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

A 56-year-old female enrollee has requested Prevacid for the treatment of her acid reflux disease. Findings:  The physician reviewer found that this patient has documented acid reflux. She has taken Prevacid for years, and there was documented failure to Protonix and Prilosec. The patient has had a stable course on Prevacid and has been doing well. The requested medication is medically appropriate and indicated for this patients care.
Appeal type: Experimental/Investigational
Decision: Upheld

A 59-year-old male enrollee has requested for a radiofrequency annuloplasty and disc decompression for treatment of his back pain. Findings:  Three physician reviewers found that the procedure in issue here is unproven in the scientific medical literature as an effective long-term treatment for lumbar radiculopathy and there is no evidence it provides greater benefit than other standard procedures.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the digital breast tomosynthesis for evaluation of her breast cancer examination. Findings:  Two physician reviewers found that There is a lack of peer-reviewed literature that supports the use of digital breast tomosynthesis compared to currently available techniques. Although breast tomosynthesis may be a promising technique, its clinical efficacy is yet to be substantiated in the peer-reviewed literature as superior to currently available standard medical therapies. Final Result: The reviewers determined that the services at issue were not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: 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: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for extracorporeal shock wave therapy performed for the enrollees chronic recalcitrant plantar fasciitis. Findings:  The 3 physician reviewers found that there is a lack of medical literature supporting the services at issue in this clinical setting. Colleagues performed a systematic review and meta-analysis to assess the efficacy of ESWT. The authors concluded that The efficacy of low-intensity ESWT is worthy of recognition. The short-term pain relief and functional outcomes of this treatment are satisfactory. However, owing to the lack of a long-term follow-up, its long-term efficacy remains unknown. Given that the lack of evidence supporting the efficacy of ESWT for the treatment of plantar fasciitis, the ESWT performed was not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Final Result: The 3 reviewers determined that the services at issue were 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 number one is board certified in podiatry 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 podiatry 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 podiatry 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 a gastroenterology consultation and endoscopy for an evaluation of her abdominal pain. Findings:  The physician reviewer found that the American College of Gastroenterology has updated its guidelines for the diagnosis and treatment of gastroesophageal reflux disease to reflect the continuing advances in this area. In patients with a history typical of uncomplicated gastroesophageal reflux disease, an initial trial of empiric medication and lifestyle changes are appropriate. Most patients with this condition experience symptom relief through medical therapy. A diagnosis of gastroesophageal reflux disease can be assumed in patients who respond to therapy. However, unresponsive symptoms do not rule out gastroesophageal reflux disease. In patients with symptoms of gastroesophageal reflux disease that are refractory to therapy, additional testing should be considered to exclude complications, and the diagnosis may need to be changed. Endoscopy is the preferred technique for diagnosing complications of gastroesophageal reflux disease because it allows for evaluation of the esophageal mucosa. However, endoscopy is medically appropriate and indicated when empiric therapy fails or in the presence of alarm symptoms. Alarm symptoms suggestive of complicated disease include dysphagia, odynophagia, bleeding, weight loss and anemia. This patient should undergo empiric therapy with proton pump inhibitors first. If she fails to respond, only then should gastroenterology consultation and endoscopy be considered.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for balloon sinus ostial dilation for treatment of the enrollees chronic bilateral frontal sinusitis. Findings:  Two physician reviewers found that in this case, the patient reportedly had headaches. He underwent successful endoscopic sinus surgery seven years previously.  Although the provider reported that the patient had some moderate frontal sinus disease that was poorly responsive to antibiotics and nasal steroids, details regarding the medical management or outcomes of that therapy were not documented. Additionally, there is no clinical objective evidence of the degree of obstruction by radiographic imaging studies. Balloon sinus ostial dilation is a technique to improve a patients symptoms of recurrent acute rhinosinusitis to help widen and dilate the sinus pathways. Researchers noted that the use of balloon dilation for patients with chronic sinus disease was met with failure in 65% of the patients on whom the procedure was performed. There are some references which indicate that there may be some improvement with the use of balloon sinus ostial dilation technology. However, many references demonstrate the lack of randomization of patient symptomatology and the fact that some patients required hybrid techniques with the use of combined balloon sinus dilation and standard functional endoscopic surgical techniques to achieve adequate success. Final Result: The reviewers determined that the services at issue were 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: Reviewers 1, 2 and 3 are board certified in otolaryngology 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: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for the convergent procedure (CPT 33266). Findings:  The physician reviewer found that the peer-reviewed medical literature, the convergent procedure is described to include epicardial and endocardial ablations, which are different but combined to provide a superior outcome. In one comparative study, Jan and colleagues evaluated patient outcomes with the convergent procedure and catheter ablation alone. The authors concluded that treatment of paroxysmal atrial fibrillation with the convergent procedure showed less arrhythmia recurrence compared to catheter ablation. In addition, Kress and colleagues demonstrated improved results with the hybrid convergent procedure in managing atrial fibrillation compared to catheter ablation. The procedure avoids the need for sternotomy, and to obtain similar efficacy to the convergent procedure would likely require open sternotomy procedure. In this patients case, the provider noted that the patients stress test was cancelled as the patient was in atrial fibrillation. A computed tomography (CT) of the chest on 7/11/18 revealed showed extensive coronary atherosclerosis, which the provider noted was concerning for ischemia or coronary stenosis. Given these findings, the requested convergent procedure (CPT 33266) is likely to provide this patient with a greater health benefit than treatment with catheter ablation alone. One reviewer found that the convergent procedure (CPT 33266) is not likely to be more beneficial for treatment of this patients medical condition than any available standard therapy. Final Result: Two of the three 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:  One reviewer is board certified in surgery with subspecialty certification in surgical critical care and is actively practicing. One Reviewer is board certified in surgery with subspecialty certification in thoracic surgery and is actively practicing.  One Reviewer is board certified in surgery with subspecialty certification in thoracic surgery 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: Experimental/Investigational
Decision: Overturned

