Persius/imr-appeals huggingface dataset:
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollees parent has requested reimbursement and prospective authorization and coverage all or any of the Food Tolerance Induction Program services (CPT 99215 and 95076). Current medical evidence has not established the efficacy of tolerance induction for the management of food allergies. Sicherer and Sampson note that the diagnosis of food allergy is largely reliant on medical history, tests for sensitization, and oral food challenges. The authors further note that management remains largely based on allergen avoidance. While it is standard of care to measure immunoglobulin E (IgE) levels to specific foods in question that the patient may have an allergic reaction to, there is a lack of support for an extensive array of blood tests examining foods to which the patient has not had a reaction. Additionally, there is a lack of support for oral desensitization to a multitude of foods to which the patient does not have a history of anaphylaxis. There is a lack of evidence in current medical literature supporting tolerance or sustained unresponsiveness with oral food desensitization. Therefore, Food Tolerance Induction Program services (CPT 99215 and  95076) were not and are not likely to be more beneficial for the treatment of the patients condition than any available standard therapy.Findings:  Three of the three physician reviewers found the Food Tolerance Induction Program services (CPT 99215 and  95076) were not and are not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the services at issue were not and are not likely to be 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 allergy and immunology and is actively practicing. Physician reviewer 2 is board certified in allergy and immunology and pediatrics and is actively practicing. Physician reviewer 3 is board certified in allergy and immunology 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: Overturned

The patient is a 42-year-old female who requested reimbursement for surgical procedures she underwent on 11/18/03. The Health Plan has denied this request indicating the surgery was not medically necessary for treatment of her pelvic pain. The patient has a 20-year history of pelvic pain. She has had multiple laparoscopic procedures for excision of endometriosis without significant improvement. In addition, she has been treated with pain medication and antidepressants.Review of the submitted clinical information reveals the diagnostic laparoscopy was medically appropriate. The lysis of adhesions, left salpingoectomy, and excision of the endometriosis are within the standard of practice for patients such as this patient. The issue of a hernia repair would have been best left to a preoperative MRI and consultation with a general surgeon and was not medically necessary based upon the information provided. The pudendal nerve block was not medically necessary or appropriate since long-term benefit is not expected. The hysteroscopy and D & C were medically warranted because of a thickened endometrial on sonogram. The uterine suspension and myomectomy did not have any medical indication. Plication of the round ligaments is not an effective method to treat retroversion and myomectomy of an asymptomatic fibroid was not medically warranted.Accordingly, I have determined a portion of the procedures at issue were within the standard of practice and medically necessary for treatment of the patients condition. Specifically, the diagnostic laparoscopy, lysis of adhesions, left salpingoectomy, excision of endometriosis, hysteroscopy, and D & C are were medically necessary for treatment of the patients medical condition. The other procedures performed on 11/18/03 were not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be partially overturned.
Appeal type: Experimental/Investigational
Decision: Overturned

