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

Nature of Statutory Criteria/Case Summary: The enrollee has requested authorization and coverage for Nutropin AQ NuSpin. The Health Plan has denied this request indicating that the requested medication is not medically necessary for treatment of the enrollees short stature.The submitted documentation does not support the requested medication in this clinical setting. The submitted records do not indicate that this patient has undergone provocative GH testing.  The records appear to indicate that the patient is underweight for his height but has normal growth factors. In addition, the records do not show the patient has known morphological abnormalities of his pituitary gland or midline structures to raise concern for GH deficiency. His growth pattern and preliminary laboratory data are not consistent with classic GH deficiency. Additionally, there are no chronic medical conditions noted in the records submitted. For these reasons, Nutropin AQ NuSpin is not medically necessary for treatment of this 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 pediatrics with sub-specialty certification in pediatric endocrinology 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: Urgent Care
Decision: Overturned

Nature of Statutory Criteria/Case Summary:  An enrollee has requested emergency room services for the treatment of her medical condition.  Findings: The physician reviewer found that the patient was noted to be febrile and tachycardic in triage at the emergency department.   Most importantly, however, is the patients self-reported inability to swallow. This is of pertinence to any patient with pharyngitis, but is of particular importance when considering the issue of early pregnancy. With inadequate oral intake, dehydration can ensue rapidly. In pregnancy, ketosis from dehydration must be avoided as severe cases can lead to failure of pregnancy. Ultimately, the patients apparently mild dehydration was diagnosed and treated and her pain was lessened by adequate narcotic analgesics. Neither of these therapies were likely available to the patient outside the context of the emergency department. Also it is apparent that the patient defined her symptoms as an emergency according to her pain and inability to swallow. The patient then appropriately sought care to treat her pain and dehydration.  Final Result:  Based upon the information set forth above, the physician reviewer found that the services in question were emergent in nature and 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 emergency medicine and is actively practicing.  The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient is a 53-year-old female who has been diagnosed with osteoarthritis of the right knee. A magnetic resonance imaging (MRI) of the right knee revealed greater than 50% thickness cartilage defects involving the medial femoral condyle. A less than 50% thickness cartilage defect was noted in the median ridge of the patella. The patient reported 40% pain relief from a right knee intra-articular steroid injection administered one month prior. The patient reported knee pain. Physical examination findings included tenderness to palpation over the right knee medial and lateral joint lines. The patient had been treated with a knee brace and physical therapy. The patient elected to pursue conservative management for knee pain. A right knee steroid injection was administered. The patient has requested authorization and coverage for Orthovisc injections in the right knee. The Health Plan denied the request and reported the requested services are not medically necessary for the treatment of this patient. At issue in this case is whether Orthovisc injections in the right knee are medically necessary for the treatment of the patients medical condition. Review of the current medical literature pertaining to viscosupplementation reveals mixed results.  Although viscosupplementation may relieve knee pain in some patients with osteoarthritis, it is unknown which patients will benefit. Viscosupplementation can only be recommended in patients with a history of lasting benefit from prior injections and in carefully selected cases where the options are limited. A clinical trial by Campos and colleagues found that viscosupplementation increased functional scores in patients with severe osteoarthritis of the knee, especially within three months of injection. In this case, the patients options are limited. The patient has tried and failed conservative treatments with the alternative being surgery. The medical evidence supports the requested services in this clinical setting. Therefore, Orthovisc injections in the right knee are medically necessary for the 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

The patient is a 28-year-old male with severe asthma.  He previously participated in a clinical trial of Xolair, which was very effective in controlling his asthma and his FEV1 increased from 41% to 84%.  Since Xolair was discontinued his pulmonary function tests have declined significantly, despite maximal therapy. The patients IgE was 301 in October 2005 and he has tested positive for aeroallergens.  The patients provider has submitted a request for authorization of Xolair.  The request was denied by the Health Plan citing a lack of medical necessity.The Health Plan indicated the patient has not demonstrated a 12% reversibility following administration of short-acting beta agonists and has not been compliant with prescribed asthma medication. The patients provider has explained that performing pulmonary function tests is difficult because it would not be safe to discontinue current medications due to the severity of the patients asthma.  There is however spirometry from February 2006 which demonstrated 20% reversibility for FEF 25-75%, which clearly documents small airway disease. Additionally, the patients acceptance for participation in the Xolair clinical trials would suggest that he met the 12% reversibility requirement at that time.  A review of the pharmacy records and the patients medical history shows no indications of non-compliance with prescribed medication.  The patients provider has documented a history of severe steroid dependent asthma, which improved dramatically during treatment with Xolair.  The record also reflects a significant decline in vital capacity and FEV1 since Xolair was discontinued.  This data supports the medical necessity of treatment with Xolair. The patient meets all FDA requirements for treatment with Xolair. Therefore, I have determined the requested therapy is medically necessary for treatment of the patients medical condition. The Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for magnetic resonance imaging (MRI) of the foot. The patients injury was at least six months prior to the presentation to the provider and the patient continues to have disabling pain. The patients physical examination and radiographs demonstrate soft tissue abnormal findings laterally corresponding to the area of clinical complaint. Since there was no fracture on initial radiograph, the injury is at least six months old, and the patient has radiographic and clinical findings which are positive, the next procedure of choice is MRI. Accordingly, the requested MRI of the foot is supported as medically necessary for evaluation of this patients lateral foot pain.Final Result: The reviewer determined that the requested diagnostic procedure 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 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: Upheld

