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

The patient is a 57-year-old man with a history of hepatitis C. The patient was given Peg-Intron and Rebetol for at least five months. Review of the submitted records indicates the patient did not clear his virus and there was only a 1.4 log drop in his viral count. A repeat course of Peg-Intron and Rebetol therapy has been recommended by the patients provider. The Health Plan indicates that a second course of Peg-Intron and Rebetol therapy is not medically indicated given the patients insufficient response to the initial course of therapy.It is not the standard of care to retreat patients who have not responded to an initial course of Peg-Intron and Rebetol therapy.  The article by Fried, et al. cited above clearly shows that if a patient does not respond to Peg-Intron and Rebetol therapy within three months (i.e., experiences a 2 log drop in viral count or undetectable viral count), there is a 97% certainty that the patient will not respond to continued therapy. Although the patient indicates that he did not receive a full six-month course of Peg-Intron and Rebetol therapy, the patient did not experience a significant decrease in his viral load after three months of therapy. Thus, a repeat course of Peg-Intron and Rebetol therapy is not likely to benefit the patient and is not medically indicated.Based upon the information set forth above, I have determined that the requested therapy is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld

The patient has requested authorization and coverage for intensity modulated radiation therapy (IMRT). This patient presents with metastatic epidermal growth factor receptor (EGFR) positive, non-small cell lung cancer (NSCLC). The standard of care radiation modality in this patients clinical setting is a course of three-dimensional conformal radiation therapy (3D-CRT). There is a lack of evidence to support improved patient health outcomes with IMRT per the current peer-reviewed medical literature. Moreover, the American Society for Therapeutic Radiation Oncology (ASTRO) does not support IMRT for palliation of metastatic lung cancer. The data suggest that 3D-CRT is adequate to provide normal tissue sparing for delivery of palliative radiation doses in this clinical setting. All told, the requested IMRT is not medically necessary for 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 radiation oncology 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 25-year-old female enrollee requested intravenous (IV) tocilizumab (Actemra) for treatment of her Takayasu arteritis. Findings:  Three physician reviewers found that Takayasu arteritis is a rare vasculitis, thus it is unlikely that any randomized placebo controlled phase III clinical trials will become available. This patient has been responding to treatment with Actemra. Ceasing treatment that has improved her condition will likely result in clinical deterioration of her condition given her history of aortic aneurysms requiring surgery. Treatment of Takayasu arteritis with Actemra has been shown to be effective in several case series. All told, the requested Actemra is supported as likely to provide this patient with an improved health outcome as compared to expected results with standard available alternatives.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for acupuncture treatment twice per week for treatment of the enrollees cervical radiculopathy. Findings:  The physician reviewer found that review of the submitted documentation and relevant literature fails to demonstrate the medical necessity of the requested service. The researchers systematically reviewed the effectiveness of balance acupuncture for the treatment of neck, shoulder, low back and leg pain. The researchers concluded that balance acupuncture is an effective and safe way for treating these conditions, however it may need further demonstration by more large-scale and well-designed randomized control trials due to the limited quantity and quality of the included studies. There is some peer-reviewed literature supporting the utility of acupuncture for the treatment of the patients medical condition. However, there is lack of peer-reviewed literature demonstrating the amount of acupuncture visits that would be beneficial in this clinical setting. Therefore, the request for acupuncture treatment twice per week has not been established as medically necessary for treatment of the patients medical condition. Final Result: The reviewer determined that the requested service is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The physician 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: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for an esophageal sphincter augmentation device for treatment of the enrollees gastroesophageal reflux disease. Findings:  2/3 of the physician reviewers found that there is a lack of randomized controlled trials with long-term follow-up demonstrating that LINX is safer or more effective than Nissen fundoplication or other surgical anti-reflux procedures. Adverse events, such as erosion through the esophagus, have been reported in the period after U.S. Food and Drug Administration (FDA) approval. Additionally, LINX (more than surgical fundoplication) is associated with severe dysphagia requiring endoscopic intervention. The currently available peer-reviewed literature does not definitively support the conclusion that LINX is more likely to be beneficial in this case than standard treatment, surgical fundoplication. For these reasons, the requested esophageal sphincter augmentation device is not likely to be of greater benefit than other available treatment alternatives.  Final Result: 2/3 of the reviewers determined that the requested services are not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: Physician reviewer number one 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.Physician reviewer number two 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.Physician reviewer number three 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

