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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage of Zepatier 50mg-100mg for 12 weeks for treatment of her hepatitis C virus. Findings:  The physician reviewer found that according to the recent 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, regardless of fibrosis stage. The guidelines recommend that treatment naive genotype 1a patients should be treated with regimens including Zepatier for 12 weeks when NS5A resistance is not found. These guideline recommendations are based on clinical trial results showing a 99 percent cure rate when NS5A resistance is absent. However, Zepatier is significantly less effective when NS5A resistance is present, and a different regimen is recommended (Zepatier and ribavirin for 16 weeks). In this patients case, NS5A resistance testing results were not provided. AASLD/IDSA guidelines cite data showing reduced survival with delayed treatment. 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 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

Findings:  The physician reviewer found that Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Prevymis 480 mg tablets. Bhoopat and colleagues note that in the treatment of cytomegalovirus anterior uveitis, valganciclovir appears effective and safe, and while long-term antiviral prophylaxis does not abolish recurrences, it may possibly reduce their frequency. Tsui and colleagues note that letermovir may be an alternative treatment for cytomegalovirus anterior uveitis in patients with persistent inflammation or side effects on valganciclovir. In this case, while the provider noted in a letter that the patient experienced side effects of dizziness and flares while on Valcyte, visit notes reported that the patients most recent flare occurred while they were off Valcyte, and that the patient preferred management with letermovir in order to avoid blood monitoring. Given that the patients most recent flare appears to have occurred due to medication stoppage rather than medication failure, the requested medication is not medically indicated. Therefore, Prevymis 480 mg tablets are 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 ophthalmology 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 authorization and coverage for a computed tomography (CT) scan for evaluation of the enrollees chest discomfort. Findings:  The 3 physician reviewers found that based on the records provided the patient is female with some coronary risk, atypical chest discomfort, a normal cardiovascular physical exam, a normal electrocardiogram and a normal troponin valve. In this circumstance if additional cardiac evaluation is indicated, a form of stress testing would be most appropriate and considered the standard of care. A coronary CT scan provides an assessment of coronary anatomy without any evaluation of the functional significance of any potential stenosis identified, thus not evaluating for a cardiac cause of the patients atypical chest pain. Also, the proposed CT scan does not assess for other potential mechanisms of coronary ischemia such as vasospasm or small vessel coronary disease, both of which could be assessed with stress testing. Coronary CT scanning is not recommended in this clinical setting. Moreover, guidelines for the management of cardiac risk do not recommend routine performance of specialized tests in the context of assessing coronary risk including coronary CT scanning for calcium scoring. As such, the request for a CT scan is not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Final Result: The 3 reviewers determined that the requested service is 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 reviewer number one 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.Physician reviewer number two 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.Physician reviewer number three 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: Medical Necessity
Decision: Upheld

A 49-year-old male enrollee has requested varicocele microsurgery for treatment of his non-infertility based condition. Findings:  The physician reviewer found that the submitted documentation fails to demonstrate that the requested services are medically necessary for treatment of the patients non-infertility based condition.  The records note small bilateral varicoceles and a history of oligospermia.  Per the current medical evidence, indications for varicocele microsurgery include infertility and significant orchialgia.  In this patients case, there is no documentation of significant orchialgia.  Thus, the records do not demonstrate a non-infertility based condition which would warrant the requested services.  All told, the requested varicocele microsurgery is not medically necessary for treatment of the patients non-infertility based condition.
Appeal type: Medical Necessity
Decision: Overturned

The enrollee is requesting authorization and coverage for Eye Movement Desensitization and Reprocessing (EMDR) therapy, provided once a week. The enrollee has post-traumatic stress disorder (PTSD), anxiety, depression and grief. The enrollee has intense symptoms of restlessness, sleep deprivation, social isolation, and grief over losing their significant other several months ago. Eye Movement Desensitization and Reprocessing (EMDR) therapy has been prescribed. The diagnosis and treatment plan indicates EMDR will be utilized to reduce the enrollees emotional reactivity to the traumatic events she has experienced and PTSD symptoms. Eye movement desensitization and reprocessing (EMDR) is prescribed to reduce emotional distress related to traumatic thoughts, feelings, and images.  The medical literature indicates trauma-focused psychotherapies that include exposure have been supported by multiple clinical trials in adults with PTSD and include exposure therapy, such as prolonged exposure, a combination of exposure and a cognitive therapy, also known as trauma-focused cognitive behavioral therapy, and eye movement desensitization and reprocessing. EMDR is one of the most studied treatments for PTSD and has the strongest recommendation for being an effective treatment in most clinical practice guidelines for the treatment of PTSD.  Over the years, there have been a multitude of clinical reports and research data confirming its success in other clinical areas including the diagnostic clusters related to anxiety, as well as complicated grief, disturbing memories, panic attacks, and stress reduction. This enrollees profile, throughout the record, indicates symptom corroboration in sync with the uses of this technique to address PTSD, grief/bereavement, anxiety, panic attacks, stress reduction, and anxiety. Standard prolonged exposure (PE) and eye movement desensitization and reprocessing (EMDR) protocols are effective, safe, and feasible in enrollees with PTSD and severe psychotic disorders, including current symptoms. Given the supportive literature, the requested Eye-Movement Desensitization and Reprocessing (EMDR) therapy, provided once a week, is medically necessary to treat the enrollees medical condition.Final Result: The reviewer determined that the requested services are medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The physician 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 similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

