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

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the immunoassay testing (AdMark Phospho-Tau/Total-Tau/A Beta42, Analysis and Interp) performed by Athena Diagnostic for evaluation of the enrollees memory decline.  Findings:  2/3 of the physician reviewers found that the diagnosis of AD is still largely based on exclusion criteria of secondary causes and other forms of dementia with similar clinical pictures. Improved methods of early diagnosis are needed, particularly because drug treatment is more effective in the early stages of the disease. Recent research focused the attention to biochemical diagnostic biomarker) and according to the proposal of a consensus group on biomarkers, three candidate cerebrospinal (CSF) markers reflecting the pathological AD processes, have recently been identified: total tau protein (T-Tau), amyloid beta (1-42) protein (A Beta42), and tau protein phosphorylated at AD-specific epitopes (P-Tau). Several articles in the peer-reviewed literature report reduced CSF levels of A beta42 and increased CSF levels of T-Tau and P-Tau in AD; the sensitivity and specificity of these data are able for discrimination of AD patients from controls. However, the specificity for other dementias is low. According to literature analysis, the combination of the CSF markers and their ratios may significantly increase the specificity and the accuracy of AD diagnosis. Therefore, the immunoassay testing (AdMark Phospho-Tau/Total-Tau/A Beta42, Analysis and Interp) performed by Athena Diagnostic was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Final Result: 2/3 of the reviewers determined that the diagnostic procedure 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: Physician reviewer number one 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.Physician reviewer number two 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.Physician reviewer number three 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: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the gene panel test. This testing is supported by the American College of Obstetricians and Gynecologists as an integral part of the current standard of care. This patients testing included screening for cystic fibrosis and spinal muscular atrophy. Thus, the gene panel test was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Findings: Three physician reviewers found the gene panel test was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the gene panel test was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Credentials/Qualifications: Physician reviewers 1, 2 and 3 are board certified in obstetrics and gynecology 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: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested reimbursement and prospective authorization and coverage for 129 hours per month of applied behavioral analysis (ABA) therapy (CPT H2019) provided for treatment of the autism spectrum disorder.  Findings:  The physician reviewer found that The services at issue were not and are not medically necessary for treatment of the patients medical condition. According to the documentation submitted for review, the patient is making progress with ABA therapy, and there is not medical indication for an additional 17 hours per month of direct ABA services. According to the records provided, the patient has had a decrease in her tantrums from 2.5 per hour lasting 30 minutes, to one per day lasting 1-30 minutes. Elopement has decreased from five per hour to 2.5 per hour. Aggression has decreased from 2.1 per hour to 0.5 per hour. Non-compliance has decreased from baseline of eight episodes per session to 4.5 per session. Property destruction has also decreased from three episodes per session to one per session. The records demonstrate that the patient has made improvement from baseline in skill deficits and problematic behaviors targeted in the treatment plan using validated assessments of adaptive functioning. For the reasons provided, the request for 129 hours per month of ABA therapy (CPT H2019) provided have not been established as medically necessary.  Final Result: The reviewer determined that the services at issue were not and 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: Overturned

A 61-year-old male enrollee has requested Ambien CR 12.5 mg for treatment of his sleep disorder.  Findings:  The physician reviewer found that this patient has sleep difficulties with intolerance to CPAP. The records indicate that he has been treated with Ambien in the past and developed a tolerance to that medication. This patients sleep history is not detailed in the records provided for review, but if he has insomnia, it is likely multifactorial for which Ambien CR may be indicated. If the patient does not experience bothersome side effects with a trial of Ambien CR, it may be more effective than Ambien, particularly for sleep maintenance insomnia. Given the prescribing information on Ambien and this patients previous response to Ambien prior to developing a tolerance, trial with Ambien CR is a reasonable therapeutic solution for this patient with insomnia.