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

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement and prospective authorization and coverage for Femring 0.05 mg/24 hour vaginal ring. As noted in the medical literature, postmenopausal female patients should be treated for their symptoms. HRT in the form of estrogen and progesterone is the most studied form with ample data on its advantages and disadvantages. The preferred form of estrogen is 17 beta-estradiol, which is structurally identical to the main estrogen produced by the ovary, and this is the estrogen contained in Femring. In this case, the patients provider reports that the benefits of using HRT outweigh the risks of discontinuation. The provider reported concern over the patients significant mood deterioration without Femring treatment. The provider also noted that the patient has been treated with other formulations with a variety of adverse side effects. Per the North American Menopause Society (NAMS) recommendations, although some data suggest that HRT should be discontinued at the age of 60 to decrease cardiovascular risk, this recommendation may be modified when appropriate, as in the case of this patients vasomotor symptoms. For these reasons, Femring 0.05 mg/24 hour vaginal ring was and is medically necessary for treatment of this patient. Final Result: The reviewer determined that the medication at issue was and 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 obstetrics and gynecology 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 40-year-old female enrollee has requested for wireless capsule endoscopy for evaluation of her iron-deficiency anemia and obscure bleeding. Findings:  The physician reviewer found that Wireless capsule endoscopy (WCE) is a major advance in visualization of the small intestine. WCE offers the following potential advantages over other more broadly used imaging techniques. It offers the potential to directly visualize the entire mucosal surface of the small bowel. It has the ability to detect subtle superficial lesions not evident on traditional contrast radiographs. It is less invasive than conventional endoscopy. It does not require sedation or anesthesia. It is well accepted by patients. At the present time, WCE is approved for the evaluation of patients with obscure GI bleed, iron deficiency anemia with negative EGD and colonoscopy, and patients with suspected Crohn's disease and other small bowel diseases such as small bowel tumors, family polyposis syndrome and arteriovenous malformation.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Xeljanz. The Health Plan has denied this request indicating that the requested medication is considered investigational for treatment of the enrollee who has a history of psoriatic arthritis and alopecia universalis.Findings:  There is support in peer-reviewed medical literature as to the efficacy of the requested medication in this patients case. Alopecia areata is a chronic immunological disorder characterized by round or oval patches of non-scarring hair loss. Alopecia universalis is a form of alopecia areata which includes hair loss in eyebrows, eyelashes and facial hair. Other autoimmune diseases are also linked with alopecia areata. In addition, treatment is challenging and aims at the regrowth of hair. Although alopecia areata is not life threatening or painful, its onset and erratic nature disrupts and affects an individuals activities of daily living as well as affect their self esteem, body image, and/or self confidence. Xeljanz is an oral JAK 1/3 inhibitor approved for the treatment of moderate to severe rheumatoid arthritis. It has been also studied for treatment of psoriasis, inflammatory bowel disease, and other immunological diseases. Several recent reports in the literature provide evidence for the effectiveness of Xeljanz in the treatment of alopecia areata. The rational for hair regrowth was the data that the JAK inhibitor treats alopecia areata. Therefore, the requested medication Xeljanz is likely to be more effective than the standard therapy available for treating this patients medical condition.Final Result: Two of the three reviewers determined that the requested medication is 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:  All three reviewers are board certified in dermatology 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

Nature of Statutory Criteria/Case Summary: An enrollee has requested Epclusa 400 mg  100 mg, for treatment of the enrollees hepatitis C.  Findings: The physician reviewer found that the current medical evidence supports the requested medication regimen in this clinical setting.  According to 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 life expectancy less than 12 months due to non-liver-related conditions.  The recommendations apply regardless of fibrosis stage.  Per the guidelines, Epclusa for 12 weeks is recommended as first-line therapy for treatment-naive, genotype 3 patients.  A delay in treatment may result in decreased survival.  All told, Epclusa 400 mg  100 mg, one tablet daily for 12 weeks is medically indicated for the treatment of this patient.Final Result: The reviewer determined that the requested medication regimen 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

The patient is a 56-year-old female who reports loss of hearing and tinnitus in her right ear since approximately August 2004. In addition, she has experienced dizziness, which appears to have since resolved, but the tinnitus is persisting and is constant. An MRI performed in 2004 revealed no evidence of an acoustic neuroma or other pathology in cerebellopontine angles. There was a small right frontal convexity meningioma noted. Based upon the information provided, it appears the patient has been seen by an ENT specialist and a hearing aid has been recommended.The patient has requested authorization and coverage for acupuncture. The Health Plan has denied this request on the basis the requested therapy is not medically necessary for treatment of the patients condition.Tinnitus is usually described as a constant buzzing or ringing in the earsin this patients case, affecting her right ear only. Some of the causes of tinnitus include but are not limited to ear disease, excessive noise or some cardiovascular conditions such as anemia or aneurysm. Additionally, severe menopausal symptoms can cause dizziness and tinnitus. No known cause or trauma is indicated. The patients medical records reveal no benefit from antibiotics, antihistamines or anti-inflammatories. MRI reveals no acoustic neuroma; only a small right frontal convexity meningioma was noted which was not felt to be the cause of the symptoms.Although there have been mixed results using acupuncture to relieve/reduce the symptoms of tinnitus (based on various studies in the acupuncture literature) there is sufficient evidence to support a trial of acupuncture in this patient. The patient has been tried on multiple therapies without benefit. As such, a trial of acupuncture is medically reasonable and appropriate.  Based upon the information set forth above, I have determined that the requested therapy is medically necessary for treatment of the patients medical condition. The Health Plans denial should be overturned. The patient should undergo a trial of six acupuncture treatments at a frequency of twice a week for three weeks with re-evaluation at the end of that period.
Appeal type: Medical Necessity
Decision: Overturned

