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

This patient is a 13-year-old male with a history of sensory motor deficits who has had multiple diagnoses associated with his developmental delays including attention deficit non-hyperactivity disorder, pervasive developmental disorder, and anxiety depressive disorder. The patients pediatric neurologist diagnosed the patient with mixed developmental disorder. He was diagnosed by neuropsychological testing with attention deficit hyperactivity disorder - predominately ineffective type; reading disorder; disorder of written expression; and anxiety disorder. A request has been made for the patient to receive speech therapy services. The Health Plan has denied the request indicating the requested therapy is not medically necessary for treatment of the patients medical condition.Review of the medical literature reveals no evidence that speech therapy is an effective treatment for attention deficit disorder. Though speech therapy is used as standard of care for pervasive developmental disorder, there is insufficient evidence in the submitted documentation to demonstrate that the patient has pervasive developmental disorder. While the patients other diagnosed learning disorders often benefit from speech therapy, treatment for such disorders is educational in nature and not medically indicated. Furthermore, there is no literature to support the use of speech therapy for treatment of anxiety disorder. Therefore, I have determined that the requested therapy is not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned

A 59-year-old female enrollee has requested for Nuvigil 250 mg for treatment of her idiopathic hypersomnia.  Findings:  The physician reviewer found that Nuvigil has the same clinical indications for use as Provigil, and the latter is widely used for typical narcolepsy confirmed by pathologic sleepiness on MSLT, and for idiopathic hypersomnolence which is another disorder of sleepiness. Thus, although a formal diagnosis of narcolepsy could not be confirmed with diagnostic testing in this patient, based on her MSLT results, the diagnosis should not be entirely excluded. The medical literature reveals that approximately one-third of narcoleptic patients do not have all of the typical features of the disorder, with the exception of excessive daytime sleepiness, as is the case with this patient.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for Optune Plus Transducers as well as prospective authorization and coverage for future Optune Plus Transducers treatment.Findings:  Three physician reviewers found that the services at issue were and are likely to be more beneficial for treatment of the patients medical condition than any other available standard therapy. In 2011, the U.S. Food and Drug Administration (the FDA) approved the Optune portable medical device for the treatment of recurrent glioblastoma. The Optune device generates low-intensity alternating electric fields, or tumor treatment fields (TTF). Approval was based on results of a clinical trial that randomly assigned 237 patients to either TTF therapy or chemotherapy. Similar survival was observed in the two groups, and TTF therapy was associated with lower toxicity and improved quality of life. A subsequent open-label randomized trial in patients with newly diagnosed glioblastoma showed prolonged progression-free and overall survival in the group assigned to TTF therapy when used in combination with post-radiation temozolomide. Consensus-based guidelines published by the National Comprehensive Cancer Network (NCCN) include alternating electric field therapy as a treatment option for patients as adjuvant therapy in combination with temozolomide or with recurrent glioblastoma. Therefore, the Optune Plus Transducers (CPT code E0766) provided to the patient were and are likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the services at issue were and are likely to be more beneficial for treatment of the patients medical condition than any other available standard therapy. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: All three physician reviewers are board certified in internal medicine with subspecialty certification in medical oncology, and they 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: Overturned

A 26-year-old enrollee has requested bilateral mastectomy with chest reconstruction for the enrollees transgender reassignment. Findings:  The physician reviewer found that review of the submitted documentation indicates the patient has a body mass index (BMI) of approximately 35. Obesity with a BMI of 35 slightly increases the risk of surgical complications. An individual with a BMI of 35 may be at higher risk for surgical and wound healing problems. However, a BMI of 35 is not a contraindication to proceeding with the requested surgery. The patient is an appropriate candidate for bilateral mastectomy with chest reconstruction from a medical standpoint. Psychological clearance for the proposed surgery should be obtained before the procedure is performed.
Appeal type: Experimental/Investigational
Decision: Upheld