The patient is a 66-year-old male with a diagnosis of prostate adenocarcinoma in 1997. He had a Gleason score total of 9 on biopsy and his PSA was approximately 7. He was then treated with hormonal therapy and radiation therapy. His PSA reached a nadir near zero, but began to rise in 2004, reaching levels of 14.9, 20.1, and 31 (according to different physician reports) with hormonal therapy changes and with ketoconanole. The submitted information indicates a bone scan performed around January 2005 was reportedly negative. In addition, an abdominal and pelvic CT scan performed in May 2005 showed no metastatic disease or prostatic enlargement. The results of a Prostascint scan reportedly showed uptake in the prostatic bed and in the aortocaval region. An oncologist has suggested consideration of salvage (radical) prostatectomy, and the patient wishes to undergo this procedure. A consulting urologist has recommended against the proposed procedure but has recommended treatment with chemotherapy.At issue is whether a salvage prostatectomy is medically necessary for treatment of the patients medical condition.The patient was diagnosed prostate adenocarcinoma with a Gleason score total of 9 approximately eight years ago. He was treated with radiation therapy and ongoing hormone therapy. His response as measured by PSA was initially excellent, falling to a nadir near zero until 2004 when his PSA began to rise, increasing to levels of 20.1-31 according to various reports. Imaging studies included a bone scan and a CT scan of the abdomen and pelvis. These were both negative for metastatic disease. A Prostascint scan demonstrated prostate cancer in the prostate and in the aortocaval retroperitoneal lymph node region.If there were no evidence the cancer had spread, then salvage prostatectomy could be considered despite its difficulty and risk of complications (as well as the possibility of failure to control the cancer). However, such is not the case with this patient. The cancer is very high grade with a Gleason score total of 9. This is statistically correlated with surgical failure. The patients PSA has been quite elevated, in the 20 to 30 range, even with hormonal deprivation therapy. This is a level that is also statistically correlated with surgical failure. The Prostascint scan, which measures prostate specific membrane antigen (PSMA) has demonstrated prostate cancer outside the prostate itself, and in the retroperitoneal lymph nodes of the aortocaval region. This would be outside the area that would be removed with salvage prostatectomy surgery.Based on the PSA and imaging studies, and even with the benefit of hormonal therapy, there is presumptive evidence that the prostate cancer has metastasized, and therefore, the patient will not benefit from a salvage prostatectomy. Rather, the patient should be considered a candidate for chemotherapy to treat his prostate cancer. In conclusion, 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: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for Afirma Gene Expression Classifier testing performed for evaluation of the enrollees thyroid nodule. Findings:  Three physician reviewers 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 very sensitive and has a high negative predictive value, a negative result is rather suggestive of a benign nodule and can therefore preclude such surgical procedures. 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 physician reviewers are board certified in internal medicine with sub-specialty certification in endocrinology, diabetes and metabolism and are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for residential treatment center (RTC) services provided. Findings:  The physician reviewer found that on admission, the patient had no withdrawal symptoms and his CIWA was 2. He did not require a detoxification protocol. He was not a danger to himself or others. He was medically and psychiatrically stable. There were no emotional, behavioral, or cognitive factors requiring residential level of care. He was not aggressive, agitated, psychotic or manic, and although he described impulsive behaviors, these did not require 24-hour monitoring in a structured setting. He denied cravings and his levels of depression and anxiety were reported to be moderate. His drinking pattern was not on a daily basis and was of a mild-to-moderate binge nature. He was motivated, cooperative, and engaged in his treatment plan. His risk for relapse and ongoing difficulties with impulsive behavior, depression, and anxiety could have been effectively and safely managed at an ambulatory level of care. For these reasons, the RTC services provided were not medically necessary for treatment of this patients behavioral health condition. Final Result: The reviewer determined that the services at issue were 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 psychiatry with sub-specialty certification in addiction 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: Overturned

