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

Nature of Statutory Criteria/Case Summary: The patients parent has requested authorization and coverage for Omnitrope. The records provided for review document that this patients growth rate is poor at 2.64 cm per year, which indicates abnormal growth. The most recent bone age prediction is 165 cm, which is significantly below his mid-parental target height of 171.5 cm. In addition, this patient has late onset CAH, which is associated with short stature, if left untreated. Consistent with the U.S. Food and Drug Administration (FDA) and Endocrine Society guidelines, treatment with GH is appropriate for well-selected patients with CAH who have poor height prediction and poor growth. Moreover, some studies have shown that GH with GnRH analogs could improve height in children with CAH. All told, the requested Omnitrope 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 pediatrics with subspecialty certification in pediatric endocrinology 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 Fasenra subcutaneous injections. Findings: Based on the available information, treatment of this patients eosinophilic-type asthma with anti-interleukin 5 (IL-5) immunotherapy is medically necessary based on his prior history of poorly controlled asthma. Moreover, the patient has demonstrated excellent response to Fasenra therapy that blocks the IL-5 eosinophilic pathway. However, the records do not document that the patient has failed to respond or has experienced intolerable side effects with the formulary alternative mepolizumab, which also blocks the IL-5 eosinophilic pathway in a similar manner as Fasenra. Overall, there are inadequate information to support treatment with Fasenra in lieu of standard therapy with mepolizumab. Therefore, the requested Fasenra subcutaneous injections are not medically necessary for 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 in internal medicine with subspecialty certifications in pulmonary disease and critical care medicine and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The enrollee has requested has requested authorization and coverage for hip replacement surgery. The Health Plan has denied this request indicating that the requested services are not medically necessary for treatment of the enrollees bilateral hip pain.Finding: In this patients case, evidence based medical guidelines and peer reviewed criteria have been met for the requested services. Evidence based medical guidelines recommend total hip arthroplasty when all reasonable conservative measures have been exhausted and other reasonable surgical options have been considered or implemented. Obesity is a relatively common finding in candidates for total joint arthroplasties. There is limited evidence to support the recommendation of weight loss in the year prior to total hip or knee replacement and to determine the effectiveness of short term nonpharmacological, nonsurgical weight management interventions on patient and surgical outcomes. A study involved more than 104,000 patients who underwent elective total joint arthroplasty for hip and knee osteoarthritis, 40 and 60 %, respectively, were obese. While there was some indication that obesity is associated with increased risks for receiving a total joint arthroplasty, providers doing large number of cases had a very small complication rate. Six months after total joint replacement, severely or morbidly obese patients reported excellent pain relief and substantial functional gain that was similar to the findings in other patients. The authors concluded that while obesity is associated with a greater risk of early complications, obesity in itself should not be a deterrent to undergoing total hip arthroplasties to relieve symptoms. A review by that pertained to bariatric surgery prior to total hip or knee arthroplasty. The authors concluded that bariatric surgery does not significantly reduce the complication rate or improve the clinical outcome. As such, the medical literature indicates that bariatric surgery prior to a total hip arthroplasty does not reduce the complication rate.  Based upon the above literature review, there does not appear to be a contraindication to undergoing a total hip arthroplasty in this patients case. As such, the requested hip replacement surgery is medically necessary for treatment of this 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 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

A 35-year-old male enrollee has requested triamcinolone injections for treatment of his allergic rhinitis.  Findings:  The physician reviewer found that the treatment of both asthma and allergies are considered a stepwise approach to achieve control with the least risk. Steroids are not immediate acting and may take 12 hours or more to take effect. When an asthmatic patient has an exacerbation fails to respond to oral steroids, the patient is treated with intravenous steroids as the standard of care. Although this patient is allergic to grass, his skin testing showed he had other allergens including trees and perennial allergens. The patients presentation to his provider corresponds to the same time last year, which is tree season. When it was tree season, the patients peak flow was marginally subpar at 78. Moreover, despite treatment with medications, he is not improving. Given the potential side effects associated with chronic, continual use of steroids, the requested triamcinolone injections are supported as medically necessary for treatment of this patients medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned

A 62-year-old female enrollee requested stereotactic radiosurgery (SRS) and stereotactic body radiotherapy (SBRT) for medical treatment of her ovarian cancer.  Findings:  Three physician reviewers found that the services were likely to be more beneficial for treatment of the patients medical condition any available standard therapy. The patient presents with oligometastatic disease, and this particular type of disease has a long interval to progression and limited sites of disease.  While the standard therapy for metastatic disease is chemotherapy there is an emerging body of literature which suggests that patients with oligometastatic disease benefit from aggressive local therapy including stereotactic radiation (Palma, et al.). Given the disease process has a relatively indolent course and that she was not a candidate for surgical resection of the lesion, stereotactic body radiotherapy to the liver metastases was likely to be more beneficial than any available standard therapy.
Appeal type: Medical Necessity
Decision: Overturned