An 18-year-old male enrollee requested three hours per day of inpatient rehabilitation services for medical treatment of his multiple fractures.  Findings:  The physician reviewer found that the requested services are medically necessary for treatment of the patients medical condition. According to the documentation submitted for review, this patient has significant functional loss, is willing to participate in therapy, and does not have acute medical issues interfering with rehabilitation. He requires multiple therapies coordinating together such as physical therapy, occupational therapy, and with his history of brain injury, access to speech/language therapy and/or neuropsychological therapy. Dahm and Ponsford note that traumatic orthopedic injury and traumatic brain injury, both of which the patient has, place an individual at risk for long-term disability and impairment of socialization. As such, intensive therapies in a highly monitored setting such as inpatient rehabilitation can reduce the risk of these adverse outcomes. In this patients case, three hours per day of inpatient rehabilitation services at the frequency of five days per week is medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned

A 49-year-old female enrollee has requested a hysteroscopy, biopsy, and laparoscopy for treatment of her pelvic pain and vaginal bleeding. Findings:  The physician reviewer found that it is possible that this patient would benefit from pathologic treatment including a D&C, and visual evaluation of her endometrial lining with a hysteroscopy. However, prior to surgery a more complete gynecologic workup is indicated, and if already done simply needs to be documented. Specifically, tissue diagnosis of the endometrium would be helpful to exclude hyperplasia in a patient of her age with suspected menorrhagia. As recommended by the American College of Obstetricians and Gynecologists (ACOG), an office endometrial biopsy, or an outpatient D&C would be a reasonable treatment option. Conversely, proceeding with a hysteroscopy without tissue diagnosis or assessment of the uterine cavity by sonogram to better assess the uterine shape, size, possible pathology is not clinically justified. Further, given the lack of data regarding the cyst, more information is needed to ascertain the need for a laparoscopy. Therefore, the requested D&C procedure and visual hysteroscopy are medically necessary while the laparoscopic evaluation of the pelvis is not indicated at this time.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient is a male with metastatic prostate cancer to the bone requesting authorization and coverage for Xtandi. The Health Plan has denied the request as not medically necessary to treat the patients medical condition.The issue, in this case, is whether the requested medication Xtandi is medically necessary for the treatment of the patients medical condition.Patients with prostate cancer, metastatic to bone, are initially treated with androgen deprivation maneuvers, including Lupron and Casodex. The next step is usually Taxotere chemotherapy, though many would use one of the newer anti-androgen therapies, either Zytiga or Xtandi. Both of these are oral agents and appear to have roughly equivalent effectiveness. However, Zytiga must be given with prednisone, whereas Xtandi does not require that.According to either NCCN or UpToDate review, there is no real preference. One study reported on 1199 men with metastatic prostate cancer, all of whom had received Taxotere. These men were then randomized to either Xtandi or placebo. There was clear superiority to the Xtandi group both in terms of overall survival and progression-free survival. This patient has had androgen deprivation therapy and Taxotere. Thus, it is clinically beneficial to treat this patient with Xtandi, without requiring he first receives Zytiga. Therefore, Xtandi is medically necessary for the treatment of the patients medical condition, and the Health Plans decision should be overturned.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 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: The patient has requested authorization and coverage for increase in dosage for Remicade infusion from 10 mg/kg every eight weeks to 10 mg/kg every four weeks. Remicade is U.S. Food and Drug Administration (FDA) approved and recommended for the treatment of ulcerative colitis. Moreover, the requested increase in dose is oftentimes required during maintenance therapy with Remicade. Current data from randomized double-blind placebo-controlled trials have reported 69% rate of remission at eight weeks with infusion of 10 mg/kg, rather than 64% with infusion of 5 mg/kg. The American College of Gastroenterology (ACG) guidelines for management of ulcerative colitis support the requested increase in Remicade dosage in patients with uncontrolled disease. Additionally, the American Gastroenterological Association (AGA) recommends an increase in Remicade dosage rather than change to an alternative medication in patients with low Remicade level when anti-Remicade antibodies are absent or at a low level, as in this patients case. The AGA guidelines for therapeutic drug monitoring state that a Remicade level of 5 ug/mL is recommended, and over 10 ug/mL is likely to be effective. This patients level is significantly lower. For these reasons, the requested increase in dosage for Remicade infusion from 10 mg/kg every eight weeks to 10 mg/kg every four weeks is supported as 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 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: An enrollee has requested authorization and coverage for intensity modulated radiation therapy (IMRT) for treatment of the enrollee who has been diagnosed with invasive adenocarcinoma of the prostate. Findings:  The physician reviewer found that There is support in the medical literature for the medical necessity of the requested services in this clinical setting. The guidelines acknowledge that the clinical decision to initiate treatment will be dependent on multiple factors including patient and provider interaction rather than a specific prostate specific antigen threshold value. In this patients case, it is reasonable to begin salvage radiotherapy based on this patients presented clinical factors. Morgan and colleagues evaluated 14 different definitions of post prostatectomy failure, but the study also took into account pathologic factors. For this patient with a Gleason score of 9 and pathologic T2c disease, a PSA failure threshold of 0.03 ng/mL is predicted to have a 77% chance of PSA progression at five years. Using a threshold of 0.1 ng/mL, there is an 88% chance of progression at five years. These numbers should then be taken into consideration along with age, life expectancy, quality of life, and patient preference. But, for any patient with a life expectancy more than two years, an 88% chance of PSA progression almost certainly warrants treatment, but especially so in a patient who is only 55. Waiting for this patients PSA to rise would not be beneficial to this patient. Therefore, in light of the medical evidence as well as this patients clinical factors, IMRT 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 radiation 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: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for an additional seven (7) physical therapy visits.The management of chronic benign low back and spinal pain can include pharmacological agents, rehabilitation, psychological treatment, complementary/alternative medicine and invasive approaches. The aim of rehabilitation is to reduce pain, reduce impairment/disability, and improve quality of life. Formal rehabilitative interventions are rendered, in conjunction with education, towards a goal of self-management, independent exercise and remaining active. Exercise and physical activity have low risk for adverse effects and are generally encouraged in the setting of chronic low back pain. The benefit of prolonged exercise in a formal therapy setting, however, is not established in the medical literature. Various exercise types (e.g., yoga and Tai Chi) and group exercise settings, moreover, may well suffice for management of this condition. There is, in addition, no proven marginal benefit of passive modalities such as massage/manual therapy, electrotherapy and thermal modalities provided in a formal setting on a prolonged basis on pain, health or functional outcomes over independently rendered interventions such as self-massage (e.g., using foam rollers, massage balls, etc.) and topical treatments such as ice or heat.In this case, the patient does not have any documented impairments that would preclude her from performing an appropriate independent exercise program, including stretching and strengthening, as well as independent soft-tissue and palliative interventions, e.g., self-massage using foam rollers or massage balls, etc., and topical treatments such as ice or heat. Although the patient has been making some nominal progress with therapy and has ongoing symptoms, there is no expectation of a marginally significant difference in clinical course or outcomes with the continued formal therapy in question over an appropriate, compliantly followed independent program based on the clinical documentation and current medical literature. The patient is no less likely to have recurrences of her symptoms with the continued formal therapy in question than without. Under these circumstances, the requested additional seven (7) physical therapy visits are not medically necessary to treat the patients medical condition.Final Result: The reviewer determined that the requested services are not medically necessary to treat 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: Medical Necessity
Decision: Overturned

A 27-year-old female enrollee has requested intensive outpatient or inpatient cognitive therapy and psychological therapy for treatment of her major depression and anoxic encephalopathy.  Findings:  The physician reviewer found that a distinction must be drawn to the difference between cognitive rehabilitation therapy and cognitive and/or behavioral psychotherapy, as these are two very different treatments for different conditions.  This patient is status post suicide attempt.  She will likely have residual impairments due to her anoxic encephalopathy, the degree of which is indeterminable at this time.  This patient requires a comprehensive cognitive rehabilitation assessment to determine her specific needs at this time.  Thus, the medical necessity of cognitive rehabilitation therapy has not been established at this time.  In terms of the patients diagnosis of major depression, effective psychotherapies are trusted interventions in the treatment armamentarium for affective disorders.  Mood disorder is the psychiatric diagnosis most commonly associated with suicide.  Considering the severity of the patients suicide attempt, and the relative proximity to the event, more frequent psychotherapy sessions during this high-risk period are indicated.  In this patients case, intensive outpatient psychotherapy sessions at a frequency of twice per week with an anticipated decrease to once per week after two weeks are medically indicated.  All told, a portion of the requested services is medically necessary for the treatment of this patient.