A 29-year-old female enrollee has requested cryoablation of tumor for treatment of her left breast fibroadenoma. Findings:  Two physician reviewers found that in this patients case, the requested services are likely to be more efficacious than other treatment options.  The current medical evidence supports the requested services in this clinical setting.  Cryoablation has been shown to be an effective treatment for breast tumors.  The medical literature has demonstrated the safety of these requested services for the treatment of this patients condition.  When compared to surgical excision, cryoablation has the advantage of little to no scarring.  Thus, cryoablation of tumor is likely to be more effective than other modalities for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary:  An enrollee has requested Rituxan for treatment of her medical condition.   The physician reviewer found that there is sufficient support for the requested medication in this patients case.  The records indicate that the patient has stiff person syndrome, a rare autoimmune disorder, with anti-glutamate decarboxylase antibodies.  She has been treated with diazepam and monthly intravenous immunoglobulin without adequate response.  Due to the rarity of this disorder, there is a lack of adequately powered, placebo-controlled, double-blind randomized trials.  The literature indicates that benzodiazepines are considered first-line therapy to reduce stiffness.  It is medically reasonable to offer a trial of Rituxan in this case, given the failure of intravenous immunoglobulin and diazepam.  Plasmapheresis and mycophenolate mofetil are also noted to be potentially beneficial, but there is no proven stepwise strategy available in the management of this disorder.  All told, Rituxan 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 neurology 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 parent enrollee has requested authorization and coverage for two, four pack boxes of epinephrine 0.15 mg/0.15 mL injectable autoinjector, not from a lot containing particulate matter. The first-line of treatment for patients experiencing anaphylaxis is epinephrine. Studies of anaphylaxis have identified important risk factors. Based on a national registry, several risk factors for anaphylaxis from foods have been identified. As anaphylactic episodes might require more than one dose of epinephrine, all patients should carry two packs of epinephrine auto-injectors. This patient has experienced prior severe allergic reactions and remains at high risk for anaphylaxis. Accordingly, the requested two, four pack boxes of epinephrine 0.15 mg/0.15 mL injectable auto-injectors, not from a lot containing particulate matter, are supported as medically necessary for treatment of this patients medical condition. Final Result: The reviewer determined that the requested medication quantity 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 allergy and immunology with expertise in pediatric allergy and immunology 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 61-year-old female enrollee has requested duloxetine (Cymbalta) for treatment of her chemotherapy induced peripheral neuropathy.  Findings:  The physician reviewer found that Cymbalta is medically necessary treatment for treatment of this patients medical condition. The patient has tried and failed to benefit from standard therapy. Additionally, the patients medical condition is both chronic and seriously debilitating. Cymbalta is supported in the peer-reviewed medical literature as a safe and effective treatment for combined disorders of chronic joint pain, neuropathy and depression. Raskin and colleagues performed a multi-center double-blind randomized controlled trial to assess the efficacy and safety of Cymbalta on the reduction of pain severity in patients with diabetic peripheral neuropathy. The study demonstrated that Cymbalta was superior to placebo. The authors concluded that Cymbalta was safe and effective in the management of diabetic peripheral neuropathy. Kajdasz and colleagues performed a post hoc analysis and reported that Cymbalta was effective and well tolerated for the management of peripheral neuropathic pain. Consistent with these findings, the requested Cymbalta is medically necessary for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patients parent has requested authorization and coverage for consultation with a cardiac electrophysiologist, magnetic resonance imaging (MRI) of the heart, electrocardiogram, and/or blood tests (thyroid stimulating hormone (TSH), T3, T4, TSH-thyroid stimulating immunoglobulin, N-terminal pro-B-type natriuretic peptide (Nt-proBNP), troponin T, and plasma ceramides). Based on the available documentation, the requested consultation with a cardiac electrophysiologist is indicated for further evaluation of this patients medical conditions. The patients clinical picture may be clearer with additional information about her brothers condition. If the patients brother sustained an episode of syncope or aborted sudden cardiac death, this could support one of several possible genetic disorders such as polymorphic ventricular tachycardia (VT), Brugada syndrome, Wolff Parkinson White (WPW) syndrome or other supraventricular tachycardias, early depolarization syndrome, and short QT syndrome. A family history of sudden cardiac death (SCD) in the absence of apparent structural heart disease is associated with an increased risk for primary SCD. It is reasonable for this patient to undergo an evaluation by a cardiac electrophysiologist to assess for these possibilities. Overall, the records do not support an indication for MRI of the heart, electrocardiogram, or the blood tests requested by the patients caregiver. Advanced imaging and laboratory testing performed as part of a patients work-up is based on the clinical judgment of the patients providers. The requested consultation will allow the provider to determine whether additional imaging and/or specific laboratory testing would be beneficial. In the absence of a current indication for the requested MRI of the heart, electrocardiogram, and blood tests, these services are not medically necessary for this patient. Given these findings, the requested consultation with a cardiac electrophysiologist is medically necessary for evaluation of this patient while the requested MRI of the heart, electrocardiogram, and blood tests (TSH, T3, T4, TSH-thyroid stimulating immunoglobulin, Nt-proBNP, troponin T, and plasma ceramides) are not medically necessary for this patient. Final Result: The reviewer determined that a portion of the requested services is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be partially overturned. Credentials/Qualifications: The reviewer is board certified in internal medicine with subspecialty certifications in cardiovascular disease and 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: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary:  An enrollee has requested Harvoni for 24 weeks for treatment of her hepatitis C virus.  Findings:  The physician reviewer found that according to the joint guidelines issued by the American Association for the Study of Liver Diseases (AASLD) and the Infectious Diseases Society of America (IDSA), all patients with chronic hepatitis C should be treated except those with limited life expectancy due to non-liver-related conditions.  The patient failed therapy in the distant past, but which therapy is not reported. Per guidelines, non-cirrhotic genotype 1 patients who have failed either interferon-based therapy (which was the primary U.S. Food and Drug Administration (FDA)-approved therapy at that time) or an interferon regimen with a protease inhibitor should be treated with Harvoni for 12 weeks. These guideline recommendations are based on multiple randomized clinical trials, and the medication is FDA-approved for all patients with chronic hepatitis C genotype 1 regardless of fibrosis stage (Afdhal, et al, Lawitz et al). The guidelines also recommend the use of Viekira Pak and ribavirin in treatment-experienced genotype 1b patients, and no clear contraindications to this regimen are provided in this case. For these reasons, treatment with Harvoni for 12 weeks or Viekira Pak for 12 weeks are supported, but the requested treatment with Harvoni for 24 weeks is not supported as medically necessary for the treatment of this patients hepatitis C infection.   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