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary:  An enrollee has requested medial branch radiofrequency ablation for treatment of her medical condition. Findings: Two physician reviewers found that Manchikanti and colleagues conducted a thorough review and concluded that there is significant evidence for the diagnostic validity of facet joint nerve blocks, and moderate evidence for therapeutic radiofrequency neurotomy and therapeutic facet joint nerve blocks in managing chronic low back pain. Similarly, McCormick and colleagues studied the long-term outcome of radiofrequency lesioning and found benefit that lasts from six months to two years. Thus, the medial branch radiofrequency ablation is likely to have been more beneficial for treatment of this patients medical condition than any available standard therapy. Final Result: Two reviewers determined that the services at issue were 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:   All three reviewers are board certified in anesthesiology with sub-specialty certification in pain management 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 patient has requested authorization and coverage for Orilissa (elagolix) 150 mg tablets. Orilissa is a gonadotropin-releasing hormone (GnRH) antagonist, which functions to suppress pituitary gonadotropin hormone production and create a hypoestrogenic state. Unlike GnRH agonists, GnRH antagonist agents are effective immediately, do not cause an initial surge in luteinizing hormone and follicle stimulating hormone, and do not require 7 to 14 days for GnRH suppression. Orilissa provides a treatment alternative for patients who do not respond to non-steroidal anti-inflammatory drugs (NSAIDs), estrogen-progestin contraceptives, or progestins. Studies support its benefit when compared with placebo for patients with endometriosis-related dysmenorrhea and noncyclic pelvic pain (Ng, et al.; Taylor, et al.). In the United States, it has been approved for treatment of moderate-to-severe endometriosis-related pain. In this case, the patient is premenopausal and has not responded to multiple standard therapies. The records document that the patient has responded well to Orilissa. For these reasons, the requested Orilissa (elagolix) 150 mg tablets are medically necessary for 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 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: Upheld

A 62-year-old female enrollee has requested for right breast reconstruction and bilateral breast reduction concurrent with right excisional biopsy with sentinel node biopsy for treatment of her invasive lobular carcinoma. Findings:  The physician reviewer found that there have been increasing reports on an oncoplastic approach to breast cancer which combines lumpectomy with immediate local reconstruction, there are no specific characteristics of this patients tumor or her breast size that indicates an oncoplastic approach would be necessary or preferred in this case. Breast reduction following treatment of breast cancer is best delayed until the completion of radiation therapy to determine the effects of the radiation on the size and shape of the breast, which can be quite variable and cannot be predicted prior to surgery. The indications for breast reduction should be reconsidered after the patients breast cancer treatment has been completed.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: A patient has requested reimbursement for dopamine transporter imaging with single photon emission computed tomography (DaT-SPECT) that was provided on 3/2/18. The Health Plan has denied this request and reported that the services at issue were investigational for the evaluation of the enrollees medical condition. A review of the records indicates that the enrollee presented to his provider on 2/19/18. The provider noted that the enrollee had symptoms suggestive of rapid eye movement (REM) behavior disorder. The records noted a history of tremors, balance problems and other symptoms suggestive of dysautonomia. The provider recommended a DaT-SPECT scan to rule out striatonigral form of parkinsonism. The Health Plan indicates that the services at issue were investigational for the evaluation of the enrollees medical condition. Therefore, the Health Plan has denied reimbursement for the services at issue. One reviewer found that the DaT-SPECT scan provided on 3/2/18 was not likely to have been superior over other methods of evaluating this patient. Final Result: Two of the three reviewers determined that the requested procedure is 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: Physician reviewers 1, 2 and 3 are board certified in neurology 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: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Epclusa with ribavirin 400 mg  100 mg tablet for 24 weeks. Findings:  The physician reviewer found that according to joint guidelines issued by the American Association for the Study of Liver Diseases (AASLD) and the Infectious Diseases Society of America (IDSA), all patients with chronic hepatitis C should be treated except those with life expectancy less than 12 months due to non-liver-related conditions. However, the patient has satisfied this recommendation with two treatments, including a failed treatment with Viekira Pak, an NS5A inhibitor. After failure of an NS5A inhibitor such as Viekira Pak, AASLD/IDSA guidelines state that Deferral of treatment is recommended, pending availability of data for patients with HCV genotype 1in whom previous treatment with any HCV nonstructural protein 5A (NS5A) inhibitors has failed, who do not have cirrhosis, and do not have reasons for urgent retreatment. The provided information does not establish the presence of cirrhosis or any of the AASLD/IDSA listed severe extrahepatic manifestations of hepatitis C. Limited data is available regarding the efficacy of Epclusa and ribavirin after failure of Epclusa . For these reasons, Epclusa with ribavirin 400 mg  100 mg tablet for 