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

A 60-year-old male enrollee has requested a nuclear cardiology scan for medical evaluation of his chest pain and shortness of breath.  Findings:  The physician reviewer found that based on the records provided, this patient has known coronary disease but no ischemia on stress echocardiography performed on the date indicated and no symptoms or objective findings concerning for ischemia on follow-up clinic visits. In this circumstance of a clinically stable patient with favorable stress testing results less than two years ago, repeat stress testing is not indicated and not considered standard of care in the medical community. The current guidelines that are endorsed by several national organizations also do not recommend repeat stress testing in this clinical setting (Hendel, et al). Generally, routine screening stress testing has not been shown to improve cardiac outcome, even in patients with high coronary risk (Young, et al). All told, the requested nuclear cardiology scan is not medically necessary for evaluation of his medical condition.
Appeal type: Medical Necessity
Decision: Upheld

A 30-year-old female enrollee requested intensive outpatient program services for medical treatment of her behavioral health conditions.  Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the services.  The submitted records indicate that the patient was making progress.  The final note indicated an increase in weight, 90-100% of meal plan adherence, and no binging or purging.  Although the patient was anxious and restricted in affect, there were no acute psychiatric safety issues or concerning symptomatologies such as psychosis, cognitive impairment, homicidal ideation or suicidality.  Her medications had been streamlined and were managed by a psychiatrist in the community.  The patient was working 20 hours per week, and she intended to resume a second job.  Based on the submitted records, the patient had improved.  She was adhering to a meal plan.  She had gained weight and was not binging or purging.  In sum, intensive outpatient program services were not medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Lyrica. Researchers describe diabetic peripheral neuropathy as a common cause of neuropathy that is unrelenting in nature, which can significantly affect quality of life. Researchers note that pregabalin is a first-line treatment in major international guidelines on the management of painful diabetic neuropathy. In this case, the patient has been diagnosed with diabetic peripheral neuropathy. The provider has prescribed Lyrica, a first-line therapy for the treatment of painful diabetic neuropathy. Therefore, Lyrica is medically necessary 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: Experimental/Investigational
Decision: Upheld

A 57-year-old male enrollee requested proton beam therapy for medical treatment of his medical condition.  Findings:  Three physician reviewers found that in this patients case, the requested services are not likely to be superior over other treatment modalities.  The current medical literature has not established the superior efficacy of proton beam therapy for the treatment of this patient.  Palliative therapies which have been administered for individuals with this patients condition include external beam radiotherapy, brachytherapy, systemic chemotherapy, radiofrequency ablation, and transarterial chemoembolization or radioembolization.  Due to the ability to deliver higher doses of radiation directly to tumor, intensity modulated radiotherapy and stereotactic body radiotherapy have also been used in this clinical setting.  Based upon the available evidence, proton beam therapy is not likely to be more advantageous than other available forms of radiation in terms of outcome.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: A male enrollee has requested authorization and coverage for Harvoni 90-400 mg for eight weeks for treatment of the enrollees 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 (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. This applies regardless of fibrosis stage, and advanced fibrosis is not required for treatment. Per guidelines, treatment-naive, genotype 1 patients should be treated with Harvoni. Patients with viral loads less than 6,000,000 IU/mL can be treated for eight weeks. These guideline recommendations are based on multiple randomized clinical trials. AASLD/IDSA guidelines cite data showing reduced survival with delayed treatment.  Therefore, Harvoni 90-400 mg 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: Experimental/Investigational
Decision: Overturned

A 21-year-old female enrollee has requested radiofrequency neurolysis for treatment of her complex regional pain syndrome. Findings:  Three physician reviewers found that radiofrequency neurolysis was likely to be more beneficial for treatment of this patients medical condition, as standard therapy had been attempted and failed to relieve the patients left lower extremity pain. Although there is limited data studying radiofrequency neurolysis in the treatment of complex regional syndrome, effective results and lower risks make it a beneficial treatment when standard therapy has failed. The patient had a positive response to lumbar sympathetic blocks, however these results were noted to be temporary. All told, the patient was an appropriate candidate for treatment with radiofrequency neurolysis and is likely to continue to benefit from this modality.
Appeal type: Experimental/Investigational
Decision: Overturned