The patient is a 48-year-old male with hepatitis C type 1 who was previously treated with an interferon formula and did not respond. The patient was on Pegasys and Copegus and has had a one-fold drop in viral load after three months of therapy. It has been recommended the patient be continued on Pegasys and Copegus. The Health Plan has denied authorization for the proposed therapy on the basis it is not medically necessary for the patients condition.Based upon a study by Fried et al., only 3% of patients who did not experience a 2-log drop by the end of 12 weeks had sustained viral response by the end of the treatment course. This study was done in naive patients. This patient has not responded to the initial therapy. In light of these findings, there is no medical justification for continuation of Pegasys and Copegus for treatment of the patients hepatitis C virus. Therefore, I have determined that the requested therapy is not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for the brand name medication, Copaxone. Researchers conducted a 15-month study to evaluate the efficacy, safety, and tolerability of switching from branded Copaxone to generic glatiramer acetate (GTR). They concluded that the efficacy and safety of GTR was maintained over two years, and that switching from branded Copaxone to GTR was safe and well tolerated. Cohen and colleagues also found that as treatment for relapsing-remitting multiple sclerosis, glatiramer acetate generic drug and brand drug had equivalent efficacy, safety, and tolerability. In this case, the patient has been diagnosed with multiple sclerosis and had been taking Copaxone for two months. The documentation submitted does not indicate the patient is allergic to or intolerant of the generic form of the medication. Given that current medical literature supports the efficacy, safety, and tolerability of the generic medication, and that there is no evidence suggesting that the generic medication would be less effective or cause an allergic reaction for this patient, the requested branded form of the medication is not medically indicated. Therefore, the brand name medication, Copaxone 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 neurology 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 49-year-old female has requested sacroiliac (SI) joint fusion using the iFuse implant for treatment of her sacroiliitis and lumbago.  Findings:  Three physician reviewers found that the patient has been diagnosed with sacroiliitis, not elsewhere classified, lumbago, and autoimmune disorder. A neurosurgery consultation note documents persistent left sacroiliac (SI) pain. A computed tomography (CT) of the lumbar spine  demonstrated Baastrups disease at L4-5, a 1 mm diffuse disc bulge at L4-5, mild to moderate degenerative facet hypertrophy bilaterally at L5-S1 with mild right neural foraminal narrowing, and right adnexal cyst versus free fluid in the cul-de-sac.The patients pain is noted to originate in the lower back. The patient has had multiple falls. The patient has been treated with acupuncture, chiropractic therapy, physical therapy (PT), and yoga. The patient was treated with radiofrequency thermal coagulation (RFTC) of the right lowest lumbar facet joint medial branch nerves with injection under fluoroscopic guidance. The providers notes describe complaints of lumbar radicular pain worse on the left at L5-S1 from neural foraminal stenosis (NFS) and stenosis as well as degenerative disc disease. The patients neurological examination on that date revealed diminished sensory to light touch bilaterally at L5, positive lumbar facet loading, and otherwise normal exam with 5 of 5 strength in the upper and lower extremities. The providers assessment was SI joint dysfunction that partially responded to therapeutic RFTC injection. The provider has recommended treatment consisting of a left SI fuse procedure. There may well be an element of pain originating from the SI joint but some of the pain may well also originate from the lumbar spine. The patients area of pain, symptoms, exam findings and imaging suggest that there may well be a component of symptoms originating from the lumbar spine. Moreover, there is not yet sufficient evidence to support that the requested SI fusion is likely to produce a better outcome than available standard therapies for SI joint pain/dysfunction.
Appeal type: Medical Necessity
Decision: Upheld

The parent of a two-year-old male enrollee has requested  circumcision for treatment of the enrollees phimosis. Findings:  The physician reviewer found that circumcision is a treatment for phimosis in patients who fail the aforementioned management and is likely to be successful in refractory cases (Robinson, et al.). In cases in which the steroid treatment fails, a follow-up visit with the provider and attempt at repeat treatment is standard of care. A circumcision would only be indicated for true failure of steroid therapy. In this case, the clinical documentation does not demonstrate the patient had undergone sufficient treatment attempts with steroid therapy to establish the failure of such therapy. All told, the circumcision performed was not medically necessary to treat the patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld

A 21-year-old male enrollee has requested out-of-network psychological evaluation and intensive outpatient psychotherapy (IOP) for the treatment of his obsessive compulsive disorder (OCD). Findings:  The physician reviewer found that the Health Plan recommended pharmacotherapy, individual psychotherapy and OCD group therapy. The care recommended by the Health Plan is consistent with practice guidelines for treatment of patients with OCD as specified by the American Psychiatric Association. It incorporated appropriate pharmacotherapy as well as individual psychotherapy and OCD group therapy. Accordingly, the recommendation made by the Health Plan was appropriate to meet the patients treatment needs.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary:  An enrollee has requested Sovaldi for treatment of his 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.  Per the guidelines, treatment-naive genotype 2 patients should be treated with Sovaldi and ribavirin for 12 weeks.  These guideline recommendations are based on multiple randomized clinical trials, and the medication is U.S. Food and Drug Administration (FDA) approved for all patients with chronic hepatitis C, genotype 2 regardless of fibrosis stage. For these reasons, Sovaldi 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: Upheld

A sixty-three year-old male diagnosed with plantar fasciitis is requesting authorization of prolotherapy.  Reviewers Findings:  The reviewing physician found that the peer-reviewed literature does not support the premise that prolotherapy offers a statistically proven advantage for optimal recovery.  The reviewing physician found that the Health Plan denial should be upheld.