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

The patient is a 39-year-old female with bilateral lower extremity pain.  She reports that her symptoms were previously treated with sclerotherapy, but the provider is no longer with the Health Plan. A vascular surgery consultation from November 2005 revealed only telangiectasias (spider veins). The patients request for additional sclerotherapy was denied by the Health Plan based on a determination that the procedure is not medically necessary.Universally, vascular surgeons consider telangiectasias to be a cosmetic condition.  While the patient may be reporting pain and other symptoms, there is no evidence in the literature that treatment of telangiectasias with sclerotherapy will resolve those symptoms. 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: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested colonoscopy for evaluation of the enrollees risk of colon cancer. Findings: The physician reviewer found that the review of the submitted documentation and relevant literature demonstrate the medical necessity of the requested colonoscopy. More than one million patients will manifest colorectal cancer (CRC) this year of which, conservatively, approximately 3% (approximately 30,700 cases) will have Lynch syndrome (LS), the most common hereditary CRC predisposing syndrome. Due to its early age of onset (average 45 years of age), colonoscopy needs to start by age 25, and because of its accelerated carcinogenesis, it should be repeated every 1 to 2 years through age 40 and then annually thereafter (Lynch, et al). Although the patient may not have definitive Lynch syndrome, her family history places her at unequivocally high risk for colon polyps and cancer. According to the U.S. Multi-Society Task Force on Colorectal Cancer CRC age-adjusted risk varies based on patient demographic characteristics. In this case, a colonoscopy is clinically appropriate given the patients risk for colon polyps and cancer. In addition, her positive first-degree and second-degree family history significantly increases her risk. Therefore, the requested colonoscopy has been established as medically necessary for evaluation of the patients medical condition.  Final Result: The reviewer determined that the requested service is 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 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

The patient is a 28-year-old female with a history of right ankle pain and clicking that began in 2004. There is no known injury or trauma; however x-ray showed mild anterior joint narrowing with osteopenia. Treatment consisted of non-steroidal anti-inflammatory medication and physical therapy. Physical therapy failed to improve her symptoms and she was referred to podiatry and then orthopedic surgery. An MRI of the right ankle in October 2004 revealed the talus had a large osteochondral defect medially. The lesion was approximately 20 by 15 millimeters. The patient was offered two surgical options and chose the less invasive. Right ankle arthroscopy, debridement of the osteochondral lesion and microfracture of the osteochondral lesion was performed in December 2004. The operative record indicated that the size of the lesion appeared to be at least 2.5 centimeters x 1.5 centimeters; larger than anticipated by preoperative imaging studies and her orthopedist expressed concern that the microfracture would not provide adequate healing. Postoperatively the patient continued to have pain and clicking and an osteochondral autograft transfer system procedure was planned, but postponed due to the patients pregnancy. MRI in March 2006 noted the ankle defect was smaller in size and a March 2006 progress note reported minimal pain and occasional clicking. The patients request for authorization of the osteochondral allograft was denied by the Health Plan citing a lack of medical necessity.The patient had a large osteochondral defect that did not respond to debridement and microfracture. Without further surgical intervention the patient is at risk for degenerative joint disease of the ankle. Osteochondral allograft transplant is the appropriate next step in her course of treatment. Therefore, I have determined the requested procedure is medically necessary for treatment of the patients medical condition. The Health Plans denial should be overturned.
Appeal type: Experimental/Investigational
Decision: Upheld

A 61-year-old female enrollee has requested CardioDx testing for evaluation of her history of chest pain.  Findings:  Three physician reviewers found that the evaluation of patients for possible coronary artery disease is often based upon established clinical risk factors as well as diagnostic tests with varying levels of sensitivity, specificity, and predictive value.  At this time, gene expression testing is not a standard approach to the evaluation of patients with suspected coronary artery disease.  There is a lack of data demonstrating that the results of testing at issue will improve patient outcomes.  Current medical guidelines do not support the testing at issue in this patients case.  She presented with chest discomfort, palpitations, and dyspnea in the setting of risk factors of hypertension, hyperlipidemia, and a family history of premature ischemic heart disease.  The documentation noted a normal nuclear stress test.  In this patients case, CardioDx testing provided on the said date was not likely to be more beneficial than other options for evaluation this patient.
Appeal type: Medical Necessity
Decision: Overturned

