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

A 60-year-old male enrollee requested a sleep study (polysomnography) for evaluation of his medical condition.  Findings:  The physician reviewer found that review of the submitted documentation and relevant literature fails to demonstrate the medical necessity of the services at issue. Based on the medical records submitted for review, the sleep study performed was not medically indicated. In this case, the medical records submitted for review indicate that the patient reports snoring and a history of headaches. By itself, snoring is a poor predictor for obstructive sleep apnea (Kushida, et al; Epstein, et al). In addition, there is no documentation of a crowded airway. There is also no documentation of witnessed apneas, sleep disruption, or excessive daytime sleepiness. In the absence of these signs or symptoms, his pre-test probability for sleep disordered breathing, such as sleep apnea, is low. Furthermore, self-limited, global morning headaches can be precipitated by obstructive sleep apnea. However, this is not this patients headache pattern. Therefore, the documentation submitted for review does not support the medical necessity of the sleep study (polysomnography) performed.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for corneal collagen cross-linking procedure, on the left eye and prospective authorization and coverage, procedure code 0402T, on the right eye. The Health Plan has denied this request indicating that the procedures at issue were and are considered investigational for treatment of the enrollees keratoconus.Findings:  There is support in the medical literature for the efficacy of the corneal crosslinking in this patients case. Cross-linking is a U.S. Food and Drug Administration (FDA) approved procedure for keratoconus and post refractive ectasia. The FDA approved this procedure in 2016. The primary purpose of crosslinking is to halt the progression of corneal thinning that occurs with conditions such as keratoconus. The procedure involves soaking the corneal stroma with riboflavin and then using UV light to create chemical bonds between collagen fibrils within the stroma.  This stiffens the cornea and halts the thinning.  Prior to this treatment, patients with keratoconus who failed medical treatment (glasses, contact lenses) and whose disease continued to progress would go on to surgical management with corneal transplantation. There have been multiple studies published which demonstrate that patients who underwent corneal cross-linking showed an improvement in keratometry values, uncorrected visual acuity and best corrected visual acuity in contrast to control group.  There is mounting evidence of the benefit of this treatment in younger keratoconic patients with evidence of disease progression. This patient has severe keratoconus with poor best corrected visual acuity.  Corneal cross-linking was medically beneficial treatment to slow the disease progression for this patient. All told, the corneal collagen cross-linking procedure, on the left eye and prospective authorization and coverage, procedure code 0402T on the right eye was and is likely to be more effective than the available standard therapy for treating this patients medical condition.Final Result: All three reviewers determined that procedures at issue were and 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 ophthalmology and are actively practicing. All three reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/ Case Summary:  The enrollee requested authorization and coverage for Trabectedin for treatment of Kaposis Sarcoma. According to a study published in 2017, Trabectedin is currently approved for unresectable or metastatic liposarcoma or leiomyosarcoma after an anthracycline containing regimen.  Further, a study published in 2017, did not show any benefit of a neoadjuvant histotype-tailored chemotherapy regimen over the standard chemotherapy regimen. Trabectedin is an approved option for treatment of advanced liposarcoma and leiomyosarcoma (LMS) in patients who have been previously treated with at least an anthracycline-containing chemotherapy combination. Experience with this agent has also underscored the relevance of stable disease as a beneficial endpoint for metastatic soft tissue sarcoma. In this case, the enrollee has not received prior therapy. Per current peer review literature and guidelines Trabectedin is being reserved for second or third line.  For these reasons, Trabectedin is not likely to be more beneficial than any available standard therapy.Final Result: Three of the three reviewers determined that the requested services are not likely to be more beneficial than any available standard therapy for treatment of the enrollees medical condition. Therefore, the health plans denial is upheld.Credentials/Qualifications: One reviewer is board certified in Hematology and Oncology and is actively practicing. Two reviewers are board certified in Oncology and are actively practicing. All three reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the blood test (Guardant360 biopsy-free tumor sequencing test). The therapy of advanced non-small cell lung cancer has been revolutionized by the finding of epidermal growth factor receptor (EGFR) mutations in adenocarcinomas. Even in patients with stage IV disease, therapy targeted to EGFR with erlotinib can result in prolonged survival when compared with standard chemotherapy regimens. The mutational landscape of non-small cell lung cancer has significantly expanded in the past few years to encompass gain of function in multiple oncogenes with major prognostic and therapeutic consequences. Generally, KRAS, TP53, and BRAF are included in these panels and are informative.The Guardant360 test analyzes oncogenes and tumor suppressor genes for mutations by next generation sequencing. The results can assist providers in selecting treatment towards these mutations. Von Hoff and colleagues reported