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Cosentyx. The records provided for review document that this patient has coped with his diagnosis of psoriasis for many years. Treatment has included multiple medication trials including topical steroids, which are first-line therapies. Cyclosporine, Otezla, triamcinolone and clobetasol have failed to provide the patient with adequate symptomatic relief from his psoriasis. Most recently, the patient was treated with Enbrel for two years with some improvement, but the provider noted that the patient still has psoriatic plaques on about 20% of his body surface area (BSA). Enbrel is a tumor necrosis factor alpha (TNF-a) inhibitor. Given that the patient is biologic experienced, treatment with Cosentyx is appropriate. Cosentyx has a different pathway than Enbrel and the patient has experienced excellent results with use of Cosentyx. For these reasons, the requested Cosentyx is medically necessary for 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 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: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for a FreeStyle Libre continuous glucose monitor (CGM). The American Diabetes Association (ADA) recommends the use of continuous glucose monitors for decreasing hemoglobin A1C levels and meeting glycemic targets. ADA guidelines state that, Intermittently scanned continuous glucose monitors in conjunction with insulin therapy are useful tools to lower A1C levels and/or reduce hypoglycemia in adults with type 2 diabetes who are not meeting glycemic targets. Scientists found that a high percentage of adults who received multiple daily insulin injections for type 2 diabetes and used a continuous glucose monitor had improved glycemic control. In this case, the patients A1C level is 13, and he is not currently meeting glycemic targets of less than 8, given his age and comorbidities. Therefore, a FreeStyle Libre CGM is medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested device 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 endocrinology, diabetes, and metabolism, 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 17-year-old male with an approximate three-year history of polysubstance abuse, most recently involving marijuana, cocaine, and amphetamine with daily use of all such drugs. He was noted as recently using about 2-3 grams of marijuana per day, about 0.3 grams of amphetamine per day, and an unclear quality of cocaine per day. However, he was also noted to be using the drugs amidst similarly drug abusing friends, otherwise at home alone for home schooling though his mother appears to be out of the house for 12 work hours a day. His father was also noted as out of the house due to his own drug recovery program. The patient had tried to maintain abstinence on an outpatient basis, but had been unable to stay sober for more than two days. He also briefly attended Alcoholics Anonymous, but did not persist with this to any extent. As a result of his drug use, he was on probation the year prior for possession, fearful of being put back on probation, and was behind in school credits, alongside a prior history of poor performance and truancy. Finally, he also noted that many of the family gatherings centered about substance use. A request has been made for reimbursement for residential treatment services the patient received from 2/8/05 to 3/8/05. The Health Plan has denied this request on the basis the services at issue were not medically necessary.Based on the gross quantity as well as regularity of use of drugs, with social consequences of increasingly poor academic performance and no real support at home to otherwise guide sobriety, the patient met criteria for residential treatment. The extent of his use of marijuana alone is staggering. There was no particular social support for his sobriety at home, what with a parent not at home during mainstay hours. Furthermore, there was support among his friends for his actually continuing such use. No matter his dedication to abstinence, removal from this environment to allow for a break in the cycle of his use was imperative. Lack of withdrawal symptoms also does not refute the patients need for active intervention in a secured setting if the level of drug abuse is egregious, which it was in this case. Therefore, I have determined that the services at issue were medically necessary for treatment of the patients medical condition. The Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Upheld

The patient is a 41-year-old female with excessive upper arm skin due to her obesity and subsequent weight loss. The patient complains of arm rashes and chafing, but the records do not include any office notes that objectively confirm a history of rashes. In addition, the records do not document a workup for arm pain or a need for analgesics. The Health Plan has denied coverage for the requested brachioplasty on the basis that it is not medically necessary for treatment of the patients condition.The submitted records do not establish medical necessity for the proposed brachioplasty.  The procedure has been proposed as a treatment for recurrent infections, but the records do not include objective evidence to verify the reported history. The patient does not have medical record documentation over time (e.g., series of office notes, dermatology consultations, pharmacy prescription records) of skin infections in the arm folds. Furthermore, the submitted photographs do not document cellulitis, ulcerations or rashes. The submitted physician letter indicates that the patient has failed conservative treatment, but it is not clear if the conservative treatment was for the pannus or arm infections. The records do not include office notes that document evaluation and treatment of persistent arm rashes by an internist or dermatologist.  The medical records do not provide any documentation in the form of PCP or dermatology progress notes that describe ongoing clinically significant dermatologic problems that have either 1) never responded to topical therapy or 2) despite initial response, have recurred and caused significant functional impairment. Given the absence of objective evidence of uncontrollable and recurrent intertrigo the patient does not meet the American Society of Plastic Surgeons criteria for third party coverage of skin resection following massive weight loss. The records do not document the failure of medically supervised conservative therapy to control this patients arm intertrigo. Therefore, I have determined 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: Upheld