A 47-year-old female enrollee has requested for the medication Revlimid for treatment of her essential thrombocytosis/myelofibrosis. Findings:  Three physician reviewers found that data from phase II studies suggest activity with Revlimid in this setting with approximately one-third of patients experiencing improvement of anemia and/or splenomegaly. In light of these findings, and in the absence of other therapies that are likely to be more efficacious for this patient, Revlimid is indicated and should be authorized.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for balloon sinuplasty. The American Academy of Otolaryngology-Head and Neck Surgery Foundation (AAO-HNSF) clinical practice guideline defines chronic rhinosinusitis (CRS) as the presence of two or more symptoms, including mucopurulent drainage, nasal obstruction, facial pain/pressure/fullness, or decreased sense of smell, plus inflammation that is documented by mucus or edema in the middle meatus or anterior ethmoid region, sinonasal polyps, and/or radiographic imaging showing paranasal sinus inflammation lasting more than 12 weeks. Piccirillo and colleagues note, Balloon dilation is not appropriate for patients with sinonasal symptoms and a computed tomography (CT) that does not show evidence of sinonasal disease. In this case, CT of the sinus reported normal frontal sinuses without significant mucosal thickening or fluid, patent frontal recesses, and no anomalous frontal air cells. There was trace mucosal thickening of the maxillary sinuses and narrowing of the maxillary infundibula due to adjacent Haller cells. No fluid was noted in the maxillary sinuses, and the findings were not classified as sinusitis. An examination reported boggy, erythematous, and hypertrophic turbinates, but no conclusive documentation of visualized edema in the middle meatuses, ethmoids, or frontal infundibula. In this clinical setting, there is insufficient peer-reviewed evidence to support the use of balloon sinuplasty. Therefore, balloon sinuplasty is not likely to be more beneficial for treatment of the enrollees condition than any available standard therapy.Findings:  Two of the three physician reviewers found the requested balloon sinuplasty is 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 requested is 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 otolaryngology with sub-specialty certification in sleep medicine and is actively practicing. Physician reviewers 2 and 3 are board certified in otolaryngology 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

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Ventolin HFA aerosol (Ventolin 90 mcg). Current medical literature, based on randomized and blinded studies, indicates that a generic albuterol inhaler is equivalent, in efficacy and in side effect profile, to the brand name Ventolin inhaler for the treatment of asthma. The U.S. Food and Drug Administration (FDA) states, Any generic medicine must perform the same in the body as the brand-name medicine. It must be the same as a brand-name medicine in dosage, form and route of administration, safety, effectiveness, strength, and labeling (with certain limited exceptions). Therefore, Ventolin HFA aerosol (Ventolin 90 mcg) 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 internal medicine and in 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 56-year-old female enrollee has requested DIEP flap breast reconstruction surgery for treatment of her bilateral mastectomies. Findings:  The physician reviewer found that this patients breast condition qualifies as an abnormal structure of the body since her current condition is a result of surgical intervention for treatment of her ductal carcinoma in situ. In addition, the patients provider reports that the requested surgery is being performed in an attempt to create as normal appearance as possible. The patient has already been treated with implants that were removed secondary to side effects. Breast reconstruction techniques using free tissue transfer (TRAM and DIEP) are accepted reconstruction options and offer this patient an opportunity for significant improvement in the appearance of her breast abnormality. As such, the proposed procedure is considered reconstructive in nature in this setting. Thus, the submitted evidence demonstrates that the requested breast reconstruction using DIEP flaps is reconstructive in nature and medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld

