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

Nature of Statutory Criteria/Case Summary: An enrollee has requested Harvoni for 12 weeks for treatment of her hepatitis C.  Findings:  The physician reviewer found that according to the most 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.  For treatment-naive patients with genotype 4, the guidelines recommend treatment with daily Harvoni for 12 weeks.  All told, Harvoni for 12 weeks is medically indicated for the treatment of this patient.Final Result: The reviewer determined that the requested medication is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.  Credentials/Qualifications: The reviewer is board certified in internal medicine with sub-specialty certification in gastroenterology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

An enrollee has requested authorization and coverage for a subcutaneous implantable cardioverter.The submitted documentation supports that the requested subcutaneous implantable cardioverter is medically necessary for the patient. Guideline statements from the American College of Cardiology (ACC) in 2011 and the European Society of Cardiology (ESC) in 2014 provide guidance on risk stratification in these patients. More recent data from Freitas and colleagues showed a strong correlation with severity of fibrosis on MRI and sudden death, which would indicate a higher risk in this patient. Based on this data, the patient could benefit from an ICD implant. This patient has hypertrophic cardiomyopathy and severe fibrosis on cardiac MRI, and symptoms of chest pain have been noted. Other findings from noninvasive studies have shown that the patient has significant septal hypertrophy. Under these circumstances, given the patients young age and no apparent need for pacing, a subcutaneous ICD device is indicated. Therefore, the requested subcutaneous implantable cardioverter is medically necessary for the treatment of this patients medical condition.Final Result: The reviewer determined that the requested device 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 cardiovascular disease and clinical cardiac electrophysiology, 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

A 54-year-old female enrollee requested disc arthroplasty (Mobi-C Disc replacement for medical treatment of her cervical degenerative disc disease.  Findings:  Three physician reviewers found that the requested services are not likely to be more effective for this patient than other available options. In this case, the patient presents with neck pain with a normal physical exam, other than positive for Hoffmans reflex. In addition, her pain generator has not been identified and she has no defined symptoms or signs of myelopathy with spasticity, weakness or gait problems. Her MRI has not shown cord compression nor signal changes. In addition, the U.S. Food and Drug Administration (FDA) has required a seven year post approval study to determine the long term safety and effectiveness of the Mobi-C device. Thus, the long-term safety and effectiveness of this product has not been substantiated. For the reasons provided, the requested services are not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/ Case Summary:  The enrollee requested coverage for laparoscopic anti-reflux procedure utilizing LINX reflux management system, According to the medical record, the patient has diagnoses of Gastroesophageal Disease (GERD), grade A esophagitis and a two cm hiatal hernia. An esophagram was normal.  Additional studies included an upper endoscopy, which revealed mild inflammation in the gastric antrum and; esophageal manometry, which showed a hypotensive lower esophageal sphincter. Surgery clinic notes indicate he had been taking omeprazole for many years, stopped taking it one year ago and is now taking Dexilant 60 mg daily. He has some regurgitation and the pH study revealed a DeMeester score of 25.5.  He is advised to have a LINX procedure for treatment of GERD. The medical literature cites an updated safety and effectiveness analysis of the LINX Reflux Management System. With regard to safety, the conclusion was that long term follow-up supports the FDA conclusions the device is safe. With regard to efficacy, there were several conclusions. The LINX implant results in pH normalization, improved quality of life and cessation of regular proton pump inhibitor use on a consistent basis. The long-term follow-up data demonstrates that the LINX Reflux Management Systems is effective in the management of GERD. Patients with moderate to severe reflux, especially if on proton pump inhibitor (PPI) therapy should be considered for minimally invasive treatment rather than increased PPI therapy. This enrollee was having continued symptoms while on PPI therapy and an abnormal pH impedence study. Laparoscopic placement of the LINX reflux management system is likely to be more beneficial than any available standard treatment for this patients medical condition.Final Result: Three of the three reviewers determined that the requested service is 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 Gastroenterology 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: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Euflexxa knee injections for treatment of her osteoarthritis of the left knee. Findings:  Two physician reviewers found that intra-articular injections of hyaluronic acid are an established part of treatment algorithms for management of osteoarthritic knee pain and is generally considered a second line treatment after pain medications such as nonsteroidal anti-inflammatory medications. Multiple studies have documented efficacy of intra-articular hyaluronic acid injection for osteoarthritic knee pain. Studies have shown that repeat injection of hyaluronic acid is safe and a multicenter randomized comparative trial determined intra-articular hyaluronic acid injection was safer than standard first line treatment with oral nonsteroidal anti-inflammatory medications. Repeat viscosupplementation is appropriate for this patient who has exhausted other non-surgical treatment options and had excellent relief with prior viscosupplementation in an attempt to avoid total knee arthroplasty. Final Result: The reviewers determined that the requested services are likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: Reviewers 1, 2, and 3 are board certified in orthopedic surgery 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