A 49-year-old male enrollee, with a history of osteoarthritis in both knees, has requested coverage for repeat Orthovisc injections.  Findings:  Two physician reviewers found that at this juncture repeat Orthovisc injections are likely to prove beneficial in terms of offering the patient some degree of intermediate relief. In light of the reported success following his original Orthovisc injections, Orthovisc is a reasonable option to help delay the need for total knee arthroplasty, which would otherwise be the next appropriate step.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for HP Acthar Gel 80 unit/ml. The submitted documentation fails to demonstrate the medical necessity of the requested medication. Although corticosteroids are used as a first-line therapy for the treatment of polymyositis, these medications can have various side effects, including osteoporosis. There are standard steroid sparing treatments for polymyositis, including methotrexate and CellCept as well as azathioprine, calcineurin inhibitors, intravenous immune globulin (IVIG) and rituximab. Furthermore, physical therapy is an important part of the polymyositis treatment plan.In this case, the patient has osteoporosis related to steroid use and does need to utilize corticosteroid sparing therapy for the treatment of her osteoporosis. She has previously been treated with methotrexate and then CellCept for her polymyositis. The medical records indicate that the patient is using CellCept 500 mg, one tablet, twice daily, which is a low dose that can be further optimized to achieve control of the disease. In addition, the patient has not utilized other usual therapies for polymyositis, such as azathioprine, calcineurin inhibitors, IVIG or rituximab. Also, the medical records do not indicate that the patient is participating in regular physical therapy. Therefore, Acthar Gel 80 unit/ml is not medically necessary for the treatment of the patients polymyositis.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 a sub-specialty certification in rheumatology 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 19-year-old female enrollee has requested for residential treatment center (RTC) services for treatment of her behavioral health issues.  Findings:  The physician reviewer found that applying the Milliman guidelines for admission and treatment at the RTC level of care, the patient must manifest symptoms and behaviors which represent deterioration from their usual status and include either self-injurious or risk taking behaviors that risk serious harm and cannot be managed outside of a 24-hour structured setting. This patient meets these criteria. Her mental health deteriorated throughout her previous state as a college student and attempted suicide. In the medical literature, Kaplan and Sadock state that, impairment from the disorder and the risk of suicide are greatest in the young-adult years and gradually wane with advancing age. By this definition, the patient is in the high-risk group for self-harm.  Consistent with these facts and the Milliman guidelines, this patient meets the medical necessity criteria for RTC.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for the MiniMed 670G insulin delivery system with hybrid closed loop technology. Findings:  Two of the three physician reviewers found that a continuous glucose monitoring system is one of several U.S. Food and Drug Administration (FDA) approved devices that record blood sugar levels at repeated intervals throughout the day and night. The main advantage of continuous glucose monitoring is that it can help identify fluctuations and trends that would otherwise go unnoticed, thereby maintaining tight glycemic control and preventing hyperglycemia and hypoglycemia. It can capture dangerously low overnight blood sugar levels which often go undetected, reveal high blood sugar levels between meals and show early morning spikes in blood sugar.  Studies have shown that use of a continuous glucose monitoring system can help optimize glycemic control and can lead to even greater improvement when used in conjunction with insulin pump therapy.  The FDA recently approved the MiniMed 670G device, which is a hybrid closed-loop insulin delivery system for use in patients who are at least 14 years of age with type 1 diabetes. The system uses an algorithm to automatically adjust basal insulin doses based on readings from a continuous glucose monitor. This patient has suboptimal glycemic control with her current insulin pump with a high degree of variability and will likely benefit from the requested device. In sum, the requested MiniMed 670G insulin delivery system with hybrid closed loop technology is likely to be superior over other treatment options.Final Result: The reviewers determined that the requested device 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.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: A male enrollee has requested reimbursement for the DecisionDx-Melanoma testing for evaluation of the enrollees melanoma. Findings:  The physician reviewer found that The DecisionDx-Melanoma assay tests the tissue genetics of the melanoma to help stratify whether a melanoma is high risk for metastasis. The DecisionDx-Melanoma test has shown some impressive accuracy in thin melanomas like this patients tumor. However, there is a lack of scientific evidence permitting conclusions concerning the effect of this test on health outcomes. The test is not considered routine standard of care and is not recommended by the National Comprehensive Cancer Network (NCCN) guidelines. The test is currently not standard of care, has not been demonstrated to provide a beneficial effect on health outcomes. Overall, there is not enough published data to support its routine use. Since this test has not been demonstrated to provide a benefit more than established tests, the DecisionDx-Melanoma assay was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Final Result: Two of three reviewers determined that the testing at issue was 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 reviewer number one is board certified in dermatology 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.Physician reviewer number two is board certified in dermatology 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.Physician reviewer number three is board certified in dermatology 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: Urgent Care
Decision: Upheld