A 64-year-old male enrollee has requested dental services for treatment of his dental complications due to leukemia treatment. Findings:  The physician reviewer found that the condition of the patients mouth, jaw and teeth constitute an abnormal structure of the body. Further, the patients dental pathology documente suggests the abnormal condition is the result of disease, namely graft versus host (GVH) disease. The patients oral manifestations of GVH disease are well described, including xerostomia, or decreased salivary flow. As oftentimes occurs in patients with decreased salivary flow, the dentition is highly prone to pathology including caries. The documentation provided clearly demonstrates that the procedures will improve function and create a normal appearance to the extent possible. Specifically, the procedures at issue will improve function and the restoration of the teeth will provide more than a minimal improvement in appearance.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: A patient has requested authorization and coverage for a power recline feature for her existing power wheelchair. The Health Plan has denied this feature as not medically necessary for treatment of the patients medical condition. Power seating functions such as power tilt-in-space and power recline can provide relief from discomfort in persons who use wheelchairs as their primary means of mobility but do not have the means to independently reposition themselves without assistance. Given the considerable amount of time wheelchair users spend in their wheelchairs, powered seating functions that allow for posture changes and pressure management are important for those who cannot independently adjust their positions or who are at risk for pressure ulcers. In this case, there are no indications that the patient has any upper limb impairments that would preclude maneuvers for repositioning in the seated position to alleviate her discomfort or lumbago. Notably, the patient also uses a manual wheelchair indoors, which suggests that she has sufficient upper limb functionality to manage her repositioning needs when she uses her power wheelchair. There are no indications that the patient has any pelvic obliquity, spinal deformities or other conditions complicating her ability to alleviate discomfort using standard repositioning maneuvers with the upper limbs. There are no indications that the patient requires power recline functionality for accomplishing her mobility-related activities of daily living, such as dressing or bowel/bladder care. There are no indications that the patient requires power recline functionality for management of hypotension or other cardiovascular or respiratory conditions. The records, overall, do not establish that the patient has impairments or conditions for which power recline functionality on a power mobility device is medically necessary. Under these circumstances, the power recline feature that has been requested for the patients existing power wheelchair is not medically necessary to treat the patients medical condition.Final Result: The reviewer determined that the requested feature 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 physical medicine and rehabilitation and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for mobile cardiac outpatient telemetry. Findings:  The physician reviewer found that  clinical condition, age, and cardiac risk factors, this patient was predicted to be at low risk for life-threatening arrhythmias. In this clinical setting, immediate telemetered data, such as provided by a mobile cardiac outpatient telemetry monitor, was not likely to be more beneficial for the evaluation of this patient than other devices, such as a standard patient-activated or auto-activated event monitor. Therefore, mobile cardiac outpatient telemetry was not likely to have been more beneficial for evaluation of the patients condition than any available standard therapy.Findings:  Three of the three physician reviewers found the mobile cardiac outpatient telemetry at issue was not likely to have been more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the equipment at issue was not likely to have been more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: Physician reviewer 1 is board certified in internal medicine with sub-specialty certifications in cardiovascular disease and in clinical cardiac electrophysiology and is actively practicing. Physician reviewer 2 is board certified in internal medicine with sub-specialty certifications in cardiovascular disease and in adult congenital heart disease and is actively practicing. Physician reviewer 3 are board certified board certified in internal medicine with sub-specialty certification in cardiovascular disease and is actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

A 20-year-old male enrollee has requested combination chemotherapy with Avastin and Tarceva for treatment of his hepatocellular carcinoma.  Findings:  The physician reviewer found that hepatocellular carcinoma (HCC) is generally is not responsive to chemotherapy. One drug, Nexavar, has demonstrated a survival benefit and has been approved for use in this cancer. This particular young patient has been treated with a variety of past treatments including Nexavar and now has progressive disease, for which there is no known standard treatment likely to be of benefit. Two studies have been published demonstrating some degree of efficacy of Avastin. The first, by Cid and colleagues, studied 12 patients with Avastin who had previously received Nexavar and found a 50% rate of clinical benefit and median overall survival of 9.5 months. This study is applicable to this patient, but is a very small study that needs corroboration in other studies. The second published trial from Siegel and colleagues reported on 46 non-metastatic patients treated with Avastin. Overall, the authors concluded that patients treated with Avastin demonstrated a 13% response rate with a median progression-free survival of 6.9 months. However, the patients in the Siegel study are not comparable to the patient in this care, in that he has metastatic disease. With regard to the requested combination chemotherapy at issue in this case, Thomas and colleagues treated 40 patients with the combination of Tarceva and Avastin. All patients had advanced disease and had not received Nexavar. The researchers documented a 25% response rate, and 37% additionally had stable disease. In addition, the median survival was noted to be longer than observed in Nexavar trials. However, the authors concluded that the Tarceva and Avastin combination needed to be compared to Nexavar directly to confirm its superiority. Thus, the data supporting the use of the requested Tarceva and Avastin combination in this patients advanced HCC already treated with Nexavar, is fairly minimal. One must conclude that there is insufficient evidence to suggest that such treatment is likely to be beneficial. Moreover, it is noted that the patient was already tried on Tarceva and could not tolerate it due to toxicity. Ultimately, it is unlikely he would be able to tolerate it any better at this point in time.
Appeal type: Experimental/Investigational
Decision: Upheld