The patient is a 46-year-old female with documented low immunoglobulin levels who has received intravenous immunoglobulin (IVIG) since 1999. The Health Plan has denied reimbursement for the IVIG therapy the patient received from June 2003 to October 2004. The primary issue in this matter is whether the observed low immunoglobulin levels in this patient represent a primary abnormality of immunoglobulins or a secondary change resulting from steroid therapy the patient received for treatment of asthma. The Health Plan is correct that steroid therapy depresses IgG levels. This patients immunoglobulin levels were obtained at times when the patient was receiving large doses of steroids.Based upon the information set forth above, I have determined the therapy at issue was not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned

A female enrollee requested repetitive transcranial magnetic stimulation (TMS) for medical treatment of her depression.  Findings:  The physician reviewer found that in the medical literature, TMS is supported in this clinical setting.  TMS is an effective treatment, has been granted a category I CPT code by the American Medical Association and, is U.S. Food and Drug Administration (FDA) approved for the patients with treatment resistant major depressive disorder. All told, the requested repetitive TMS is medically necessary for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld

A 55-year-old female has requested Botox injections for treatment of her migraine.  Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested therapy in this patients case.  Based upon the current medical evidence, Botox injections are not medically indicated for the treatment of this patient.  Botox may be indicated for patients with chronic migraines.  However, the criteria for chronic migraines are very specific.  In order to meet the criteria for chronic migraines, the patient must have an established history of migraine, must experience headaches on at least 15 days of each month for at least three consecutive months, and the majority of those headaches each month either have features characteristic of migraine or have been responsive to drugs which are relatively specific for migraines.  Per the submitted medical records, the patients medical condition does not meet the criteria for chronic migraines.  The medical records indicate that the patients chronic headaches may be attributed to another disorder, such as cervicalgia.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Butrans patches (20 mcg per hour dosage). In studying the safety and efficacy of buprenorphine for chronic pain, Pergolizzi and Raffa found that buprenorphine is an equally effective but potentially safer treatment option for chronic pain than full opioid receptor agonists. They concluded that a comparison of current clinical data along with the results of responder and safety analyses supported the use of buprenorphine over full opioid receptor agonists for effective preferential treatment of chronic pain. Webster and colleagues convened an expert panel to reach consensus on the use of buprenorphine for chronic pain management. The panel recommended that buprenorphine be considered before some Schedule II, III, or IV opioids in patients with a favorable risk/benefit profile on the basis of metabolic factors, abuse potential, and tolerability. In this case, the patient has had chronic back pain after lumbar laminectomy and fusion surgeries. His pain was managed with the Butrans patch, Norco, and gabapentin. He was switched to Suboxone, combined with Norco, to manage his chronic pain. The patient found that his current medications were not helpful in managing his pain and requested returning to the Butrans patch. The medical literature validates the efficacy of buprenorphine for use in chronic pain population and as a first-line treatment over traditional full opioid agonists due to better safety profile, tolerability and non-inferior analgesic effects. Therefore, Butrans patches (20 mcg per hour dosage) are 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 anesthesiology with sub-specialty certification in pain 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

A 61-year-old male enrollee has requested Harvoni 90mg-400mg for treatment of his hepatitis C. Findings:  Two physician reviewers found that in this patients case, the requested medication is not medically indicated.  The submitted laboratory testing results are consistent with negligible fibrosis, at a stage considerable lower than the F2 stage indicated by the provider.   As noted by the patients provider, the American Association for the Study of Liver Diseases considers patients with non-alcoholic steatohepatitis (NASH) and debilitating fatigue as high priority for treatment.  However, this patients transaminases are not elevated.  Based upon the records, this patient does not meet American Association for the Study of Liver Diseases and Infectious Diseases Society of America guidelines as highest priority, high priority, or at increased risk for treatment.  Therefore, the requested Harvoni 90mg-400mg is not medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Overturned

The patient has requested authorization and coverage for Adderall 10 mg tablet as needed and Adderall XR 25 mg capsules ER 24 hour, two capsules every day in the morning. The patient has been diagnosed with attention deficit/hyperactivity disorder (ADHD). The provider noted only brand name Adderall was effective for the patient as she has tried and failed the generic formulation, with no significant response or benefit. The patient was noted to have experienced dizziness and headache with generic Adderall. Researchers have reported that generic substitution may give rise to compliance issues and may not be as economically profitable as once hoped. Switching between formulations should be done on a case-by-case basis, in collaboration with the patient and with close monitoring. The medical evidence supports the requested medications in this clinical setting. Therefore, Adderall 10 mg tablet as needed and Adderall XR 25 mg capsules ER 24 hour, two capsules every day in the morning are medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested medications 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 psychiatry 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.