A 48-year-old female enrollee has requested a bilateral breast MRI for evaluation of her family history of breast cancer.  Findings:  Three physician reviewers found that the patient has undergone screening breast MRI at yearly intervals based on a strong family history.  Breast MRI was performed on the dates in question.  A bilateral breast MRI was ordered on the said date as a follow-up to a BIRAD 3 finding in the right breast. This abnormality was only seen on MRI.  The patients radiologist recommended six month follow-up, as short interval follow-up is recommended in this clinical situation per American College of Radiology guidelines.  Therefore, the bilateral breast MRI performed on the date in question was likely to have been the most efficacious method of evaluating this patient.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a nine-year-old male enrollee has requested  for Vyvanse for treatment of the enrollees attention deficit hyperactivity disorder.  Findings:  The physician reviewer found that Vyvanse is approved by the Food and Drug Administration (FDA) for treatment of ADHD. While d-amphetamine has been used for many years for this indication, Vyvanse is converted into active d-amphetamine throughout the day, having a continuous therapeutic effect. Clinically, long-acting medications are preferred as they prevent multiple dosing and side effects are lessened due to a more continuous and even dispersion.
Appeal type: Experimental/Investigational
Decision: Upheld

Physician 1: The patient is a 37-year-old female with degenerative disc disease. She has had a positive discogram at L4-5 and L5-S1. Her provider is recommending a two-level ProDisc disc replacement at these levels. The Health Plan considers this procedure experimental. The Health Plan is correct that the proposed procedure is considered experimental. There is no evidence to support disc replacement surgery at two levels. There is no data to support such a procedure. There are no known outcomes at two years or more. ProDisc is currently being investigated for single level disc replacement in the treatment of degenerative disc disease in the lumbar spine. Current data for single level disc replacement demonstrates a 63% short-term success rate; however, long-term outcomes are unknown and complications may be severe. Because there is no evidence supporting the safety and efficacy of a two-level disc replacement, I have determined the requested procedure 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. Physician 2: The patient is a 37-year-old female with degenerative disc disease. She is seeking authorization for two-level disc replacement utilizing the ProDisc. The Health Plan has denied this request because it considers the ProDisc experimental.The current clinical evidence regarding ProDisc is based upon short-term follow-up in one study. Additional claims of efficacy are based upon a small number of short-term, non-randomized studies. There is no evidence for reduced long-term adjacent level disease progression compared to fusion. There are no studies that indicate long-term superiority over fusion. ProDisc is considered experimental and there is no evidence it is superior to available standard treatment. Therefore, I have determined the requested procedure is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Plans denial should be upheld. Physician 3: The patient is a 37-year-old female with two-level degenerative disc disease at L4-5 and L5-S1. A two-level disc replacement has been recommended. The patient is status post posterior discectomy with continued back pain. The Health Plan has denied authorization for the requested procedure. The proposed procedure is experimental with no established efficacy. There are no studies supporting a two-level disc replacement. The safety profile is unknown. There is no clinical indication for the proposed procedure. There are other treatments available. For these reasons, I have determined the requested procedure 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.
Appeal type: Medical Necessity
Decision: Upheld

A 51-year-old male enrollee has requested high dose rate (HDR) brachytherapy for treatment of his prostate cancer.  Findings:  The physician reviewer found that while there is growing interest in HDR as an emerging technique for low-risk, early stage prostate cancer, the data supporting its use remains limited. There are no randomized studies to show a benefit of monotherapy HDR over other treatment modalities. In addition, some of the data on HDR has been retrospective, which is subject to bias. In summary, although HDR is a means to deliver radiation, and has a track record comparable to other radiation modalities, it is not medically necessary in this patients clinical situation given that other radiation approaches are available that compare favorably with respect to toxicity and cancer control.
Appeal type: Medical Necessity
Decision: Overturned

A 60-year-old female enrollee requested brand name medication, Vytorin for medical treatment of her hyperlipidemia.  Findings:  The physician reviewer found that based on the current data demonstrating Vytorins clinical effectiveness; there are circumstances where the use of this medication is indicated, such as in this case. This patient had been on Vytorin for the past seven years with good LDL and glucose control, as the ezetimibe had allowed for a lower dose of statin to be used. The patient has had issues with glucose control on both higher doses of some statins and with more potent statins (atorvastatin), and had previously demonstrated good control with Vytorin. Therefore, in this clinical setting, in light of current efficacy data, the use of the combination drug Vytorin (simvastatin/ezetimibe) is medically necessary for keeping her LDL at goal while maintaining tight glucose control.
Appeal type: Medical Necessity
Decision: Overturned

A 32-year-old female enrollee has requested laparotomy and excision of a left ovarian mass for treatment of her left ovarian cyst. Findings:  The physician reviewer found that given the diagnostic and clinical findings in this patient of a persistent left adnexal cystic complex and associated pain, surgical intervention is warranted. In this clinical scenario, surgery based on the adnexal mass and pain is appropriate. Laparoscopy is the preferred route since there is a lack of documentation that the patient has had extensive prior intra-abdominal surgery, which would require laparotomy due to likely need for adhesiolysis. Absent an extensive past surgical history of intra-abdominal procedures, the request for exploratory laparotomy should be denied as not medically necessary, but laparoscopy and excision of a left ovarian mass is supported as medically necessary for treatment of this patients medical condition.