A 63-year-old female enrollee has requested YAG laser posterior capsulotomy for treatment of the enrollees injury to right eye due to failed cataract surgery.  Findings:  The physician reviewer found that based on review of the available records, YAG laser capsulotomy is medically necessary for the patient. In the medical literature, Hayashi and colleagues evaluated the correlation between visual acuity, contrast sensitivity, and contrast sensitivity with glare source (glare sensitivity), and the degree of posterior capsule opacification (PCO) before and after neodymium:yttrium-aluminum-garnet (Nd:YAG) laser posterior capsulotomy.  The authors reported that, Before Nd:YAG laser capsulotomy, visual functions correlated significantly with the degree of PCO and after capsulotomy, these visual functions improve markedly and no longer have a significant correlation with PCO. Due to the patients symptoms of debilitating glare and intolerance of contact lenses, it is medically necessary to perform YAG laser capsulotomy for treatment of her symptoms.Since this patient had a complicated surgery and poor outcome under the care of an In-Plan provider, it is reasonable for the patient to be uncomfortable with continuing care with that provider. However, the Health Plan has offered access to other well qualified ophthalmologists within the network to provide care. Accordingly, the requested procedure has been demonstrated to be medically necessary for treatment of the patients medical condition and should therefore be approved.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary:  An enrollee has requested authorization and coverage for Synvisc-One injections to bilateral knees.An exhaustive review of the current medical literature pertaining to viscosupplementation reveals mixed results. Evidence from eight systematic reviews and six randomized controlled trials indicates that although viscosupplementation may relieve knee pain in some individuals with osteoarthritis, it is not known as to which individuals will benefit. Different studies have tried mixing hyaluronic acid with corticosteroids, platelet rich plasma, and other agents to make it more effective. The current evidence is limited, and guidelines from organizations such as the American Academy of Orthopedic Surgeons indicate that the evidence is not conclusive. In light of the foregoing, viscosupplementation can only be recommended in individuals with a history of lasting benefit from prior injections, and in carefully selected cases where everything else has been tried, and the options are limited. In this case, the patient has a history of good response to viscosupplementation. The patients options are limited, with the alternative being bilateral total knee arthroplasties. Therefore, Synvisc-One injections to bilateral knees are medically necessary for the treatment of the patients medical condition.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: Experimental/Investigational
Decision: Upheld

A 59-year-old male enrollee has requested for CyberKnife stereotactic radiosurgery for treatment of his prostate cancer.  Findings:  Three physician reviewers found that the NCCN guidelines do not indicate that stereotactic radiosurgery utilizing CyberKnife is superior to the standard options available in this setting. Currently, there is insufficient outcome data from which to conclude that CyberKnife is likely to be more efficacious for the treatment of intermediate risk prostate cancer than standard modalities.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the gene test (BRAF mutation analysis) for evaluation of the enrollees stage IV metastatic adenocarcinoma of the sigmoid colon.Findings:  Three physician reviewers found that BRAF mutation testing is the standard of care for patients with colon cancer and are recommended by the National Comprehensive Cancer Network (NCCN) guidelines. BRAF activating mutations, most of which occur in codon 600 (V600E), occur in less than 10% of sporadic colorectal cancer and are a strong negative prognostic marker for both early stage and advanced/recurrent tumors in non-MSH-H tumors. In MSI-H tumors, in which most of the BRAF mutations occur, the presence of a mutation does not have the same adverse prognostic significance. The available data also support the view that BRAF V600E mutations confer resistance to anti-EGFR therapy. Final Result: All three reviewers determined that the testing at issue was 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 physician reviewers 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