A 37-year-old female enrollee has requested eight weeks of psychiatric residential treatment services for the treatment of her posttraumatic stress disorder, depressive and personality disorders and alcohol abuse. Findings:  The physician reviewer found that a psychiatric residential treatment program would be inadequate to meet this patients needs and is therefore medically inappropriate. I agree with the Health Plans recommendation, and that of the patients treatment team, in recommending a dual diagnosis residential program that would address her depression, borderline personality disorder and alcohol abuse.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a male enrollee requested growth hormone (GH) therapy with Genotropin for medical treatment of the enrollees Prader-Willi syndrome.  Findings:  The physician reviewer found that GH therapy for treatment of short stature from Prader-Willi syndrome is approved by the U.S. Food and Drug Administration (Wilson, et al). GH treatment of children with Prader-Willi syndrome has been shown not only to improve linear growth, but also promotes growth of lean body mass, decreases fat mass by increasing fat oxidation and total body energy expenditure, and improves cardiovascular risk factors and motor and mental development. Complications of GH therapy in children with Prader-Willi syndrome are infrequent, and with close monitoring, GH therapy is considered to be generally safe in this population. All told, the GH therapy with Genotropin is medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld

A 63-year-old female enrollee has requested Nexium 40mg for treatment of her gastroesophageal reflux disease. Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested medication.  As a drug class, proton pump inhibitors are indicated for healing erosive esophagitis and peptic ulcer disease, as well as for managing symptomatic gastroesophageal reflux disease and acid hypersecretory states.  Duration of action and side effects characterize proton pump inhibitor variations.  No particular proton pump inhibitor has been demonstrated to provide superior results, since as a class proton pump inhibitors are interchangeable.  In this patients case, the medical records do not document that her gastroesophageal reflux disease is advanced or refractory to multiple proton pump inhibitors, and she has not demonstrated intolerance to specific proton pump inhibitors.  All told, the requested Nexium 40mg is not medically indicated 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 seven-level lumbar spinal fusion. This patient presents with longstanding neck and back pain due to degenerative scoliosis with clinical evidence of associated radiculopathy. She has failed conservative treatment including opioids and pregabalin, physical therapy, and bilateral T12-L1 epidural steroid injections. Her provider has recommended long segment fusion, which has been demonstrated to be superior to short segment fusion for correcting lumbar scoliosis curvature and coronal imbalance, as well as improving rotational subluxation of the apical vertebra. With regard to the length of the fusion, the horizontal vertebra should be selected to balance the spine. Fusion to T10, as in this case, is appropriate to prevent junctional problems at the proximal adjacent vertebra. Proximal adjacent segment disease is a long-term complication that can develop at the upper end vertebrae in patients with degenerative lumbar scoliosis. Given these findings, the requested seven-level lumbar spinal fusion is medically necessary for treatment of this patient. 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: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for magnetic resonance angiogram (MRA). Fibromuscular dysplasia is a disease of the arteries which predisposes aneurysm formation and dissection. In a review of the U.S. Registry for Fibromuscular Dysplasia, incidence of dissection was noted in approximately 25% of patients (Kadian-Dodov, et al.). Given the high incidence of aneurysms and dissections as well as subsequent hemorrhagic and ischemic complications, the authors recommend baseline imaging in all patients with fibromuscular dysplasia. In this case, the patient underwent cervical vessel imaging because she was symptomatic with headaches and pulsatile tinnitus. A computed tomography angiography (CTA) six months ago revealed internal carotid artery vessel dissections and vessel narrowing. The patient was placed on antiplatelet therapy for the prevention of dissection propagation and stroke. At this time, it is unknown whether the patients dissections have improved, remained stable, or worsened since her initial diagnosis. OConnor and Gornik noted that considering the risk of complication, imaging surveillance is required, although the exact timeline of imaging has not been determined. In this clinical setting, the patients provider is an interventional neuroradiologist subspecialized in the care of the vessels of the head and neck. The patients provider has recommended a six month interval for follow-up after diagnosis and initiation of treatment. On follow-up, the provider recommended further evaluation with an MRA. Per the American College of Radiology (ACR), MRA is appropriate for the initial and follow-up evaluation of this patients cervical vessel anomaly. Therefore, the requested MRA is medically necessary for evaluation of this patient. Final Result: The reviewer determined that the requested services are medically necessary for evaluation of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in neuroradiology with subspecialty certification in diagnostic radiology 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 parents of an eleven-year-old male with type-1 diabetes are requesting authorization of a Medtronic MiniMed Paradigm insulin pump.  The patients parents have been endeavoring to keep the patient's blood glucose levels in tight control, which generally the patient has achieved by taking several injections of insulin and having frequent blood glucose monitoring.Reviewers Findings:  The reviewing physician found that there is sufficient evidence to conclude that an insulin pump is necessary for treatment of this patient.  The reviewing physician found that the Health Plan denial should be overturned.