Findings:  The physician reviewer found that An enrollee has requested reimbursement for an advanced lipoprotein test. Current medical literature does not demonstrate that advanced lipoprotein testing adds significant actionable information to what is already known from a basic fasting lipid profile. There is a lack of randomized trials showing that therapies to correct any novel lipoprotein abnormalities, such as lipoprotein(a), have any effect on cardiovascular outcomes such as myocardial infarction, stroke or death. In this clinical setting, there is insufficient evidence to support the use of the service at issue, particularly given this patients low-risk based on atherosclerotic cardiovascular disease (ASCVD) criteria. Therefore, advanced lipoprotein test 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 advanced lipoprotein test at issue was not likely to have been more beneficial for evaluation of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the service at issue was not likely to have been more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned

A 46-year-old female enrollee has requested a board certified gynecologic oncologist to perform the requested services (including risk reducing salpingo-oophorectomy and specialized pathology examination of the specimens) for treatment of her BRCA2 positive.  Findings:  The physician reviewer found that The American College of Obstetricians and Gynecologists (ACOG) indicates that the surgical procedures for risk reduction include complete removal of the ovary and fallopian tube, pelvic washings, and thorough assessment of the peritoneal cavity with biopsies as indicated. Some patients will have an occult malignancy identified at thorough surgical sectioning of these ovaries and fallopian tubes. Overall, ACOG does not specify what type of provider should perform this type of surgery. However, a surgeon capable of complete removal of the ovary including skeletonization of the infundibulopelvic ligament to allow for division of that ligament away from the ovarian parenchyma and the ability to appropriately assess the peritoneal cavity is necessary. If gross evidence of a malignancy is encountered, the availability of a gynecologic oncologist at the time of surgery or for rapid referral is required. There is specialized pathologic assessment required, including the need for serial sectioning (2-3mm) of the entire ovary and fallopian tube. In this clinical scenario, involving a symptomatic patient with a high risk predisposition, a gynecologic oncologist as the primary surgeon is warranted. Therefore, the requested services are supported as medically necessary for treatment of this patients medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for magnetic resonance spectroscopy. Findings:  Two of the three physician reviewers found that magnetic resonance spectroscopy is an imaging modality that has been used for evaluation the brain for various conditions. However, studies have produced mixed results. As per the treating provider, the lesion appeared more vascular in nature, and this decreases the utility of this study. The proximity to bone in this patient further decreases the utility and reliability of this imaging modality. There is a lack of evidence to suggest that magnetic resonance spectroscopy would have been superior over conventional MRI of the brain. Therefore, magnetic resonance spectroscopy was not likely to have been of greater benefit than other methods of evaluating this patient. Final Result: The reviewers determined that the services at issue were 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 and 3 are board certified in neurology and are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a two-year-old male enrollee has requested authorization and coverage for speech therapy. The Health Plan has denied this request indicating that the requested therapy is not medically necessary for treatment of the enrollees expressive language delay.  Findings:  The physician reviewer found that this patient has an identified delay in expressive speech of greater than 50%. Speech therapy is indicated with any delay greater than 25%. Extensive review of the literature including a meta-analysis by Law, et al. noted the positive effect of speech and language therapy interventions for children with expressive phonological and expressive vocabulary difficulty. Feldman, et al. notes that treatment for language disorders is predicated primarily on the childs language profile and level of communication skills. According to the authors, approximately one-half of children delayed at two years catch up to peers by three years of age. Those children with mild to moderate disorders are more likely to resolve their delay compared to those with severe disorders. Children who participate in speech-language treatment show greater improvement than those children who receive no treatment. Gallagher, et al. evaluated speech and language interventions for 24 preschool children with specific language impairment. The authors found statistically greater improvement with intensive direct speech and language therapy delivered by speech and language therapists over an eight-month period when compared to no intervention or nursery-based intervention. As such, speech therapy is medically appropriate and necessary for this patient.
Appeal type: Medical Necessity
Decision: Upheld

The parent of a two-year-old male is requesting coverage for a cranial DOC band. The patient has been diagnosed with a cranial deformity secondary to left torticollis-plagiocephaly deformation sequence. The patients physician noted a difference in the patients cranial diagonal measurement of 0.5cm. A cranial DOC band was recommended. The Health Plan has denied coverage for the requested equipment on the basis it is not medically necessary for treatment of the patients condition.  Review of the current medical literature indicates most experts have not found benefit to band treatment after one year of age. Cranial band treatment is recommended for those with greater than 1cm differential, i.e., one ear greater than 1cm anterior over the other. Based on the records provided, the patient does not meet this criteria. In light of the evidence provided, cranial band treatment is not likely to be of benefit for this patients condition. Therefore, I have determined that the requested equipment is not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld

The parent of a 16-year-old male has requested a mastectomy for treatment of his gynecomastia.  Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested procedure in this clinical setting.  Per the submitted photographs, the grade of gynecomastia is unclear.  There is no documentation regarding how long this patient has had gynecomastia.  Gynecomastia is considered a normal variation of puberty and typically spontaneously regresses within 18 to 24 months.  If adolescents undergo surgery before or near completion of puberty, the hormonal imbalance that caused the gynecomastia may cause recurrence.  Generally, the use of mastectomy for gynecomastia in patients under the age of 18 or in those who are not yet at least 18 months after the end of puberty is not considered an acceptable alternative to nonsurgical forms of treatment.  Additionally, obesity causes gynecomastia by the conversion of androgens to estrogen in peripheral fat.  In such cases, the gynecomastia should first be treated by diet, exercise, and weight loss.
Appeal type: Experimental/Investigational
Decision: Overturned

A 51-year-old female enrollee has requested for speech therapy for treatment of her dysarthria and aphasia secondary to stroke.   Findings:  Three physician reviewers found that the submitted clinical evidence demonstrates this patient experienced a stroke with resultant deficits in language and speech. Speech therapy is a vital part of the rehabilitative process. As this patient has aphasia, this indicates a language processing problem that is best treated with speech therapy. By definition, all language issues, including verbal and auditory memory, are affected by left-hemispheric strokes in the left middle cerebral distribution. The records indicate the proper use of typical and standard speech therapy techniques in treating this aphasic patient. The type of speech therapy utilized in this case includes some cognitive techniques and is appropriate to treat the patients speech disorders.
Appeal type: Medical Necessity
Decision: Upheld

The patient is a 53-year-old woman with a 42-year history of type 1 diabetes mellitus. She is being managed by an endocrinologist on an insulin pump. In March 2003, the patients Hgb A1c was 7.1%. The submitted medical records include evidence of mild reflux esophagitis and chronic duodenitis with villous atrophy, thought to be secondary to celiac sprue based on biopsies performed three years ago. A consultation note from the patients transplant surgeon dated 8/22/03 notes only cataracts and retinopathy involving the left eye in the review of systems. The patient wishes to undergo pancreas-only transplantation. The Health Plan has denied authorization for the requested procedure on the basis that it is not medically necessary for treatment of the patients medical condition.Patients who receive only a whole body pancreas transplant face a higher risk of dying compared to patients awaiting the same procedure. In light of the associated risks of morbidity/mortality, it must be demonstrated that optimal medical management has failed before pursuing pancreas-only transplantation. Based upon the submitted information, there is not sufficient evidence that the patients metabolic status and microvascular status warrant pancreas-only transplantation. Therefore, I have determined that the requested procedure is not medically necessary for treatment of the patients medical condition at this time. The Health Plans denial should be upheld at this time. However, if the patients treating physicians provide evidence of frequent, acute and severe life-threatening complications such as ketoacidosis or severe hypoglycemia, rapid progression of microvascular disease, and failure of frequent monitoring of intensive insulin therapy with multiple doses, then the patients request for a pancreas-only transplant should be reconsidered.
Appeal type: Medical Necessity
Decision: Overturned

The patient has idiopathic short stature (ISS) in that he is below the 1st percentile for height and weight and has a poor growth velocity of 2.82 cm/year, but has normal growth hormone dependent IGF-1 and IGFBP-3 levels, normal thyroid tests, and a negative celiac screen. His predicted adult height based on a recent bone age of 11.5 years at a chronological age of 11 years and 3 months is 52. The patient has been examined by a pediatric endocrinologist who has recommended initiation of growth hormone therapy. The Health Plan has denied coverage for the proposed therapy on the basis that it is not medically necessary for treatment of the patients medical condition.As stated above, the patients predicted adult height is 52. As such, he fulfills the FDA guidelines of July 2003 for growth hormone therapy for ISS. The patients IGF screens document that he is not growth hormone deficient. He also fulfils the FDA intent that he be treated under the supervision of a pediatric endocrinologist. Growth hormone therapy for this patient is medically appropriate and indicated. Therefore, I have determined the requested therapy is medically necessary for treatment of the patients medical condition. The Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Adcirca at 50 mg daily. The enrollee has severe symptomatic pulmonary hypertension that after evaluation was thought to be idiopathic (World Health Organization [WHO] Group 1 pulmonary hypertension). Tadalafil (Adcirca) is FDA approved and indicated to improve exercise ability in WHO Group I PAH patients. According to researchers, in the PHIRST-1 trial, patients taking Adcirca 40 mg achieved a 33-meter improvement in six-minute walk distance compared to the placebo group and experienced less clinical worsening (defined as death, lung transplantation, atrial septostomy, hospitalization because of worsening PAH, initiation of new PAH therapy, or worsening WHO functional class) compared to the placebo group. researchers explain that current guidelines also consider tadalafil reasonable and appropriate treatment in this patient population. However, there is no indication in the medical records, or any of the documentation provided, to exceed the recommended dose of 40mg daily. Therefore, the requested medication dosage is not medically necessary for treatment of this patients condition. Final Result: The physician reviewer determined that the requested medication dosage is not medically necessary for treatment of the enrollees condition.Credentials/Qualifications: The physician reviewer is board certified in cardiology 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.