A 52-year-old male enrollee requested reimbursement and prospective authorization and coverage for Levitra provided from a specific date and forward.  Findings: The physician reviewer found that the patients medical history includes difficulty with erectile dysfunction (ED) with specific complaint of difficulty with erection. This symptom is consistent with the diagnosis of ED but the origin of the condition was not identified. The evaluation that was included for review did not lead to a specific cause of his symptoms. The medication that he is requesting may improve this symptom, but does not treat the cause of the problem. Although the origin of the symptom is not always identified in a completed work-up, overall, the submitted clinical documentation does not meet the requirements as defined by the American Medical Association (AMA) to consider Levitra medically necessary. The AMA defines medical necessity as: Health care services or products that a prudent physician would provide to a patient for the purpose of preventing, diagnosing or treating an illness, injury, disease or its symptoms in a manner that is: (a) in accordance with generally accepted standards of medical practice; (b) clinically appropriate in terms of type, frequency, extent, site, and duration. Given that this patient is not reportedly taking any medications and does not have a diagnosis that may cause ED the requested Levitra has not been demonstrated to be medically necessary for treatment of this patients medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld

A 37-year-old female has requested ProDisc cervical artificial disc procedure (ProDisc C5-6 discectomy with interbody device placement) for treatment of her persistent C6 radiculopathy and C5-6 degenerative disc disease.  Findings:  Three physician reviewers found that the patient has a history of worsening pain in her neck and right upper extremity.  The patients history is significant for trigger point injections and epidural steroid injections.  An MRI of the cervical spine revealed stable mild multilevel degenerative changes of the cervical intervertebral discs and facets, including a mild annular disc bulge and a broad-based right paracentral protrusion at C4-5.   In this patients case, the requested procedure is not likely to be superior over other available treatment options.  It is known that the metal to methyl methacrylate bearing surface of ProDisc-C will be exposed to the wear mechanisms of abrasion, adhesion, fatigue and third body wear.  A continuing particulate load of these particles will occur.  At age 37, this patient will be exposed to the effects of this particulate debris over time.  Her specific response will be influenced by the response of her immune system, although there is a universal giant cell reaction and chronic inflammation in response to wear debris. The question of whether total disc arthroplasty as compared to arthrodesis will be beneficial in terms of adjacent segment degeneration remains controversial both by reason of gradual loss of motion at the arthroplasty index site and by the possibility that adjacent segment degeneration is an expression of a progressive disease process rather than a complication of arthrodesis.  Jawahar and colleagues studied 93 patients randomized for either total disc arthroplasty or anterior cervical discectomy and fusion.  These authors concluded that that total disc arthroplasty is equivalent to anterior cervical discectomy and fusion in the risk of developing adjacent segment degeneration.  Additional controversies concerning total disc arthroplasty reference the limitations in the engineering of the implants themselves.  Unlike total knee arthroplasty and total hip arthroplasty, the vertebral motion segment is a complex joint with a syndesmotic joint and a synovial joint.  The center of motion at each motion segment of the spine is complex and variable.  It is likely that the total disc replacement will alter facet joint loading and edge loading with posterior facet joint mediated pain as a complication of the procedure.  In sum, the requested ProDisc cervical artificial disc procedure (ProDisc C5-6 discectomy with interbody device placement) is not likely to be more efficacious than other treatment alternatives in this patients case.