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

The patient is a 47-year-old female with metastatic non-small cell adenocarcinoma of the lung. She provided an annotated history detailing the course of her treatment.  In May 2003 Carboplatin and Gemzar were started with minimal response. Later in 2003 the patient began a clinical trial with G3139, which resulted in a minor response and then disease progression.  The patient was treated with Iressa in August 2004, and remained stable. In February 2005 there was progression of the patients bone disease and treatment with Tarceva was attempted and aborted.  One CT was done during this timeframe, but there is no information indicating whether Tarceva might have been active at the time. The patient was treated with radiotherapy in April 2005 and restaging showed further progression of her disease. Pemetrexed and Carboplatin were attempted in May 2005 but discontinued due to a non-specific neurological reaction. In June 2005 the patient began treatment with Avastin plus Alimta. A July 2005 CT showed mixed response and a September 2005 CT showed disease progression. Tarceva was then added and a November 2005 CT showed some regression of the patients disease.  The patient was treated with Avastin in combination with other drugs from June 2005 through February 2006.  The Health Plan authorized the initial three months of therapy, and the enrollee has requested reimbursement for the six months of therapy from September 2005 through February 2006.  The Health Plan denied her request based on a determination that continued therapy with Avastin was not medically necessary.The Health Plan initially denied authorization of Avastin as part of a fourth-line treatment approach, but subsequently authorized three months of treatment.  Nonetheless, the September 2005 CT showed progression of the patients disease after approximately three months of Avastin and Alimta therapy. In September 2005, in an apparent effort to achieve remission, her provider added Tarceva to the Avastin and Alimta regimen and a November 2005 CT did in fact show a regression of the patients disease. The patients clinical history leads to the conclusion that the addition of Tarceva was helpful in achieving the regression noted in November 2005. This is logical as there was no apparent failure of Tarceva when it was initially tried in February 2005.  Continued Avastin therapy was not indicated in September 2005 and it is unlikely that it contributed to the regression of the patients disease.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. The Health Plans denial should be upheld.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the placement of perirectal spacers (SpaceOAR). A concern during prostate radiation is rectal toxicity due to exposure of the adjacent rectum to radiation. The SpaceOAR system deals with this issue by creating a space between the prostate and rectum, so that the rectum is out of the radiation treatment field. In a phase 3 study to examine absorbable hydrogel spacer use in prostate radiotherapy, Karsh and colleagues found that patients who underwent treatment with perirectal space experienced reduced rectal radiation, rectal toxicity and decreased rates of decline in bowel quality of life (QOL). The National Comprehensive Cancer Network (NCCN) guidelines for the management of prostate cancer endorse the use of perirectal spacers to improve sparing of the adjacent rectum. Therefore, the placement of perirectal spacers (SpaceOAR) was likely to have been more beneficial for treatment of the patients condition than any available standard therapy.Findings:  Two of the three physician reviewers found the placement of perirectal spacers (SpaceOAR) at issue was likely to have been more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the service at issue was likely to have been more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: Physician reviewers 1, 2, and 3 are board certified in radiation 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: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for a peroral endoscopic myotomy (POEM) procedure. Findings:  The physician reviewer found that the management of gastroparesis involves correcting fluid, electrolyte and nutritional deficiencies, identifying and treating the cause of delayed gastric emptying such as diabetes mellitus, and suppressing or eliminating symptoms with pharmacological agents as first-line therapies. Bharucha and colleagues report that initial options for the management of diabetic gastroparesis include dietary modifications, supplemental oral nutrition, and antiemetic and prokinetic medications, and for patients with more severe symptoms, a venting gastrostomy or jejunostomy and/or gastric electrical stimulation. In this case, the patient has a history of diabetic gastroparesis with nausea, vomiting, bloating and early satiety. There is a lack of evidence in current medical literature that the requested POEM procedure would result in improved health outcomes over conventional therapies such as lifestyle modifications along with medical therapy. Therefore, the requested POEM procedure is not likely to be more beneficial for treatment of the patients condition than any available standard therapy.Findings:  Two of the three physician reviewers found the requested peroral endoscopic myotomy (POEM) procedure 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 service 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 reviewers 1, 2, and 3 are board certified in internal medicine with sub-specialty certification in gastroenterology 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 authorization and coverage for laparoscopic anti-reflux surgery utilizing the LINX Reflux Management System (CPT Code 43284). The Health Plan has denied the requested service as investigational for treatment of the enrollees gastroesophageal reflux disease (GERD).Findings:  Three physician reviewers found that Persistent symptoms of heartburn and regurgitation warrant careful monitoring. Ignoring persistent reflux symptoms can lead to severe complications, such as esophageal strictures, Barretts esophagus, and esophageal adenocarcinoma. Consideration of other treatments may become necessary when medical therapy fails to control symptoms. Sphincter augmentation with the LINX Reflux Management System is a surgical option for patients with chronic gastroesophageal disease and an inadequate response to proton pump inhibitors (PPIs). The patient has acid reflux with the predominant symptom of heartburn that was confirmed by a positive wireless pH test and response to a PPI. Other manifestations of acid reflux such as regurgitation or supra-esophageal symptoms including asthma, sinusitis or a cough, are not documented. Lifestyle changes such as weight loss, dietary changes, elevating the head of the bed, and the impact of his symptoms on his quality of life are also not detailed. As such, laparoscopic anti-reflux surgery utilizing the LINX Reflux Management System (CPT Code 43284) is not likely to be more beneficial for treatment of the patients condition than any available standard therapy.Final Result: The reviewers determined that the requested procedure is not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: Physician reviewers 1, 2 and 3 are board certified in internal medicine with subspecialty certification in gastroenterology 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: Overturned

