, a stimulation test is not needed to confirm the diagnosis of GH deficiency. Thus, the diagnosis of GH deficiency is established and the requested Nutropin GH therapy is medically necessary for treatment of her medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested Harvoni for eight weeks for treatment of his hepatitis C virus.  Findings:  The physician reviewer found that as per the American Association for the Study of Liver Diseases and Infectious Diseases Society of America, all patients with chronic active hepatitis C are eligible for treatment and should be treated regardless of fibrosis score. In this case, Harvoni is medically necessary and is considered the standard of care for the treatment of patients with hepatitis C genotype 1. In addition, the patient is treatment naive with a low viral load and therefore eight weeks would be the appropriate duration. Therefore, Harvoni for eight weeks is medically necessary based on national guidelines.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: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for doxorubicin hydrochloride liposome injection for treatment of the enrollees multiple myeloma. Findings:  The physician reviewer found that The submitted documentation fails to demonstrate the medical necessity of the requested medication. The use of Doxil in combination therapy with dexamethasone and Velcade is reserved for relapsed or refractory multiple myeloma. Per National Comprehensive Cancer Network guidelines, doxorubicin, not pegylated-doxorubicin or Doxil, is considered a standard first-line therapy for high-risk multiple myeloma patients who are eligible for transplant in combination with dexamethasone and Velcade. There is no rationale why the patient requires the substitution of Doxil for doxorubicin. Therefore, the requested doxorubicin hydrochloride liposome injection is not medically necessary for the 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 internal medicine with sub-specialty certification in medical oncology 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 Lyrica for treatment of his medical condition. Findings: The physician reviewer found that the patient presents with sciatic neuropathy from piriformis syndrome with neuropathic pain and has tried and failed first-line therapies for neuropathic pain. The use of Lyrica is supported in the peer-reviewed literature for the treatment of neuropathic pain. Robertson and colleagues noted that the use of Lyrica has shown favorable outcome for treatment of sciatica (sciatic neuropathy). In addition, Chaparro and colleagues noted that Lyrica has demonstrated benefit for various neuropathic pain conditions alone and in combination with other pharmacologic therapies. The systematic review and meta-analysis by Yu and colleagues noted that Lyrica demonstrated improvement in pain related to radiculopathy in sciatic distribution similar to gabapentin. Given the support in the peer-reviewed literature, Lyrica has been established as medically necessary for treatment of the patients medical condition. 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 physician 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

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for a pigmented lesion assay. Melanoma staging is characterized by the American Joint Committee on Cancer (AJCC) TNM system that defines cutaneous melanoma stages 0-IV. While the majority of clinical stage I patients will be disease-free at five years, some stage I patients will develop advanced disease. The DermTech pigmented lesion assay (PLA) is a non-invasive gene expression test that can help providers guide pigmented lesion management decisions and rule out melanoma. The assay analyzes samples for expression of two key genes, PRAME and LINC00518, which are known to be overexpressed in melanoma. The test result is positive or negative based on the detection of one or both genes. PLA positive cases are generally biopsied to establish the histopathologic diagnosis, while PLA negative findings are considered for ongoing monitoring. However, the current gold standard for melanoma diagnosis remains visual inspection with histopathology, which has a relatively low negative predictive value of approximately 83%, confirmed in clinical studies and current practice. All told, the pigmented lesion assay was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Findings:  Three physician reviewers found the pigmented lesion assay was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Final Result: The reviewers determined that the services at issue were not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: Physician reviewers 1, 2 and 3 are board certified in dermatology 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: Upheld

A 46-year-old female enrollee has requested platelet rich plasma injections for treatment of her left elbow pain.  Findings:  Three physician reviewers found the peer-reviewed medical literature fails to evidence that the platelet rich plasma injections were likely to be more beneficial to the treatment of the patients medical condition than any available standard therapy. The patient presented with a new problem of left elbow pain and the clinical notes did not indicate the patient had exhausted lower levels of conservative treatment for her epicondylitis. There was no documentation submitted indicating use of anti-inflammatories, bracing, physical therapy interventions, acupuncture, chiropractic treatment, or other conservative treatment prior to implementing the use of platelet rich plasma injections. In sum, the use of platelet rich plasma injections was not more likely beneficial for treatment of the patients medical condition than any available standard therapy.
Appeal type: Medical Necessity
Decision: Overturned

