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

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the Decipher Gene Expression test. The National Comprehensive Cancer Network (NCCN) recommends molecular profiling post-biopsy for patients with low or favorable intermediate risk disease. Such testing may include the Decipher tumor based molecular assay. Retrospective studies have shown that molecular assays performed on prostate biopsy or radical prostatectomy specimens provide prognostic information independent of NCCN risk groups. Patients with clinically localized disease may consider the use of tumor-based molecular assays to guide treatment decision making. For these reasons, the Decipher Gene Expression test was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Final Result: One reviewer found that the Decipher Gene Expression test was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Two of the three 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: One reviewer is board certified in internal medicine with sub-specialty certification in medical oncology and is actively practicing. One Reviewer is board certified in internal medicine with sub-specialty certification in medical oncology and is actively practicing.  One Reviewer is board certified in internal medicine with sub-specialty certification in medical oncology and is 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: Upheld

The patient is a 30-year-old male with complaints of daytime hypersomnolence and fatigue. He reports snoring, waking up gasping for air, and difficulty going to sleep and staying asleep. The patient has an Epworth Sleepiness scare score of 10. An overnight polysomnography study obtained in December 2004 documents mild upper airway resistance, but no significant obstructive sleep apnea. Overall sleep efficiency was 85.3%. Apnea/hypopnea index (AHI) was 4.9. Oxygen saturation dropped from a baseline of 97% to a low of 93%. At the time of this study, the patient was 57 weighing 160 pounds. Therapeutic treatment options based upon the results of the polysomnogram included weight loss (if applicable), use of oral appliances, application of surgical techniques (if clinically indicated), and a second overnight sleep study for the purpose of CPAP titration. Another overnight polysomnography CPAP report was obtained. CPAP was titrated to 10 cm of water where all sleep disordered breathing events (apneas, hypopneas, and snoring) were eliminated. Sleep efficiency was 76%. The patient has requested authorization for a CPAP machine. The Health Plan indicates the patient does not meet medical necessity criteria for authorization of the requested equipment.Overnight polysomnography is used to evaluate sleep disordered breathing and diagnose significiant obstructive sleep apnea. The patients polysomnography results do not meet criteria for authorization of the use of CPAP for obstructive sleep apnea. The patient has an AHI of less than 5 with no associated comorbidities; as such, use of a CPAP device is not clinically indicated. 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: Overturned

Nature of Statutory Criteria/Case Summary:  An enrollee has requested Harvoni 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 current guidelines, treatment-naive genotype 1 patients should be treated with Harvoni. Patients with viral load of less than 6,000,000 IU/mL can be treated for eight weeks. These guideline recommendations are based on multiple randomized clinical trials. For these reasons, the requested treatment with Harvoni is medically necessary for the treatment of this patients hepatitis C infection. 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: Experimental/Investigational
Decision: Overturned