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Gammagard IVIG treatment.Medical literature does not support that the requested medication is medically necessary. The optimal therapy of postural tachycardia syndrome (POTS) is not clear and likely varies depending on individual symptoms. The Heart Rhythm Society Expert Consensus Statement on the treatment of POTS states that few treatments have been tested with the usual rigor of randomized clinical trials, and there is no consensus as to whether specific treatments should be targeted to subsets of POTS or whether a uniform approach should be used. Standard therapy for treatment of patients with POTS include exercise training, lower extremity compression, volume expanders (liberalization of salt intake, florinef), beta-blockers and vasoconstrictors (midodrine). Other therapies remain under investigation, and evidence of benefit is needed before they can be recommended. The Heart Rhythm Society Expert Consensus Statement on the treatment of POTS does not include IVIG among its recommended treatments for POTS. Vernino and Stiles state that the published literature is limited to a small number of case reports noting improvement in POTS symptoms after intravenous immunoglobulin. In this case, the patient has a diagnosis of postural tachycardia syndrome (POTS) and her provider has recommended intravenous immunoglobulin (IVIG) therapy. The expert consensus statement on the treatment of POTS does not include IVIG among the recommended treatments, however, and there is insufficient evidence for its use under these circumstances at this time. Accordingly, Gammagard IVIG treatment is not medically necessary to treat the patients medical condition.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.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a 16-year-old male enrollee has requested Vyvanse for the treatment of the enrollees attention deficit/hyperactivity disorder (ADHD). Findings:  The physician reviewer found that the Health Plans criteria for this medication requires that the patient is between the ages of 6 and 12 years, has had an unsatisfactory response to a medication in the amphetamine and methylphenidate class and treatment does not exceed 70mg per day. The patient meets the latter two criteria but is 16 years old. The Health Plan reports that Vyvanse is not FDA approved for the treatment of children over age 12.The patient does have ADHD, and he has responded favorably to treatment with Vyvanse 70mg daily. Vyvanse is approved by the FDA for the treatment of this condition, and that approval was based upon clinical data in children from 6 to 12 years of age. FDA approval defines the marketing claims a manufacturer of a medication may make. Practitioners may prescribe a medication for indications that are not specifically approved in the product label, and they may likewise prescribe a product outside the age range in which the product was studied. The age difference of 12 versus 16 years does not appear to be clinically relevant. To suggest that the patients medication be changed simply because he is 4 years beyond the age of 12 is not clinically appropriate and may not be safe.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary:   An enrollee has requested stem cell transplant, in conjunction with the approved kidney transplant for treatment of his end stage renal disease.   Three physician reviewers found that in this patients case, kidney transplantation as authorized by the Health Plan is clinically indicated. However, there is a lack of adequate evidence to support that an immunosuppressive clinical trial using bone marrow/hematopoietic stem cell transplant (HSCT) in conjunction with the living donor kidney transplant would be more beneficial. The long-term benefit of a living donor kidney transplant utilizing stem cell transplant has not been established to have the best outcome nor has it been proven in the literature as an established transplant practice.  The requested clinical procedure is not the standard of care for patients that undergo kidney transplantation. The risk of opportunistic infections in this patients low risk immunosuppressive protocol living donor kidney transplantation is low. Therefore, based upon the peer-reviewed literature, the requested stem cell transplant, in conjunction with the approved kidney transplant is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.  Final Result: Three 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: One reviewer is board certified in surgery with sub-specialty certification in transplant surgery and is actively practicing. One reviewer is board certified in surgery and critical care surgery with sub-specialty certification in transplant surgery and is actively practicing. One reviewer is board certified in nephrology with sub-specialty certification in renal transplantation and is actively practicing.  All three reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

A 38-year-old female enrollee has requested Subutex for the treatment of her major depressive disorder. Findings:  The physician reviewer found that the patient has been prescribed a great variety of medications for her treatment. It is not entirely clear if each of these has been used at its fullest dose for an adequate duration of time. She indicates Subutex (buprenorphine) is the only drug that has been effective. Subutex is used to manage patients with opiate dependence. It is not an entirely safe and appropriate treatment, or adjunctive treatment, for depression. I therefore concur with the Health Plan. I believe the conditions the Health Plan sets forth for the use of this drug are entirely appropriate. Based upon the evidence provided, Subutex is not medically indicated in this particular case.