The parents of a sixteen year-old male with bipolar disorder are requesting authorization of psychiatric residential treatment services.  Reviewers Findings:  The reviewing physician found that the submitted clinical information indicates the patient has a number of diagnoses and whether the patient was most affected by bipolarity or pervasive developmental disorder, one or both clearly affected the patient quite adversely.  The reviewing physician found that the Health Plan denial should be overturned.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for weekly allergy shots. The Health Plan has denied this request indicating that the requested medication frequency is not medically necessary for treatment of the enrollee who has sensitivity to numerous allergens.Findings:  Weekly maintenance dosing is a nonconventional schedule for allergen immunotherapy.  There is unclear evaluation for other potential factors for nonresponse in this patients case noted above. It is unclear from the documentation exactly how long the patient continued on monthly dosing prior to discontinuation. On 8/17/17, a case note reported that nasal congestion has increased on monthly shots, but this same documentation noted symptom control had improved. It is unclear if more minor adjustments in dosing/frequency were tried. Data is lacking regarding the need and effectiveness for more frequent maintenance dosing (i.e., every week). There is not a clear rationale provided for the nonconventional and more frequent dosing in this case. As such, the medical necessity for weekly allergy shots has not been demonstrated for the treatment of this patients medical condition. Final Result: The reviewer has determined that the requested medication frequency 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 pediatrics and 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

The patient is a 45-year-old woman with an ankle fracture. During the course of her treatment a bone stimulator was utilized. The patient had proper immobilization of her fracture. It was noted at eight to ten weeks that she had no callus and persistent tenderness. Ultimately, it was felt she had a delayed union and surgical intervention was recommended. The patient is seeking reimbursement for the use of the bone growth stimulator. The Health Plan has denied her request citing a lack of medical necessity for the device.The use of a bone growth stimulator in this case was medically reasonable and acceptable. If the bone growth stimulator was effective, the patients pain would have diminished and her condition would have improved without the need for invasive treatment (i.e., surgery). Unfortunately, in this case union was not achieved and surgery was required. However, since the bone growth stimulator provided the potential of preventing the patient from having surgery, its use was clinically appropriate. Therefore, I have determined the device at issue was medically necessary for treatment of the patients medical condition. The Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary:  An enrollee has requested a biopsy of a lump in her neck and a computed tomography (CT) scan of the chest, neck, abdomen, and groin area for evaluation of her medical condition. The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested services.  This patient has multiple systemic symptoms as well as a lump in her neck that concerns her.  As she has already had extensive imaging studies done, there is no medical indication to repeat them.  Radiologically, she has been found to have two right-sided adnexal cysts, with no other abnormality.  In this patients case, the requested CT scan of the chest, neck, abdomen, and groin is not likely to reveal new information.  With regards to the lump at the right posterior triangle of the neck, there is documentation of multiple physical examinations having been done by various providers, and only two mention this finding.  One provider describes this finding as a small node and the other providers impression was a subcutaneous cyst.  Ultrasound evaluation of this lump describes it as a 2-3 mm short axis normal-appearing lymph node.  This method of evaluation has been shown to be accurate in differentiating benign from malignant nodes in the neck.  The node does not show any malignant characteristic by either structure or size criteria.  Excision of this node is not likely to yield further useful medical information in this case and, as the node appears to be in the posterior triangle, the procedure holds possible risk of damage to the spinal accessory nerve.  All told, the requested biopsy of a lump in her neck and a CT scan of the chest, neck, abdomen, and groin area are not medically indicated for the evaluation of this patient.  Final Result: The reviewer determined that that the requested services are not medically necessary for evaluation of the patients medical condition. Therefore, the Health Plans denial should be upheld.  Credentials/Qualifications: The reviewer is board certified in otolaryngology with sub-specialty certification in head and neck 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: An enrollee has requested surgical intervention for 1 cm colloid cyst of the third ventricle in the brain for treatment of the enrollees colloid cyst. Findings:  The physician reviewer found that this patient has chronic headaches. Imaging found a foramen of Monro lesion consistent with a colloid cyst. She has maintained a normal neurological examination and an unchanged MRI scan. She has been advised nonsurgical management for her incidental colloid cyst brain tumors by two neurosurgeons and a third neurosurgeon recommended surgical treatment. Colloid cysts are rare brain tumors found on routine imaging and generally incidental findings. Medical nonsurgical management is considered the standard of care. Surgery is indicated for increased growth of lesions, if ventriculomegaly is seen on follow-up studies, if transependymal cerebrospinal fluid migration is noted, or the sulci are effaced. In this patient, there is no increase in size of the lesion, no hydrocephalus or ventriculomegaly, no transependymal migration of cerebrospinal fluid, and the sulcal pattern is unchanged. Final Result: The reviewer determined that the requested surgery 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 neurological 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