A female enrollee requested air ambulance services for medical treatment of her brain hemorrhage, left-sided paralysis and severe cognitive defects.  Findings:  The physician reviewer found that the patient sustained a cerebrovascular accident (CVA) and was transported from her current state to a mid-western state for further rehabilitation. Her transport via commercial air or by ground over the distance covered would not have been feasible. However, the patient could have received further care appropriate to her condition much closer to the facility in her current state, where her rehabilitation care was being provided. Transporting the patient to a mid-western state was not medically necessary. Therefore, the ambulance services were not medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Zepatier 50/100 mg for treatment of the enrollees hepatitis C infection. Findings:  The physician reviewer found that According to the recent joint guidelines issued by the American Association for the Study of Liver Diseases (AASLD) and the Infectious Diseases Society of America (IDSA), all patients with chronic hepatitis C should be treated (except those with limited life expectancy due to non-liver-related conditions). This recommendation applies to all patients, regardless of fibrosis stage. The guidelines recommend that treatment naive genotype 1b patients should be treated with regimens including or Zepatier for 12 weeks, based on clinical trial results showing a 99% cure rate regardless of NS5A resistance. AASLD/IDSA guidelines cite data showing reduced survival with delayed treatment. For these reasons, treatment with Zepatier 50/100 mg 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: Medical Necessity
Decision: Upheld

A 63-year-old female enrollee has requested for an additional test and possible surgery for treatment of her sinusitis. Findings:  The physician reviewer found that there is no evidence of a need for additional testing or surgical intervention for this patient. Evidence based guidelines such as those noted above demonstrate that patients who have self-limited viral type acute sinusitis will resolve spontaneously without the need for any surgery. Additionally, CT scan imaging when performed too early cannot differentiate between viral episodes or bacterial episodes. Under current medical guidelines, surgical interventions are only indicated for episodes of recurrent acute rhinosinusitis documented with symptoms, physical findings of acute sinusitis and radiographic imaging which confirms the persistence of inflammatory changes within the paranasal sinuses (Sinus & Allergy Health Partnership).
Appeal type: Experimental/Investigational
Decision: Upheld

A 46-year-old male enrollee has requested for proton beam therapy for treatment of his hepatocellular carcinoma.   Findings:  Three physician reviewers found that proton beam therapy is not approved by Medicare for hepatocellular carcinoma. As of February 2008, the patient is asymptomatic of the hepatocellular carcinoma (HCCa). HCCa has responded favorably to the chemoembolization of the liver. As of February 2008, there are four sites to be treated with proton beam therapy, and this is not practical even if it were approved by Medicare.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Euflexxa injections every six months for treatment of the enrollees bilateral knee osteoarthritis. Findings:  The physician reviewer found that there is adequate evidence that intraarticular hyaluronic acid injections reduce pain and increase function in knee osteoarthritis, and the benefits are long-lasting as compared with intraarticular corticosteroids. Colleagues conducted a systematic review of overlapping meta-analyses comparing viscosupplementation with other non-operative treatment modalities for knee osteoarthritis. The authors reported that the current highest level of evidence suggests that intraarticular hyaluronic acid is a viable option for patients with knee osteoarthritis which results in improvements in knee pain and function that can persist for up to 26 weeks. Viscosupplementation has a good safety profile, and its use should be considered in patients with knee osteoarthritis. All told, the requested Euflexxa injections every six months is supported as medically necessary for treatment of this patients knee osteoarthritis. Final Result: The reviewer determined that the requested services are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in orthopedic 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: Upheld

A 20-year-old male has irregular thickening of his left first toenail. The patient reports that his toe is painful and foul smelling. His physician prescribed Lamisil tablets. The Health Plan has denied coverage for Lamisil on the basis it is not medically necessary for treatment of the patients medical condition.Review of the submitted clinical records provides insufficient evidence that the patient has a fungus infection. The results of a fungus culture have not been provided. The foul smelling nature of the toe suggests the possibility of a bacterial infection. Both a fungus culture and a culture for bacteria should be obtained. Based upon the submitted information, there is no medical justification for use of Lamisil at this time. Therefore, I have determined that the requested medication 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: The patient has requested authorization and coverage for stand-up magnetic resonance imaging (MRI). In this case, the patient reports panic attacks in a conventional MRI unit. Given that open configuration MRI units are standard of care for patients with anxiety or claustrophobia, the requested service is medically indicated. Therefore, a stand-up MRI is medically necessary for the evaluation of this patient. Final Result: The reviewer determined that the requested services 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 orthopedic 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: Upheld

A 45-year-old female enrollee has requested Botox injections for the treatment of her migraine headaches. Findings:  Three physician reviewers found that Botox is a useful migraine therapy, however, it is not a first-line therapy for migraines.  The data for its use in the treatment of migraines is limited and therefore its use should be reserved for patients who fail more traditional therapies (prophylaxis medication and abortive medications). At this time, the use of Botox for this patient cannot be supported given the absence of documentation demonstrating a failure on first, second, and third-line medications for migraine.