24 weeks is not supported as medically necessary for treatment of the patients medical condition. Final Result: The reviewers 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: Physician reviewer number one 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: An enrollee has requested authorization and coverage for botulinum toxin injections. Findings:  The physician reviewer found that The American Headache Society (AHS) recommends preventive treatment when attacks significantly interfere with daily routines despite acute treatment; when a patient has four or more attacks per month; or when a patient has contraindication to, failure, or overuse of acute treatment. OnabotulinumtoxinA (Botox) has been approved for the treatment of chronic migraine. The lack of need for slow dose escalation, the rapid onset of therapeutic benefits, and the favorable tolerability profiles are advantages that injectable therapies have in common. In 2016, the American Academy of Neurology (AAN) updated its 2008 guidelines on using botulinum neurotoxin for brain disorders. Botulinum toxin A is now recommended for the management of chronic migraine, defined as attacks lasting four or more hours on at least 15 days each month for three months. Frampton and Silberstein performed a review of the current evidence of onabotulinumtoxinA in the prevention of chronic migraine. The authors reported, The totality of evidence from clinical trials and real-world studies indicates that onabotulinumtoxinA is an effective and generally well-tolerated option for the prevention of chronic migraines that may be particularly useful for patients who have previously failed to respond to or are intolerant of commonly prescribed oral prophylactics. In this case, the patient has a history of chronic migraines and has not responded to multiple oral preventative medications. Based on the AHS statement, AAN guideline, and study noted above, the patient is a candidate for prophylactic treatment with botulinum toxin therapy. Moreover, the patient has experienced clinical improvement with botulinum toxin therapy. Therefore, the requested botulinum toxin injections are medically necessary for the treatment of the patients medical condition.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 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: Overturned

Nature of Statutory Criteria/Case Summary: The patient has been diagnosed with hepatitis B. The provider noted that the patients hepatitis B was undetectable while being treated with Viread. She had been treated with Viread since 2017, and she has had a successful pregnancy while taking Viread. The provider noted that the patients hepatitis B was well-controlled on Viread. The patient was noted to be planning a pregnancy. The patient has requested authorization and coverage for the brand name medication Viread. The Health Plan has denied this request and reported that the requested medication is not medically necessary for the treatment of this patient. At issue in this case is whether the brand name medication Viread is medically necessary for the treatment of the patients medical condition. Authors reported, Tenofovir and entecavir are preferred because of their potency and minimal risk of resistance, decompensation, and serious side effects. The authors also noted that tenofovir disoproxil fumarate (TDF) is classified as pregnancy category B. Researchers reported, In a cohort of hepatitis B e antigen (HBeAg) positive mothers with an hepatitis B virus (HBV) DNA level of more than 200,000 IU per milliliter during the third trimester, the rate of mother-to-child transmission was lower among those who received TDF therapy than among those who received usual care without antiviral therapy. Studies reported, We conclude that TDF treatment initiated at 24 weeks of gestation in high-viremia, HBsAg/HBeAg-positive mothers efficiently prevents mother-to-child HBV transmission without adverse events in mothers and infants. In this case, the patient has been treated with Viread since 2017 and had a successful prior pregnancy. The medical evidence supports the requested medication in this clinical setting. Therefore, brand name medication Viread 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 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 Dupixent 300 mg/2 mL. Dupixent is U.S. Food and Drug Administration (FDA) approved for patients with moderate to severe eczema. The records provided for review document that this patients condition has been persistent for at least four years. Treatment has included mometasone, triamcinolone, and clobetasol, as well as several courses of prednisone and an antihistamine to control itching. Work-up revealed that the patient also has a component of allergic contact dermatitis, as demonstrated by positive patch testing and biopsy. Her disease has recently worsened with new involvement of the face and 10% of her overall body surface area. The provider charted that the patients symptoms have been affecting her quality of life and ability to work. The patient experienced a positive response to Dupixent, which waned upon stopping the medication. Dupixent has been shown to be effective in the treatment the atopic dermatitis and its associated itching component. Drucker and colleagues reported that Dupixent and cyclosporine are the most effective treatments after 16 weeks of therapy, while Dupixent has a more favorable risk profile than cyclosporine. Given this support, the requested Dupixent 300 mg/2 mL is medically necessary for 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.