Findings:  The physician reviewer found that A 59-year-old male enrollee has requested authorization and coverage for Mavyret 100-40 mg tablets for 12 weeks. According to the most recent joint guidelines issued by the American Association for the Study of Liver Diseases (AASLD) and the Infectious Diseases Society of America (IDSA), all patients with chronic hepatitis C should be treated except those with limited life expectancy due to non-liver-related conditions. The guidelines recommend that non-cirrhotic treatment naive genotype 1a patients should be treated with Mavyret 100-40 mg three tablets daily for eight weeks (Kwo, et al; Zeuzem, et al). For these reasons, the requested treatment with Mavyret 100-40 mg tablets for 12 weeks is not medically necessary for the treatment of this patients hepatitis C infection. 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 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

A 57-year-old male enrollee has requested Xolair 375mg subcutaneous injection every two weeks for treatment of his asthma.  Findings:  The physician reviewer found that the submitted documentation supports the medical necessity of the requested medication in this patients case.  The current medical evidence supports the use of Xolair in this clinical setting.  Xolair is indicated as add-on therapy to improve asthma control for patients with severe and persistent allergic asthma, and this medication is often recommended when other systemic therapies have failed.  Per the clinical notes, this patient has tried and failed standard therapy.  Additionally, he has required hospitalization for an exacerbation of his condition.  All told, Xolair 375mg subcutaneous injection every two weeks is medically indicated for the treatment of this patient.
Appeal type: Experimental/Investigational
Decision: Overturned

A 49-year-old female enrollee has requested sleeve gastrectomy for the treatment of her morbid obesity. Findings:  The physician reviewer found that the laparoscopic vertical sleeve gastrectomy has been shown to be an efficacious surgical procedure for the treatment of morbid obesity. The procedure is approved as a primary treatment for morbid obesity in the well-selected patient by the American College of Surgeons and the American Society for Metabolic and Bariatric Surgery (ASMBS) based on the available medical literature documenting safety, efficacy and the availability of five-year data. There are multiple studies involving a total of 2,570 patients with intermediate term follow-up reported in the literature at 3, 4, and 5-year intervals. These studies suggest comparable rates of improvement and remission of diabetes, hypertension, hyperlipidemia, and sleep apnea compared to other restrictive procedures, with relatively low major complication rates. Thus, the requested procedure, sleeve gastrectomy, is an appropriate modality for the treatment of morbid or super morbid obesity in the well selected patient such as this patient. As with any weight loss surgical procedure, the patient should undergo appropriate pre-surgical workup including psychological evaluation, dietary evaluation and documentation of normal TSH level prior to the procedure.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for Afirma Gene Expression Classifier testing for evaluation of the enrollees thyroid nodules. Findings:  The physician reviewer found that The physician reviewer found that while a fine needle aspiration biopsy of a suspicious thyroid nodule is typically an accurate means of assessing whether the nodule is benign or malignant, approximately 15% of fine needle aspiration biopsy results are considered to be indeterminate. Until recently, the only way to establish whether the nodule was thyroid cancer was via surgical excision, even though the majority of the cases turn out to be benign. Afirma Gene Expression Classifier testing utilizes a gene expression classifier in order to help determine the likelihood of malignancy of nodules with indeterminate cytology on fine needle aspiration biopsy, thereby decreasing the need for unnecessary surgeries.  Because it is sensitive and has a high negative predictive value, a negative Afirma result is rather suggestive of a benign nodule and can therefore preclude such surgical procedures. All told, Afirma Gene Expression Classifier testing provided on 3/17/17 was likely to have been more effective than other methods of evaluating this patient. Final Result: The 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: Physician reviewer number one 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.Physician reviewer number two 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.Physician reviewer number three 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.