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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Harvoni 90-400 mg oral tablets.Findings:  The physician reviewer found that according to the most 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. The guidelines recommend that all patients should be treated, regardless of fibrosis stage. The guidelines recommend that non-cirrhotic treatment naive genotype 1 patients should be treated with Harvoni for 12 weeks or Zepatier for 12 weeks. In addition, these medications are U.S. Food and Drug Administration (FDA) approved for all patients with chronic hepatitis C genotype 1 regardless of fibrosis stage. The guidelines recommend either Harvoni or Zepatier as acceptable first-line therapy, and neither has been proven safer or more effective than the other in a direct comparison trial. The 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: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for genetic testing (cell-free fetal DNA-based prenatal screening for fetal aneuploidy). Findings:  Three physician reviewers found that there is sufficient support for the services at issue in this clinical setting. Noninvasive prenatal screening by cell-free DNA is increasingly becoming accepted as an appropriate method for first trimester aneuploidy screening. Noninvasive prenatal screening is more sensitive than sequential screening and does not require the invasive procedure of chorionic villus sampling or amniocentesis. Therefore, genetic testing (cell-free fetal DNA-based prenatal screening for fetal aneuploidy) was likely to have been more effective than other methods of evaluating this patient.Final Result: The reviewers determined that the services at issue were 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 is board certified in clinical biochemical genetics and is actively practicing. Physician reviewers 2 is board certified in obstetrics and gynecology and is actively practicing. Physician reviewers 3 is board certified in clinical cytogenetics and genomics 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: Experimental/Investigational
Decision: Upheld

A 58-year-old male enrollee has requested Destr Paravertebral Nerve I/S and Destr Paravertebral radiofrequency neurolysis for treatment of his chronic lower back pain with lumbar radiculopathy. Findings:  Three physician reviewers found that this patient has chronic low back pain and radicular pain and is status post spinal fusion. In 2009, Chou, et al. noted that facet injections are not effective and radiofrequency denervation is inconsistent in treating chronic lower back pain with radiculopathy. In 2011, Chou noted that treating chronic low back pain with radiofrequency treatments is not recommended. A study by van Wijk and colleagues noted no difference between the results of radiofrequency ablation and sham when treating chronic low back pain. Additionally, Cahana, et al. noted that the clinical advantage of radiofrequency ablation remains unclear. The available medical literature also indicates that radiculopathy and previous spinal fusion are contraindications to performing radiofrequency procedures. Given the above, radiofrequency treatment is not likely to result in a better clinical outcome for this patient as compared to standard modalities, and in fact, is contraindicated based on the patients documented history.
Appeal type: Medical Necessity
Decision: Overturned

The patient is a 58-year-old female with irritable bowel syndrome and constipation. She is taking massive doses of Correctol and Milk of Magnesia. She is reportedly having up to 10 bowel movements a day. There is also the belief that she may have Hirschsprungs disease. Various motility studies and manometry studies have been recommended but it does not appear as though they have been performed. The patient has been taking Zelnorm and it is noted that her symptoms have improved. It is unclear whether the patient is continuing to take massive doses of laxatives. The Health Plan has denied further authorization of Zelnorm.The Health Plans denial should be overturned. The submitted evidence demonstrates that Zelnorm is helping the patients condition. This is further evidenced by the fact that the patient is gaining weight and is not becoming dehydrated. For these reasons, the patient should continue on Zelnorm for another three months. At the end of this three-month period the patient should be re-evaluated to determine whether Zelnorm is still benefiting her condition.Based upon the information set forth above, I have determined the requested medication is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.
Appeal type: Experimental/Investigational
Decision: Upheld

A 47-year-old female enrollee has requested reimbursement for soft tissue neurography and injection treatment of the sciatic nerve (chemical neurolysis of the sciatic nerve) for treatment of the enrollees pelvic neurologic symptoms.  Findings:  Three physician reviewers found that the patient has a history of complex right pelvic neurologic syndrome involving the obturator internus muscle.  The patient underwent open magnetic resonance (MR) image-guided approach for percutaneous chemomyolytic treatment of the right obturator internus, chemoneuroplastic treatment of the sciatic nerve in the upper portion of the ischial tunnel, and chemoneuroplastic treatment of the nerve to the obturator internus at the level of the ischial spine.  Interpretation of the MR neurography of the pelvis noted that findings were consistent with sciatic irritation associated with an obturator internus muscle spasm syndrome.  The patient has requested reimbursement for soft tissue neurography and injection treatment of the sciatic nerve (chemical neurolysis of the sciatic nerve).  The current medical evidence does not support the services at issue in this clinical setting.  In this patients case, the requested image-guided procedure was not likely to be more beneficial than available standard therapies.  The records provided for review do not demonstrate that the patient had sufficient treatment with more standard treatments for this condition.  Standard therapies include physical therapy, home strengthening exercises, and medication management.  The superior efficacy of soft tissue neurography and injection treatment of the sciatic nerve (chemical neurolysis of the sciatic nerve) has not been established in this patients case.
Appeal type: Medical Necessity
Decision: Overturned