A 59-year-old male enrollee has requested Erbitux (cetuximab) for treatment of his non-small cell lung cancer. Findings:  Two physician reviewers found that in this patients case, the requested medication is not likely to be more effective than other treatment options.  Erbitux has been shown to provide marginal benefit in the treatment of non-small cell lung cancer when used as first-line therapy in combination with a platinum agent and vinorelbine.  However, the use of Erbitux in this clinical setting as a third-line agent is not supported by the current medical evidence.  All told, Erbitux is not likely to be more efficacious than other available treatment alternatives.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Harvoni for eight weeks.Findings:  The physician reviewer found that according to 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 should be treated except those with limited life expectancy due to non-liver-related conditions.  This applies regardless of fibrosis stage or viral load, and advanced fibrosis is not required for treatment. Per the guidelines, treatment naive genotype 1 patients should be treated with Harvoni. Patients with viral loads less than 6,000,000 IU/mL can be treated for eight weeks. These guideline recommendations are based on multiple randomized clinical trials. For these reasons, Harvoni for eight weeks is medically necessary for the treatment of this patient.  Final Result: The reviewer determined that the requested medication regimen 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

The parent of a 16-year-old female enrollee requested accessories for the allowed power wheelchair for medical treatment of the enrollees infantile hemiplegia and cerebral palsy.  Findings:  The physician reviewer found that according to the National Institutes of Health (NIH), the goal of treatment for patients with cerebral palsy is to foster independence to the extent possible. Wheelchairs, walking aids, muscle and bone braces, hearing aids, and glasses may help with communication and learning. Physical therapy, occupational therapy, orthopedic health and other treatments may also be needed to help with daily activities and care. The records indicate that this patient is able to operate a manual wheelchair but only for limited distances. A manual wheelchair would mean she could only independently navigate in the home which would be very limiting for her. Given these findings, the requested equipment, including the recommended seating system, is medically necessary in this case.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested Harvoni for treatment of his hepatitis C virus.  Findings: The physician reviewer found that according to the 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 limited life expectancy due to non-liver-related conditions. This applies regardless of fibrosis stage or viral load. The guidelines recommend that treatment-naive genotype 1 patients should be treated with Harvoni for 12 weeks. These guideline recommendations are based on multiple randomized clinical trials, and the medication is U.S. Food and Drug Administration (FDA)-approved for all patients with chronic hepatitis C genotype 1 regardless of fibrosis stage AASLD/IDSA guidelines cite data showing decreased survival with delayed treatment. For these reasons, the requested treatment with Harvoni 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 budesonide EC 3 mg CAPDR  ER is medically necessary for treatment of this patient. In this case, the patients celiac disease has not responded to attempts at a gluten-free diet. Biopsies have shown ongoing infiltration with intraepithelial lymphocytes consistent with persistent disease activity (Rubio-Tapia, et al.; Husby, et al.). The American College of Gastroenterology (ACG) guidelines recommend consideration of treatment with medication as an adjunct to gluten-free diet in this clinical setting (Rubio-Tapia, et al.). Patients attempting a strict gluten-free diet often experience accidental gluten exposure (Therrien, et al). The standard option for the treatment of refractory celiac disease is open-capsule budesonide, which has demonstrated clinical and histologic improvement in celiac disease refractory to other measures (Mukewar, et al.; Therrien, et al.). In this case, the patient has attempted a gluten-free diet for over one year, with persistent histologic celiac disease. For these reasons, the requested budesonide EC 3 mg CAPDR  ER 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 internal medicine with subspecialty 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 tethered cord release surgery. Gao and colleagues found that surgical treatment on adult patients with tethered cord syndrome can improve the neurologic deficits which are associated with the course of disease, and early treatment has much better curative effect. In this case, given the patients diagnosis of symptomatic tethered cord syndrome, release of the filum terminale is medically indicated. Therefore, tethered cord syndrome is medically necessary for the evaluation of this patient.Final Result: The reviewer determined that the requested service 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 neurological 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 Gilotrif 40 mg tablet once daily for five months. Gilotrif is U.S. Food and Drug Administration (FDA) approved for the treatment of metastatic epidermal growth factor receptor (EGFR) mutated non-small lung cancer or metastatic squamous cell carcinoma with progression after platinum-based therapy. Phase I and II studies have demonstrated promising activity in human epidermal growth factor receptor 2 (HER2) positive breast cancer. However, a Phase III randomized study of Gilotrif in trastuzumab-resistant metastatic breast cancer was halted early due to unfavorable risk-benefit analysis from the Independent Data Monitoring Committee (IDMC) (Hurvitz, et al.). In this case, the provider reported that the patient is in remission. Based on the current peer-reviewed medical literature, there is a lack of support for use of Gilotrif in this clinical setting as preventative treatment. Therefore, the requested Gilotrif 40 mg tablet once daily for five months 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 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: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested transcranial magnetic stimulation, exceeding the clinical standard for treatment duration, for treatment of the enrollees major depressive disorder.  Findings: The physician reviewer found that Transcranial magnetic stimulation is a novel, non-invasive, neuro-stimulatory intervention endorsed by the American Psychiatric Association for the treatment of acute phase depression in the adult population.  A typical treatment course of transcranial magnetic stimulation consists of 30 to 40 sessions spanning four to six weeks.  At this time, there is a lack of adequately powered, controlled studies showing the benefit of longer courses of transcranial magnetic stimulation therapy.  In general, for those who respond to transcranial magnetic stimulation, oral medications remain the primary vehicle for maintenance of remission.  In this case, according to the validated rating scales, the patient achieved remission within typical treatment parameters.  Further, there was no mention of psychotherapy or the specifics regarding prior pharmacological and psychosocial interventions.  The medical records indicate that standard therapies had not been exhausted while the medical evidence does not support a reasonable expectation that additional transcranial magnetic stimulation therapy at the time would have improved the patients condition or prevented a more serious episode of illness.  Thus, 10 sessions of transcranial magnetic stimulation onward were not medically necessary for the treatment of this patient.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 psychiatry and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