A 37-year-old male enrollee requested arthroscopic surgery on the left shoulder for medical treatment of his partially torn rotator cuff. Findings:  The physician reviewer found thatbased on the medical records, the requested left shoulder arthroscopic surgery is medically necessary for treatment of this patients MRI documented and clinically documented condition of superior to anterior labral tear associated with a paralabral cyst. It is not likely that further conservative care will be beneficial in the face of these objective findings. It is medically necessary for this patient to have arthroscopic shoulder surgery, repair of the SLAP lesion and repair of the 4.6 cm paralabral cyst as recommended by his provider.
Appeal type: Experimental/Investigational
Decision: Upheld

A 40-year-old female enrollee has requested for magnetic resonance neurography (MRN) of the lumbar/sacral plexus for evaluation of her sciatica. Findings:  Three physician reviewers found that MRN has been requested to investigate the cause of the patients peripheral sciatica and to rule out conditions such as peripheral nerve tumor or chronic nerve compression. To date, there have been only small studies with anecdotal case reports regarding the usefulness of MRN in this setting. The literature suggests that further investigation with larger study groups is needed to clearly delineate the utility of MRN in the evaluation of peripheral sciatica. The literature does not presently support MRN as a standard imaging study in this context.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for positron emission tomography (PET) scan. Findings:  Three physician reviewers found that there is sufficient support for the services at issue in this clinical setting. This patient has a difficult tumor to manage and to image after surgery and chemotherapy. Due to the chemotoxicity of the drug epirubicin, it was imperative to determine if the benefits of the drug outweighed the toxic effects. Thus, it was important to quantitatively measure the tumor response to epirubicin prior to continuing treatment with this toxic agent. Due to the propensity for local and distant metastases of this aggressive tumor and the difficulty in assessing tumor recurrence after such extended surgical and chemotherapy, PET was the imaging procedure of choice. Conventional imaging does not allow for the physiologic measurement of tumor activity, which is crucial in the face of prior extensive treatment. Therefore, PET scan was 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 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, 2 and 3 are board certified in diagnostic radiology 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

A 53-year-old female enrollee has requested a positron emission tomography/computed tomography (PET/CT) scan  for evaluation of her medical condition.  Findings:  The physician reviewer found that it is well established in the peer-reviewed literature that CA-125 testing is not effective as a screening test for ovarian cancer. WebMD states that, The CA-125 test is not recommended as a screening test for ovarian cancer at this time because it often has false-positive results. Further, researchers for UpToDate report that, Ovarian cancer cannot be diagnosed based upon the results of a CA-125 test. Many women with early ovarian cancer will have a normal CA-125 level. For this reason, the authors concluded that, CA-125 is not recommended as a standalone screening test for ovarian cancer. It has also been shown that elevated CA-125 can be secondary to non-malignant conditions. Physicians writing for UpToDate noted that, non-cancerous conditions can cause CA-125 to be elevated, including endometriosis, uterine fibroids, pelvic inflammatory disease, heart failure, and liver and kidney disease. In addition, a review of the peer-reviewed medical literature returned a paucity of support for the utility of a PET/CT scan in the evaluation of patients with an elevated CA-125 but no personal history of cancer. All told, an elevated CA-125 in a patient with no personal history of cancer is not specific for cancer. Further, PET/CT scans are not medically indicated for cancer screening. For these reasons, the diagnostic PET/CT imaging done on the date in question was not medically necessary or reasonable for evaluation of this patients medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for anthralin 1% cream. Researchers note that data on treatment options in pediatric alopecia areata are limited, and that prior results on the efficacy of anthralin in children with alopecia areata have been mixed. However, the authors noted that based on a retrospective study of 37 patients started on topical anthralin before age 17, topical anthralin provided the potential for significant scalp regrowth with minimal systemic effects. In this case, the patient presents with a history of alopecia universalis and has failed several standard therapies such as topical steroids, minoxidil, and squaric acid. There is a lack of evidence supporting the use of other standard therapies, which may be associated with side effects, Janis kinase (JAK) inhibitors in children, or systemic therapies, which may carry an unfavorable risk/benefit profile for children, over the requested medication. Therefore, anthralin 1% cream is likely to be more beneficial for treatment of the patients condition than any available standard therapy. Findings:  Three of the three physician reviewers found the requested for anthralin 1% cream is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the requested medication is 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: Physician reviewers 1, 2, and 3 are board certified in dermatology and are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Humira Pen Crohn-UC-HS starter 40 mg/0.8 mL pen IJ kit. Findings:  The physician reviewer found that the current medical literature supports the medical necessity of Humira in this clinical setting. Failure of tumor necrosis factor (TNF) inhibitors can occur for many reasons. This patient has failed Remicade given colonoscopy findings showing ongoing inflammation while on Remicade. In the ULTRA 1 trial, which was a high-quality randomized double-blind placebo-controlled trial, Humira proved safe and effective for induction and maintenance of remission of ulcerative colitis; it subsequently proved to increase maintenance of remission, mucosal healing, and quality of life over multi-year follow-up. A TNF inhibitor such as Humira is appropriate therapy over immunomodulators, which can take several months to induce remission.  The patient reports that he has already failed 6-mercaptopurine.  Additionally, American Gastroenterological Association guidelines for management of ulcerative colitis state that after failure of a TNF inhibitor such as Remicade, another TNF inhibitor (such as Humira) or the medication vedolizumab should be used; immunomodulators such as azathioprine and 6-mercaptopurine are useful as adjunct medications only.  For these reasons, the requested Humira Pen Crohn-UC-HS starter 40 mg/0.8 mL pen IJ kit is medically necessary for the treatment of this patient. Final Result: The reviewers 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: Physician 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