A 21-year-old enrollee has requested amphetamine salt combination (generic Adderall XR) for the treatment of her Attention-Deficit-Hyperactivity-Disorder (ADHD).The submitted clinical information, although limited, is sufficient to establish the medical necessity for this patient to be maintained on amphetamine salt combination (generic Adderall XR). The patients physician states that shorter-acting stimulants have not proven satisfactory, and that generic Adderall XR has been successful in treating the patients ADHD. Additionally, the patient states that the long-acting Adderall XR has been successful in controlling symptoms of ADHD for 12 hours, which allows the patient to get through the school-day, and that other medications have caused significant side effects. The paper by Huskam and colleagues is on point in this case. This paper reported that in cases in which patient or physician preference has no weight in the selection of the stimulant medication, there is a significant (17%) probability that the patient will not take any medication. The paper by Faraohe and Anishe discussed adult ADHD. It reported, in 2008, that only two medications have been approved by the Food and Drug Administration: extended release mixed amphetamine salt combination (i.e., generic Adderall XR) and lisdexamfetamine dimesylate, although other medications may be considered for treatment. Spencer and colleagues stated that Adderall is effective and well-tolerated in adults with ADHD. The paper by Kolar and Keller reports that if side-effects [occur] switching to another stimulant is warrantedan important advantage [of Adderall XR] is its extended duration of action. As the cited literature demonstrates, there is significant evidence to support the patients and physicians claims that generic Adderall XR is the drug of choice for this individual. The literature strongly supports that this patient be maintained on generic Adderall XR.
Appeal type: Experimental/Investigational
Decision: Upheld

The enrollees parent requested reimbursement for the tryptase blood test. The enrollee has a reported food allergy to corn and corn derivatives. He underwent a tryptase blood test. Records indicate the tryptase test measures both the alpha and beta forms of tryptase, and measuring both forms increases the sensitivity for the diagnosis of mastocytosis, and mast cell degranulation as a cause of anaphylaxis. Literature reports serum tryptase is useful in diagnosing drug and venom anaphylaxis.  Its use in food anaphylaxis is unknown.  For this enrollee, there is no data to support the utility of a tryptase level, unless the enrollee is undergoing a food challenge or has a documented history of anaphylaxis to the known food. The scientific evidence and peer-reviewed literature does not support a result of improvement in health outcomes. This enrollee is not a good candidate for the tryptase blood test.Final Result: Three of the three reviewers determined that the requested services are not likely to be more beneficial than any available standard therapy for treatment of the enrollees medical condition. Credentials/Qualifications: Three reviewers are board certified in allergy and immunology 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

A 30-year-old female enrollee has requested the knee extension device, DynaSplint system for treatment of her status post total knee arthroplasty.  Findings:  The physician reviewer found that postoperative stiffness is a debilitating complication of total knee arthroplasty, and even more so in patients under the age of 40 years.  Manipulation is most successful if done within the first three months after surgery. If performed for an inadequate period of time, effectiveness is less evident, but with an appropriate length of time, the benefits can be lasting.  Focused programs, including physical therapy and bracing, may be of increased value. There is support for the efficacy of the low-torque-long duration technique, such as the technique is used in DynaSplint.  In this case, the patient is young.  After a lack of response to therapy, a manipulation under anesthesia was done, with improvement. However, there again was a lack of response, and the DynaSplint requested.  Since there was a documented improvement, the use of the DynaSplint system was appropriate during the time period. The continuation of use was medically necessary, since the literature supports the continued use of the methodology to maintain improvement.  All told, the knee extension device, DynaSplint system, utilized during the time frame in question was medically indicated for this patient.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested authorization and coverage for an adaptive stroller and pressure vest for treatment of the autism spectrum disorder and gross motor delay. Findings:  The physician reviewer found that there is a lack of peer-reviewed literature supporting the requested equipment as medically necessary for treatment of the patients medical condition. A study examined the effects of the weighted vest during a functional analysis, in which the participant wore a five pound weighted vest or no vest. The researchers reported that The results do not suggest the existence of a functional relationship between the use of a weighted vest and challenging behavior, as the weighted vest had no marked effect on levels of aggression and self-injurious behavior. Similarly, another study found that an inflatable wearable vest known as the Snug Vest failed to reduce any participants stereotypy. Adaptive strollers may be helpful for some autistic children with elopement issues. The stroller can assist with keeping the child contained in a larger stroller when going out in the community. However, in this case, the patient has mild gross motor delay with skills ranking at the 16th percentile per PDMS-2. The records demonstrate that the patient can walk and ambulate within the community. In addition, the records do not show the patient exhibits elopement or dropping to the floor behaviors. Based on the clinical documentation provided for review, the request for an adaptive stroller and pressure vest are not medically necessary for treatment of the patients medical condition. Final Result: The reviewer determined that the requested equipment 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 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: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested Afirma gene expression classifier test for evaluation of the enrollee, who was diagnosed with a follicular thyroid lesion. Findings: Three physician reviewers found that a biopsy showed a cytopathology consistent with follicular neoplasm. The specimen was sent for genetic expression classifier to Afirma laboratory. The Health Plan denied reimbursement for the services at issue. Per the Health Plan, the services at issue were investigational for evaluation of this patient. The patient has a thyroid nodule, which is consistent with follicular neoplasm. The risk of malignancy is 5-15% in these nodules (Cibas, and Ali). The Bethesda System recommends a diagnostic thyroid lobectomy for this type of nodule (Cibas, and Ali). The 2015 American Thyroid Associations guidelines state that for follicular neoplasm nodules, molecular testing may be used to supplement malignancy risk assessment data in lieu of proceeding directly with surgery. Informed patient preference and feasibility should be considered in clinical decision-making. If the genetic test is suspicious, the risk of malignancy increases to 40% (Cibas, and Ali; Haugen, et al). However, the risk of malignancy decreases to less than 6% with benign findings by genetic testing (Cibas, and Ali; Haugen, et al). As such, based on clinical data, the Afirma test is beneficial for medical decision making. Proceeding directly to the genetic testing could have prevented a possible unnecessary surgery, if the result were benign, with possible complications. In this case, the results were suspicious. These results were helpful to direct subsequent management, in this case, surgery. Proceeding with genetic testing was highly effective and in line with current specialty standards. Therefore, Afirma gene expression classifier was superior to other standard methods of evaluating this patient.Final Result: The reviewers determined that the services at issue were 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: All three physician reviewers are board certified in internal medicine with sub-specialty certification in endocrinology, diabetes and metabolism 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 Klonopin for treatment of her behavioral health condition.  Findings:  The physician reviewer found that in this case, the patient meets criteria for sedative, hypnotic or anxiolytic (benzodiazepine) use disorder. More than one provider involved in the patients care have agreed that Klonopin is no longer indicated. The patients urine drug screen was negative for benzodiazepine. Klonopin has a half-life of 15 to 30 hours. Thus, at steady dosing of 2 mg three times a day, the urine drug screen would be expected to detect benzodiazepine more than five days after the last dose. Further, the patient had negative benzodiazepine screens on several dates interspersed among positive results during the time frame. 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 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