on a study of 86 patients where the progression free survival (PFS) on regimen selected by molecular profiling was compared to PFS on the last chemotherapy regimen. The authors found that the regimen selected by molecular profiling offered a 27% survival advantage. Given this support, the blood test (Guardant360 biopsy-free tumor sequencing test) was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Findings:  Three physician reviewers found the blood test (Guardant360 biopsy-free tumor sequencing test) was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the blood test (Guardant360 biopsy-free tumor sequencing test) was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Credentials/Qualifications: Physician reviewers 1, 2 and 3 are board certified in internal medicine with sub-specialty certification in medical oncology 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: An enrollee has requested authorization and coverage for Repatha Pushtronex 420 mL once a month. The Health Plan has denied this request indicating that the requested medication is not medically necessary for treatment of the enrollee who has a history of hyperlipidemia.The submitted documentation fails to demonstrate the medical necessity of the requested medication. Based on the records provided the patient has a history of hyperlipidemia on maximum tolerated statin medication and increased coronary risk but no documented cardiovascular disease. Repatha (evolocumab) is a proprotein convertase subtilisin/kexin type 9 inhibitor studied in and approved for patients with heterozygous familial hypercholesterolemia or for patients with documented clinical atherosclerotic heart disease who require additional lowering of LDL-cholesterol.  This patient does not fit either of these categories. The diagnosis of heterozygous familial hyperlipidemia requires not only elevated LDL-cholesterol levels that significantly exceed 180 mg/dL but also a combination of physical examination findings (arcus cornealis below the age of 45, tendon xanthomatas), a strong family history of coronary disease (younger than 50 years in second degree relative or aged younger than 55-60 years in first degree relatives) and documented genetic defects related to cholesterol metabolism according to published criteria. The records do not support this patient has either heterozygous familial hyperlipidemia or clinical cardiovascular disease.  There is a lack of literature supporting the use of  inhibitors in patient populations such as this patient. For these reasons Repatha Pushtronex 420 mL once a month is not medically necessary for treatment of the patients medical condition. Given these findings, the requested medication is not medically necessary for treatment of this patients medical condition. Final Result: The reviewer determined that the 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 sub-specialty certification in cardiovascular disease 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. Findings:  The physician reviewer found that Findings:  The physician reviewer found that
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary:   An enrollee has requested breast tomosynthesis for evaluation of her medical condition. Findings:  Three physician reviewers found that tomosynthesis provides radiologists the ability to separate dense glandular elements from underlying mass/architectural distortion resulting in a decrease in callbacks and increase in detection of small cancers compared to two-dimensional imaging alone. In this case, the original screening mammogram was performed with two-dimensional imaging only. Therefore, the follow-up diagnostic exam which included tomosynthesis was indicated. Neither breast had been evaluated using tomosynthesis on the initial screening exam. The tomosynthesis utilized as part of the follow-up diagnostic exam allowed evaluation of the areas of concern identified on the original screening study, in addition to the entire breasts for the first time. For this reason, the tomosynthesis portion of the diagnostic exam was likely of greater benefit to the patient than had this exam been done with two-dimensional imaging alone. Final Result: 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:  All three reviewers are board certified in diagnostic radiology and are actively practicing. All three reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Vemlidy 25 mg for treatment of the enrollees chronic hepatitis B virus. Findings:  The physician reviewer found that guidelines for the treatment of hepatitis B from the American Association for the Study of Liver Disease (AASLD) recommend entecavir and tenofovir compared with alternatives for the treatment of chronic hepatitis B. In comparison with Viread, which the patient is taking, the Vemlidy formulation of tenofovir is effective for hepatitis B, but is associated with lower incidence of side effects such as osteopenia and renal disease. For this reason, the request for Vemlidy 25 mg is supported as medically necessary for the treatment of this patients chronic hepatitis B. 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: Upheld