A 64-year-old male enrollee has requested a Real-Time Heart Monitor for the treament of his paroxysmal supraventricular tachycardia and syncope. Findings: Two physician reviewers found that based on the records provided, the patient underwent two weeks of continuous outpatient mobile cardiac telemetry to assess for a cause of syncope under the diagnosis code of paroxysmal supraventricular tachycardia. In this circumstance, if cardiac monitoring were thought to be medically necessary then non-real time (off-line) monitoring devices such as Holter monitoring or event monitoring should be sufficient for identification of both symptomatic and asymptomatic dysrhythmias. Continuous off-line 24-48 hour Holter monitoring should be able to effectively identify symptomatic or asymptomatic dysrhythmias that occur frequently. Likewise, self-activated non-real time and non-continuous monitoring devices (event recorders) should be effective at recording symptomatic dysrhythmias during less frequent symptoms. In cases of infrequent asymptomatic dysrhythmias that require identification, non-real time (off-line) monitoring devices with auto-triggering capability should be sufficient. With regard to this patient, there is no documentation to indicate he is not able to effectively manage the standard monitoring devices and no indication that these have been previously obtained to evaluate the patients condition. Current expert consensus guidelines endorsed by several national organizations also consider Holter monitoring and patient activated event recorders appropriate initial tests for evaluation of possible supraventricular dysrhythmias. Thus, continuous real-time monitoring by telemetry services such as CardioNet was not indicated in this case since off-line analysis of a patient activated device, auto-triggered device or continuous Holter monitor should be sufficient to identify dysrhythmias or conduction disorders without jeopardizing patient safety. Similarly, immediate recognition and reporting of dysrhythmias or conduction disorders through a call center provided by real-time mobile telemetry services such as CardioNet is also not indicated and has not been shown to improve health outcomes compared to standard monitoring techniques. For these reasons, the use of real-time outpatient telemetry monitoring services in the evaluation of this patients condition was therefore more for the convenience of the patient and physician, yet not likely to provide additional relevant information when compared to standard alternatives to diagnose and treat the patients condition.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a six-year-old female enrollee has requested  for acute inpatient psychiatric treatment for treatment of the enrollees psychosis.  Findings:  The physician reviewer found that that time should be sufficient for the patient to gain further control of her aggressive impulses. In addition, the standard of care would include an immediate comprehensive evaluation. During these additional days, an appropriate partial hospital program should be found along with the wrap around services. With regard to the possibility of residential care, based upon the severity of the patients illness, such care may be needed at some future date. However, given the patients young age, every attempt possible should be made to treat this patient without a prolonged separation from her family, as might be engendered by residential care.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for phenoxybenzamine HCL 10 mg capsule. Whelton and colleagues note that alpha blockers are not used as first-line therapy for hypertension as they are less effective for the prevention of cardiovascular disease than other first-step agents, such as thiazide diuretics. The authors further note that selective alpha-1 blockers such as doxazosin, prazosin, and terazosin are considered second-line agents. In this case, the patient has a diagnosis of essential hypertension. Given that alpha blockers such as phenoxybenzamine are not recommended as first-line therapy for hypertension, and that the documentation does not reflect that the patient has tried and failed selective alpha-1 blockers, the requested medication is not medically indicated. Therefore, phenoxybenzamine HCL 10 mg capsule 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 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: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for the DecisionDx-Melanoma testing performed.Findings:  The physician reviewer found that the DecisionDx-Melanoma Assay tests the tissue genetics of the melanoma to help stratify whether a melanoma is high risk for metastasis. The DecisionDx test has shown some impressive accuracy in thin melanomas like this patients tumor. However, there is a lack of scientific evidence permitting conclusions concerning the effect of this test on health outcomes. The test is not considered routine standard of care and is not recommended by the National Comprehensive Cancer Network (NCCN) guidelines. The test has not been demonstrated to provide a beneficial effect on health outcomes. Overall, there is not enough published data to support its routine use. Since this test has not been demonstrated to provide a benefit more than established tests, the DecisionDx-Melanoma 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 testing at issue was 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 & 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.