The patient is a 13-year-old female who has been diagnosed with obsessive-compulsive disorder with delusions and attention-deficit hyperactivity disorder. The patients medication regimen includes prescribed Lexapro and Focalin. The Plan has denied coverage for Focalin on the basis it is a non-formulary medication and is not medically necessary.Since the patient is stable it would be inappropriate to stop her current medication regimen in order to give a trial of formulary medications, which may or may not be effective. Furthermore, Focalin has a unique mechanism of action (receptor binding affinities, etc.) and generic equivalents do not exist. Therefore, I have determined that the requested medication is medically necessary for treatment of the patients medical condition. The Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested authorization and coverage for a minimum of 35 hours per week of applied behavioral analysis (ABA) therapy necessary for treatment of the autism. Findings:  The physician reviewer found that ABA therapy is medically indicated for treatment of the patients medical condition. One study found that children with autism who started ABA at an earlier age with intensive ABA hours were more likely to have an optimal outcome. ABA therapy has been effective for treatment of the patients autism. He has made progress in communication, executive function and adaptive skills. Although he does continues to have whining and tantrum. Treatment planning should include parent training goals to address the patients maladaptive behaviors. In this clinical setting, the Health Plans authorization of 107 hours per month of direct ABA therapy, 10 hours per month of supervision and eight hours per month of parent training are medically reasonable and appropriate. Therefore, the requested minimum of 35 hours per week of ABA therapy is not medically necessary for treatment of this patients autism. 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 pediatrics with sub-specialty certification in developmental-behavioral pediatrics 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 authorization and coverage for total bilateral ankle replacement. Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested services. Total ankle arthroplasty or tibiotalar arthrodesis is indicated for surgical management of end-stage ankle arthritis. Although the complication rate of the total ankle arthroplasty is higher than ankle arthrodesis, it is more widely requested by patients. In this patients case, x-rays revealed no tibiotalar arthritis on the left side and narrowing of the joint space and slight irregularity of the tibiotalar joint on the right side, with no bone destruction. These radiology findings do not support the request for total ankle arthroplasty, which is indicated as an option for end-stage arthritis. The current medical evidence does not support the requested services in this clinical setting. Therefore, total bilateral ankle replacement is 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 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: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for positron emission tomography (PET) scan (CPT code 78815 and HCPCS code A9552). This patients records document a history of stage IIA moderately differentiated adenocarcinoma of the ascending colon status post right hemicolectomy in July 2019 and subtotal hemicolectomy in July 2020. The patients provider has recommended follow-up imaging with a PET scan. Per the National Comprehensive Cancer Network (NCCN) guidelines, PET scans are not recommended for routine surveillance of patients with colon cancer (Benson, et al.). Furthermore, the additional major professional guidelines for colon cancer do not support the clinical utility of PET imaging for use in this clinical setting (Meyerhardt, et al.; El-Shami, et al.; Kahi, et al.). All told, the requested PET scan (CPT code 78815 and HCPCS code A9552) is not medically necessary for 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 internal medicine with subspecialty 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: Experimental/Investigational
Decision: Overturned

A 57-year-old female enrollee has requested for photochemotherapy for treatment of her granuloma annulare. Findings:  Two physician reviewers found that photochemotherapy is a well-established and commonly employed first-line option for this patients condition. There is a lack of high-quality data demonstrating that other therapies are likely to result in a superior outcome in this setting as compared to photochemotherapy. Furthermore, photochemotherapy has a more favorable safety profile than other options. As such, photochemotherapy is a more appropriate treatment option for this patient than the standard alternatives available.
Appeal type: Medical Necessity
Decision: Overturned