 Nature of Statutory Criteria/Case Summary:  An enrollee has requested reimbursement for advanced lipoprotein for evaluation of her medical condition.  Findings:  Three physician reviewers found that based on the records provided the patient has been diagnosed with hyperlipidemia but no documented coronary disease. In this circumstance, primary prevention guidelines for the management of cardiac risk and dyslipidemia have been established by several national organizations. These guidelines currently do not recommend routine performance of specialized tests in the context of assessing coronary risk including lipoprotein-associated phospholipase A2 (Lp-PLA2), lipoprotein(a), C-reactive protein (CRP), high sensitivity CRP, insulin, fibrinogen, genetic testing and homocysteine (Greenland, et al; Stone, et al). Treatment change or addition based on the results of screening with these specialized tests has not been shown to improve cardiac outcome incremental to that achievable by treatment based on standard risk factor profiling and basic lipid analysis. All told, the advanced lipoprotein testing was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Final Result: Three 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:   All three reviewers are board certified in internal medicine with sub-specialty certification in cardiovascular disease and are actively practicing. All three reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Monovisc injections for bilateral knees. The Health Plan has denied this request indicating that the requested treatment is not medically necessary for treatment of the enrollees bilateral knee osteoarthritis. At issue in this case is whether the requested Monovisc injections for the knees are medically necessary for treatment of the enrollees medical condition.Three separate clinical practice guidelines have found that viscosupplementation does not produce clinically significant improvement as compared to placebo injections. None of these practice guidelines support the continued use of viscosupplements. Therefore, the requested Monovisc injections are not medically necessary.Final Result: The reviewer determined that the requested treatment 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 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:  An enrollee has requested Praluent for treatment of her medical condition.  Findings:  The physician reviewer found that the submitted documentation supports the requested medication in this clinical setting.  This patient presents with coronary risk and markedly elevated cholesterol despite maximal tolerated statin medication and ezetimibe.  In this circumstance, additional cholesterol lowering is medically necessary to help reduced the risk of developing obstructive coronary disease.  Praluent, a PCSK9 inhibitor, is approved as an adjunct to diet and maximally tolerated statin therapy for the treatment of adults with heterozygous familial hypercholesterolemia or clinical atherosclerotic cardiovascular disease, who require additional lowering of LDL-C. This patient likely has heterozygous familial hyperlipidemia.  PCSK9 inhibitors have been show to reduced adverse cardiovascular outcomes in this setting and are associated with an acceptable safety profile.  All told, Praluent is medically indicated 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 internal medicine with sub-specialty certification in cardiovascular disease 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 60-year-old female enrollee has requested a radiofrequency neurolysis at T10-T11 for treatment of her thoracic pain.   Findings:  Three physician reviewers found that there is some increasing evidence that radiofrequency ablation may be an effective treatment for facet joint pain.  However, most of the medical literature still indicates that the evidence in support of such treatment is only fair. There is better evidence that a facet block can provide temporary relief and aide in the diagnosis of facet arthropathy. The diagnostic criterion is 80% pain relief. In this patients case, she had a 50% reduction in pain after receiving a left T10-11 and T11-12 facet block with local anesthetics and steroid. Therefore, this patient does not meet the diagnostic criteria for facet arthropathy. Because there is only fair evidence in support of the use of radiofrequency ablation for the treatment of facet pain, in this patients particular case, radiofrequency ablation is not likely to be more beneficial in treating her not clearly diagnosed facet arthropathy than any available standard therapy.
Appeal type: Medical Necessity
Decision: Overturned

The patient has requested authorization and coverage for oral and maxillofacial procedures. This patient has ectodermal dysplasia, which is a hereditary disorder, characterized by morphological and functional hypoplasia of ectodermally derived organs and tissues. The primary dental-related features of ectodermal dysplasia patients include the congenital absence of multiple teeth and an abnormal tooth shape. Treatment strategies for missing teeth include approaches such as removable partial or complete dentures, tooth-supported fixed partial dentures, overdentures, and implant-supported prostheses. Reports have shown that an implant-retained prosthesis is an ideal option, when possible. This patients provider noted that this is the best option in this patients case. Moreover, the requested treatment will provide more than a minimal improvement in the appearance of the patient and will attempt to create a normal appearance to the extent possible. Given these findings, oral and maxillofacial are 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 oral and maxillofacial 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

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Entresto. Based on the records provided for review, this patient has congestive heart failure with a mildly reduced ejection fraction of 45%. In the circumstance of a mildly reduced ejection fraction, Entresto has not been demonstrated to improve patient outcomes and is not considered the standard accepted therapy in this setting. Solomon and colleagues reported on the PARAGON-HF trial and compared outcomes with Entresto versus valsartan in patients with heart failure, left ventricle ejection fraction of 45%, and elevated natriuretic peptide levels. The authors found that there were no statistically significant differences identified. Current data suggests that Entresto is indicated for patients with heart failure and an ejection fraction below 40%. Given these findings, the requested Entresto is not medically necessary for 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 with subspecialty certification in cardiovascular disease 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.