A 73-year-old male enrollee has requested for stereotactic radiosurgery for treatment of his lung cancer.   Findings:  Three physician reviewers found that the standard of care in this situation is normally surgical intervention. However, this patient is a high risk for surgery. The alternative curative treatment is stereotactic body radiation therapy (SBRT). Although there are no randomized trials available, there is sufficient evidence in peer-reviewed medical literature to support the efficacy of SBRT.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested authorization and coverage for a custom lightweight wheelchair with a fabric cushion. The submitted documentation does not support that the requested durable medical equipment is medically necessary. Pediatric patients with Ehlers-Danlos may, at times, require assistive devices for ambulation; however, the need for a wheelchair would be very unusual for this reason. If a wheelchair were indicated for any patient, a detailed physician history/examination and physical therapy/wheelchair seating evaluation would be essential.In this case, the patient had a high end mobility assessment performed that noted that the patient was a functional ambulator and that she would not be bed or chair confined without the use of a wheelchair. The records reflect that the patient does not utilize her current wheelchair 90 percent of the time. She has reported a preference for trying to ambulate without any assistive devices. She is noted to be actively participating in extracurricular activities. The available records do not document any musculoskeletal or neurological exam to suggest an impairment requiring a wheelchair. Under these circumstances, the requested custom lightweight wheelchair with a fabric cushion is not medically necessary to treat 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 physical medicine and rehabilitation and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for a sock butler. Stroke is known to result in severe, chronic functional deficits reducing independence with activities of daily living especially bathing, grooming, and dressing. In some cases, a patient who has sustained a stroke or has another disabling medical condition, can benefit from durable medical equipment that increases their mobility and ability to perform their own self-care tasks. Various types of durable medical equipment should be utilized when appropriate to enhance the patients independence and reduce the burden of care, including the number of hours of formal or informal caregiver assistance provided. Based on the records provided for review, there is a lack of documentation that the patient is physically and safely able to use the requested dressing aide to help don her socks and thereby enhance her independence. Accordingly, the requested sock butler is not medically necessary for treatment of this patient. Final Result: The reviewer determined that the requested device 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 physical medicine and rehabilitation and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for 120 pills per month of Nucynta 50 mg (once every six hours). The submitted documentation does not support that the requested medication regimen is medically necessary. In the documentation available for review, no objective treatment goals for pain and function are noted for the requested medication, and several requirements for opioid prescribing have not been documented. The need to use opioids as the primary medication treatment strategy for pain has not been established in this documentation. The CDC states that when starting opioid therapy for chronic pain, clinicians should prescribe immediate-release opioids instead of extended-release/long-acting (ER/LA) opioids. The CDC also states when opioids are started, clinicians should prescribe the lowest effective dosage. Clinicians should use caution when prescribing opioids at any dosage, should carefully reassess evidence of individual benefits and risks when considering increasing dosage to 50 morphine milligram equivalents (MME)/day, and should avoid increasing dosage to 90 MME/day or carefully justify a decision to titrate dosage to 90 MME/day. In this case, the patient was recently taking 160 MME/day. No medical evidence based rationale is given by the physician or the patient, nor is there recognition of the long term consequences with the continual increase in opioids. Risk and benefit analysis must be done to justify the requested level of 80 MME/day. No clear objective goals with this high of a dose of opioid has been established by the physician or the patient. Moreover, pure mu agonists are not considered evidence based treatments for Fibromyalgia, not to mention the adverse effects in Fibromyalgia patients specifically. Also, not all non-opioid medications classes have been documented to have been optimized or tried. Under these circumstances, the request for 120 pills per month of Nucynta 50 mg (once every six hours) is not medically necessary for treatment of the enrollees medical condition.Final Result: The reviewer determined that the requested medication regimen 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 anesthesiology, with subspecialty certification in pain management. 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 43-year-old male enrollee has requested lumbar epidural steroid injections for treatment of his back pain.  Findings:  The physician reviewer found that this patient demonstrates signs of lumbar radiculopathy.  An MRI revealed signs of lateral recess and L5 foraminal narrowing. Surgery was recommended several years ago, and the patient has attempted conservative care. This patients current symptoms have failed to respond to medication therapy.  The treating physician has recommended lumbar epidural steroid injections, and the patients current pain level limits his ability to participate in physical therapy at this time. The current medical evidence supports lumbar epidural steroid injections in this clinical scenario. Based upon the current medical literature, the requested services are medically indicated in this patients case. All told, the requested lumbar epidural steroid injections are medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for endovenous ablation therapy of incompetent vein, extremity, inclusive of all imaging guidance and monitoring, percutaneous, radiofrequency, first vein treated left greater saphenous vein and, stab phlebectomy of varicose veins, one extremity, more than 20 incisions. Findings:  The physician reviewer found that the recommend compression therapy for patients with symptomatic varicose veins, and endovenous thermal ablation for treatment of an incompetent great saphenous vein. In this case, the submitted records noted paresthesias affecting the left foot and toes, possibly neuropathic in nature. The documentation did not describe symptoms within the distribution of the veins to be treated, multiple episodes of superficial thrombophlebitis, or mention phlebitis. The records did not reflect trials of conservative therapy for varicose veins or edema. In this clinical setting, given the lack of reported symptoms in the distribution of veins to be treated and lack of documentation showing conservative efforts to treat the patients edema, the requested services are not medically indicated. Therefore, endovenous ablation therapy of incompetent vein, extremity, inclusive of all imaging guidance and monitoring, percutaneous, radiofrequency, first vein treated left greater saphenous vein and, stab phlebectomy of varicose veins, one extremity, more than 20 incisions are not medically necessary for the treatment of this patient.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 vascular surgery 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 parent of a seven-year-old female enrollee has requested speech therapy two times per week for 36 weeks (30 minute sessions for treatment of the enrollees global developmental delay.  Findings:  The physician reviewer found that there are many conditions in which the corpus callosum develops abnormally. These are typically diagnosed with neuroimaging and are often discovered when a child presents with a developmental delay. These conditions range from dysgenesis of the corpus callosum to hypoplasia of the corpus callosum to partial agenesis of the corpus callosum and complete agenesis of the corpus callosum.  The corpus callosum is a large connective pathway connecting the right and left cerebral hemispheres. Defects in the corpus callosum can lead to cognitive impairments as well as motor impairments. Children with disorders of the corpus callosum often have global developmental delays including speech and language delay.  The role of speech and language therapy in children with developmental disabilities is well-published in the medical literature.  Given this patients diagnosis of dysgenesis of the corpus callosum and global developmental delay, the requested speech therapy is medically indicated.  The current medical evidence supports speech therapy in this clinical scenario.  All told, the requested speech therapy, two times per week for 36 weeks (30 minute sessions), is medically indicated for this patient.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: A patient has requested authorization and coverage for Mavyret 100 mg-40 mg, three tablets daily for eight weeks. The Health Plan has denied this request indicating that the requested medication regimen is not medically necessary for treatment of the patients chronic hepatitis C virus, genotype 1a. The submitted documentation supports the medical necessity of the requested medication regimen. According to the most recent joint guidelines, all patients with chronic hepatitis C should be treated except those with limited life expectancy due to nonliver-related conditions. The guidelines recommend that all patients should be treated, regardless of fibrosis stage. The guidelines recommend that non-cirrhotic, treatment naive, genotype 1a patients should be treated with Mavyret for eight weeks. ASSLD/IDSA guidelines cite data showing reduced survival with delayed treatment. For these reasons, Mavyret 100-40 mg, three tablets daily for eight weeks is medically necessary 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: Upheld