A 49-year-old female enrollee has requested continued acupuncture treatments for treatment of her pain associated with Kearns Sayre Syndrome.  Findings:  The physician reviewer found that the patient is an excellent candidate for continued acupuncture. She has chronic myofascial pain and intractable intercostal neuralgia. She has received excellent relief with physical modalities, including physical therapy and acupuncture. The submitted medical documentation demonstrated a high level of efficacy of these services, and the patient experienced increased pain when acupuncture was discontinued. There is sufficient medical evidence demonstrating the benefits of acupuncture in myofascial pain and a variety of neuropathic pain disorders. In this patients case, she has responded to prior treatment and is unable to tolerate traditional pain medications.  All told, in this patients case, continued acupuncture is medically indicated.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Acthar for treatment of her relapsing multiple sclerosis (MS).  Findings:  The physician reviewer found that according to the documentation submitted for review, the patient presents with mild loss of vision of 20/60, no pain with eye movements which is characteristic of optic neuritis, and no optic nerve enhancement, or imaging evidence of active disease. In this case, the provider recommends treatment with Acthar due to reports of previous intolerance with oral and IV steroids, however the medical records do not document intolerance or adverse side effects. Given the lack of documentation demonstrating intolerance with steroids, Acthar is not medically necessary for treatment of the patients medical condition. Final Results: 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 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

Nature of Statutory Criteria/ Case Summary:  The patient has severe pain from osteoarthritis of  both knees. Based on the current medical studies, hyaluronic acid is no longer recommended for patients with symptomatic osteoarthritis. Scientific evidence indicates there are currently no clinical indications for this technology and strongly do not recommend use. Final Result: The reviewer determined that the service at issue was not medically necessary for treatment of the patients condition.  Therefore, the health plans denial was upheld.Credentials/Qualifications: The physician reviewer is board certified in Orthopedic Surgery and is actively practicing.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary:   An enrollee has requested lumbar and cervical trigger point injections for treatment of her medical condition.  The physician reviewer found that the request for lumbar and cervical trigger point injections is not medically necessary in this clinical setting. The patient presents with a number of medical problems and complaints. However, there is a lack of documentation of previous treatments or therapies tried and failed. In addition, the medical literature indicates that the trigger point is a focus of hyperirritability in the muscle, that when compressed, is locally tender, and if sensitized, gives rise to referred pain and tenderness. Furthermore the medical literature indicates that the criteria for trigger points include localized spontaneous pain, spontaneous pain or altered sensations in the expected referred area for a given target area, a taut, palpable band in an accessible muscle, exquisite localized tenderness in a precise point along the taut band and a certain degree of reduced range of movement when measurable. In this case, there are no documented palpable points, or previous therapies tried and failed. For the reasons provided, the requested services are not medically necessary for treatment of the patients medical condition.  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 anesthesiology and 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

A 51-year-old female enrollee has requested a hysterectomy for treatment of her increased bleeding and pelvic pain. Findings:  The physician reviewer found that the American College of Obstetrics and Gynecology, in its Practice Bulletin, states that surgical therapy is appropriate for women with excessive anovulatory bleeding in whom medical management has failed and who have completed their childbearing. Surgical options include hysterectomy and endometrial ablation. Removal of the uterus via hysterectomy is the most effective treatment for bleeding and overall patient satisfaction rates approximate 85 percent. Moreover, subjective improvement of dysmenorrhea and premenstrual symptoms has also been reported following hysterectomy. The decision to remove the uterus should be made on an individual basis and should usually be reserved for woman with other indications for hysterectomy, such as pain, leiomyomas or uterine prolapse. This patient has evidence of significant pelvic pain. Thus, the proposed procedure is medically necessary.
Appeal type: Medical Necessity
Decision: Overturned

A 55-year-old male enrollee has requested for Aciphex (20mg/BID) for treatment of his GERD and dyspepsia. Findings:  The physician reviewer found that this patient has reflux esophagitis. He has tried and failed multiple proton pump inhibitors including, Protonix, Prilosec, and Prevacid. He could not complete the trial with Protonix because of nausea. Aciphex is the only medication that works for the patient.
Appeal type: Medical Necessity
Decision: Upheld

The parent of a 15-year-old female enrollee has requested for residential treatment services for treatment of the enrollees bipolar disorder. Findings:  The physician reviewer found that there appears to be very little to support the patient needing something as intensive as residential placement at any time. The patient was not a particular management problem when in residential placement. She was not suicidal and also was not particularly interested in treatment (exhibited by running away).