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for intensive in-home family treatment (IIFT) comprised of: 24-hour video monitoring in the home setting and utilization of clips of negative interactions for therapeutic and family therapy purposes; one hour weekly individual therapy in the office setting (code 90837); one hour weekly individual therapy in the home setting (code 90837); one hour weekly family therapy with enrollee present in the home setting (code 90847); and one hour weekly family therapy without the enrollee present in the home setting (code 90846); for six to nine months with a reduction in hours as the enrollees condition improves. Researchers evaluated the effectiveness of an IIFT program to prevent patient placement outside of the home. This patients provider noted that IIFT has been shown to reduce family separations and reduce psychiatric admissions for patients in this clinical setting. All told, the requested IIFT comprised of: 24-hour video monitoring in the home setting and utilization of clips of negative interactions for therapeutic and family therapy purposes; one hour weekly individual therapy in the office setting (code 90837); one hour weekly individual therapy in the home setting (code 90837); one hour weekly family therapy with patient present in the home setting (code 90847); and one hour weekly family therapy without the patient present in the home setting (code 90846); for six to nine months with a reduction in hours as the patients condition improves, is 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 psychiatry with subspecialty certification in child and adolescent 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: Upheld

A 43-year-old female enrollee has requested for Prevacid 30 mg tablets for treatment of her gastroesophageal reflux disease (GERD) and peptic ulcer disease (PUD).  Findings:  The physician reviewer found that proton pumps inhibitors (PPIs) continue to be the mainstay of therapy for acid suppression and are standard care for the treatment of GERD. All PPIs decrease acid secretion by inhibiting the parietal cells proton pumps. From a biochemical and pharmacodynamic points of view, subtle differences among the various PPIs may influence the clinical response. Inter-patient variability in efficacy has been noted with the PPIs because of their dependence on the polymorphic distribution of P450(CYP) 2C19. This inter-patient variability in efficacy is seen most often with Nexium (esomeprazole) and Protonix (pantoprazole), and least often with Prevacid (lansoprazole) and Aciphex (rabeprazole).
Appeal type: Urgent Care
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for urgent care services provided on 10/15/14 and 10/21/14.Findings:  The physician reviewer found that the urgent care services provided on 10/15/14 and 10/21/14 were not necessary for treatment of an emergency medical condition. On 10/15/14, the patient presented with a headache for two days. She denied any other neurologic symptoms. She was not febrile. Her neurologic exam was normal. Her symptoms on this date were not acute in onset. On 10/21/14, the patient presented with complaints of headache and dysuria. She denied any focal neurologic complaints. Her exam was unremarkable. The patient was evaluated the day prior by her primary care provider and a urinalysis had been ordered. Additionally, the patient had been referred for a neurology evaluation. Since this patient had already been examined and treated for these symptoms the day prior, and no acute deterioration had been documented, her symptoms were not necessary for treatment of an emergency medical condition. Final Result: The reviewer determined that the patient did not receive emergency medical services on the dates of service at issue. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in emergency 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.