A 49-year-old female enrollee has requested intensive speech therapy for treatment of the enrollees aphasia status post stroke.  Findings:  The physician reviewer found that ongoing speech therapy for chronic aphasia is effective in well selected patients (Moss and Nicholas). However, the duration and intensity of the therapy necessary to achieve outcomes has not been established (Meinzer, et al). It is unclear whether intensive speech therapy achieves sustainable goals or promotes a brief increase that is not sustained without continued practice from the patient (Moss and Nicholas). This patient has a stable speech pattern that shows little change from the year indicated. The records indicate that she showed very moderate progress when attending the intensive speech program at the specified facility and did not reach her goals. The Health Plan has offered outpatient therapy and made a number of recommendations to the patient. Her speech has stabilized and there is no evidence in the literature the specific activities and intensive therapies at the independent facility are superior to the range of services available within the Health Plan. Therefore, the requested services are not medically necessary for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: A enrollee has requested authorization and coverage for panniculectomy. Findings:  The physician reviewer found that based on the available documentation, the requested panniculectomy is not medically necessary for treatment of this patients excess abdominal skin. The medical records do not provide any documentation from the patients providers that describe ongoing clinically significant dermatologic problems that have either never responded to physician directed topical therapy or despite initial response, have recurred and caused significant functional impairment. Overall, supervised medical management for rashes is not documented in any of the progress notes. Moreover, the patient has not reportedly had any ulcerations, panniculitis or sepsis from her infections. Physician supervised treatment is the simplest and safest method of managing this patients problems, and conservative treatment with appropriate hygiene and topical medications has a reasonable likelihood of correcting the condition. In addition, the requested panniculectomy is not reconstructive in nature. The patients condition does constitutes an abnormal structure of the body caused as a result of weight loss surgery in treating the patients obesity. However, the requested surgery has not been requested to improve function, and will not create a more than minimal improvement in the patients appearance. Therefore, conservative, non-operative treatment is recommended such as improved hygiene, topical creams or powders, and watchful waiting. Surgical lipectomy is reserved for patients who have failed optimal medical management for intertrigo, which is not documented to be the case for this patient. For these reasons, the requested panniculectomy is not medically necessary and is not reconstructive in nature for treatment of this patients excess abdominal skin. Final Result: The reviewer determined that the requested surgery is not medically necessary and is not reconstructive in nature for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in plastic surgery 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 authorization and coverage for bronchial thermoplasty for treatment of the enrollee, who has been diagnosed with severe persistent asthma. Findings:  Three physician reviewers found that based on the submitted documentation, this patient is a good candidate for bronchial thermoplasty. She is still symptomatic despite maximal medical therapy. She reportedly has been compliant with her treatment and does not have another condition that can explain her symptoms. She has no other condition that contraindicates or increases the risk of bronchial thermoplasty. Multiple studies have shown that although bronchial thermoplasty is not curative, it does decrease symptoms, improve the quality of life, and decrease the use of medications and frequency of exacerbations.  Bronchial thermoplasty has been found to be safe in follow-up studies up to five years following the procedure. Thus, bronchial thermoplasty is likely to be more efficacious than other modalities for treating this patients condition. 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: All three reviewers are board certified in internal medicine with sub-specialty certification in pulmonary disease 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.