The patient has requested authorization and coverage for Orthovisc injections for the right knee. This patient has a history of severe osteoarthritis and anterior cruciate ligament deficiency of the right knee. Treatment has included non-steroidal anti-inflammatory drugs (NSAIDs), corticosteroid injections, and viscosupplementation. She reports little response to corticosteroids but had excellent relief from viscosupplementation in the past. Her provider recommended repeat viscosupplementation with Orthovisc injections as they gave the patient excellent relief in the past. 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 standard 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, there is a long history of excellent relief from viscosupplementation in the past. Furthermore, the options are limited. The patient has tried and failed other conservative treatments with the alternative being a total knee arthroplasty. For these reasons, Orthovisc injections for the right knee are 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: Experimental/Investigational
Decision: Overturned

A 62-year-old female enrollee requested Afirma gene expression classifier (CPT 84999) for evaluation of her thyroid nodule.  Findings:  Two physician reviewers found that the Afirma gene expression analysis was likely to be more effective for this patient than other available treatment options. The patient had a biopsy with an indeterminate diagnosis. In this case, the genetic testing performed was a useful tool to aid in the distinction of a cytologically indeterminate nodule. Moreover, the medical literature supports the use of Afirma gene expression classifier in this clinical setting. As such, the services at issue were likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary:  An enrollee has requested Subsys for treatment of his medical condition. Findings:  The physician reviewer found that based on the clinical documentation submitted for review, the medical necessity for Subsys has not been established. Subsys is not medically necessary in this clinical setting. The requested medication is indicated for malignant pain. The patient has chronic non-malignant pain. The current standard of care for chronic pain is treatment in a multidisciplinary practice to include physical therapy, massage therapy, behavioral therapy, and injections to help reduce pain. There are a variety of anticonvulsants and anti-depressants considered adjunctive to this therapy. If there is poor response to conservative therapy then interventional treatments should be considered. High dose opioids are associated with a high risk of dependence and tolerance, and therefore are not recommended. Researchers reported that high dose and short acting opiates might contribute to pain sensitization via opioid-induced hyperalgesia, decreasing patient pain threshold and potentially masking resolution of a preexisting pain condition. In this retrospective study, the majority of patients undergoing detoxification of high dose opiates for chronic pain reported a significant decrease in pain at the end of the study, further supporting the theory of opioid-induced hyperalgesia. In addition, short-acting opiates are more likely to cause adverse outcomes. Additional researchers reported that prolonged use of high dose, short-acting opiates might induce tolerance, and abnormal pain sensitivity. For the reasons provided, the patients request for Subsys is not medically necessary. 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 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.