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for 12 physical therapy sessions. Overall, the documentation does not support that skilled physical therapy services are required to treat the patients illness or injury, improve or maintain her condition, or to prevent deterioration of the patients condition. The records do not report that the patients condition requires the services of a skilled physical therapist or require direct supervision of a skilled therapist. Physical examination on 12/14/18 did not reveal significant objective findings. In addition, the documentation does not include evidence of significant objective functional improvement from prior physical therapy visits to support additional services. Moreover, the patient has had extensive prior knee therapy and should be well versed in a home exercise program. Accordingly, the requested 12 physical therapy sessions are not medically necessary for treatment of this patients knee pain. Final Result: The reviewer determined that the requested services are not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in physical medicine and rehabilitation with subspecialty certification in neuromuscular medicine and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

The patient is a 38-year-old female who is two years post-operative from gastric bypass surgery for morbid obesity. Following the procedure the patient experienced complications. She is stated to have lost 100 pounds. The patient is seeking authorization for a panniculectomy. The Health Plan has determined the patient does not meet medical necessity criteria for the requested procedure. The Health Plans denial should be upheld. The submitted medical records do not demonstrate a panniculectomy is medically necessary. There is no significant evidence provided in the documents submitted that suggests an inflammatory process within the patients panniculus. In addition, there is no significant evidence of skin ulcerations, intertrigo, and utilization of conservative therapy. As such, there is no evidence that the proposed panniculectomy is reconstructive in nature or medically necessary. Therefore, I have determined that the requested procedure is not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned

The patient is a 54-year-old female who had 27-year-old silicone breast implants. Bilateral capsulectomy with implant removal was performed in December 2004. The operative report indicated that both implants were severely damaged with leakage of silicone outside of the silicone shell. Silicone granulomas were also present on the left. These findings are in contrast to an apparently benign pre-operative mammogram. The patient developed complications in the left breast (operative report indicates right breast) and a capsulectomy revision was performed in January 2005. The patients request for reimbursement for surgical procedures performed in December 2004 and January 2005 and related services was denied by the Health Plan based upon a determination that the procedures were not medically necessary.Although not recognized preoperatively, the operative note from December 2004 clearly describes bilaterally ruptured silicone implants. Removal of such implants is consistent with the recommendations of the FDA Advisory Panel and the breast implant manufacturer. The advisory states The diagnosis of rupture of a gel-filled breast implant is important because the release of silicone gel and fluid into the tissues may result in local complications. An intracapsular rupture may become extracapsular, and both are generally agreed to indicate the need for removal of the implant.  The American Society of Plastic Surgeons (ASPS ) supports this recommendation and it is their position that broken or failed implants, infection, implant extrusion, siliconoma, granuloma, or interference with the diagnosis or treatment of breast cancer are indications for reoperation. This patient had both ruptured implants and silicone granulomas. The implant removals were medically necessary. The bilateral capsulectomies were medically necessary as well as the literature suggests that retained capsules following silicone implant explantation can interfere with mammography and can lead to cysts and seromas.  Lastly, the capsulectomy revision performed in January 2005 was also medically necessary to treat the patients non-healing breast wound. This condition was presumably due to residual free silicone, and the wound was unlikely to close without removal of the foreign material. Ancillary services and pathology related to the capsulectomies should also be considered medically necessary.Based upon the information set forth above, I have determined the procedures at issue were medically necessary for treatment of the patients medical condition. The Health Plans denial should be overturned.