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

Nature of Statutory Criteria/Case Summary: An enrollee has requested Harvoni for treatment of her hepatitis C virus.  Findings:  The physician reviewer found that 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. Per guidelines, treatment-naive genotype 1 patients should be treated with Harvoni. Patients with viral load of less than 6,000,000 IU/mL can be treated for eight weeks. These guideline recommendations are based on multiple randomized clinical trials (Kowdley, et al; Afdhal, et al). AASLD/IDSA guidelines cite data showing reduced survival with delayed treatment (Jezequel, et al). For these reasons, the requested treatment with Harvoni is supported as medically necessary for the treatment of this patients hepatitis C infection. 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: Medical Necessity
Decision: Upheld

A 64-year-old male enrollee has requested for spinal fusion at the L4-5 and L5-S1 levels for treatment of her chronic low back pain. Findings:  The physician reviewer found that there is a lack of high quality studies examining the role of surgical fusion as a treatment for lumbar disc herniation and radiculopathy (Resnick, et al.). However, Resnick and colleagues noted the following with regard to fusion: lumbar spinal fusion is not recommended as routine treatment following primary disc excision in patients with a herniated lumbar disc causing radiculopathy; lumbar spinal fusion is recommended as a potential surgical adjunct in patients with a herniated disc in whom there is evidence of preoperative lumbar spinal deformity or instability; lumbar spinal fusion is recommended as a potential surgical adjunct in patients with significant chronic axial low back pain associated with radiculopathy due to a herniated lumbar disc; re-operative discectomy is recommended as a treatment option in patients with a recurrent lumbar disc herniation; re-operative discectomy combined with fusion is recommended as a treatment option in patients with a recurrent disc herniation associated with lumbar instability, deformity or chronic axial low-back pain. Further, the American Pain Society has also developed evidence-based recommendations on the use of interventional surgeries for low back pain of any duration, which states that surgical benefits are often only moderate and appear to decrease over time (Chou, et al.). Given the paucity of studies demonstrating the safety and efficacy of surgical fusion in this setting, as well as the lack of evidence that the patient meets clinical indications for surgical fusion, the requested procedure is not medically necessary for treatment of the patients low back pain.
Appeal type: Experimental/Investigational
Decision: Overturned

A 72-year-old female enrollee has requested for CyberKnife Stereotactic Radiosurgery for treatment of her refractory obsessive compulsive disorder. Findings:  Three physician reviewers found that per the American Psychiatric Association practice guidelines, stereotactic radiosurgery represents a potentially efficacious alternative for a few carefully selected patients with very severe obsessive compulsive disorder. The Yale Brown Obsessive Compulsive Score has been used as the standard for severity of obsessive compulsive disorder symptomatology in most studies.  This score has been shown to decrease with the use of stereotactic radiosurgery. CyberKnife Stereotactic Radiosurgery was likely to have been the most beneficial treatment option available to this patient.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested Aubagio 14 mg for treatment of the enrollees multiple sclerosis. The Health Plan offers Copaxone, Tecfidera or a beta-interferon (Avonex or Rebif) for treatment of the enrollees medical condition and has denied Aubagio 14 mg as not medically necessary. Findings: The physician reviewer found that the submitted documentation does not support the medical necessity of the requested medication for treatment of this patients MS. The medical literature does not indicate a preference or superiority of Aubagio over interferon or Tecfidera for the treatment of MS. This patient was diagnosed with MS in 1999. The patient was treated with Copaxone. The patient was on Copaxone until 2007 when the medication was discontinued.  The records do not report that this patient had tried other medications for treatment. There were no specific contraindications to using interferon or Tecfidera noted in the submitted medical records. Accordingly, Aubagio 14 mg for treatment of this patient is not medically necessary.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 neurology 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 authorization and coverage for a Positron Emission Tomography (PET) scan.The submitted documentation does not support that the requested services are medically necessary. Chronic lymphatic leukemia (CLL) is an indolent lymphoma and is not considered a fluorine 18 fluorodeoxyglucose (FDG) avid disease, and PET scanning is therefore not generally indicated. A PET scan is sometimes utilized in CLL if transformation to a more aggressive lymphoma is suspected. In this case, the patient has CLL and has received treatment due to thrombocytopenia. There is no documentation, however, that the patient has signs or symptoms to suggest transformation. Under these circumstances, a Positron Emission Tomography (PET) scan is not medically necessary to treat the patients medical condition.Final Result: The reviewer determined that the requested services are not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denials should be upheld.Credentials/Qualifications: The reviewer is board certified in internal medicine, with subspecialty certification in hematology and medical oncology, and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

A 37-year-old female enrollee has requested Nuvigil for treatment of her chronic fatigue syndrome.  Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested medication.  Armodafinil is a wake-promoting agent that selectively increases neuronal activity in the hypothalamus, particularly in the wakefulness center of the tuberomammillary nucleus.  This medication has been approved for the treatment of excessive sleepiness associated with narcolepsy, obstructive sleep apnea/hypopnea as an adjunct to standard treatment, and shift-work sleep disorder.  Although this patient reports excessive fatigue, there is no mention in the record of narcolepsy, obstructive sleep apnea or shift-work sleep disorder.  Further, the patient is prescribed several sedating medications.  On the said date, the patient reported that Ritalin helped with energy, which suggests that current pharmacotherapy strategies have not yet been optimized.  There is a lack of well-designed studies published in the peer-reviewed literature demonstrating the safety and efficacy of armodafinil in this clinical setting.  All told, the requested medication is not medical necessary for the treatment of this patient.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary:  An enrollee has requested authorization and coverage for a computerized knee ankle foot orthosis (HCPCS L2006).Findings: Two out of three physician reviewers found that a computerized knee ankle foot orthosis (HCPCS L2006) is not likely to be more beneficial for you than any available standard therapy.Deems-Dluhy and colleagues concluded, The microprocessor swing and stance controlled knee-ankle-foot orthosis may contribute to improved quality of life and health status of patients with lower-extremity impairments by providing the ability to have better walking speed, endurance, and functional balance. Probsting and colleagues concluded, The microprocessor stance and swing control orthosis may facilitate an easier, more physiological, and safer execution of many activities of daily living compared to traditional leg orthosis technologies. The microprocessor stance and swing control orthosis offers new functions, including controlled knee flexion during weight bearing and dynamic swing control, resulting in significant improvements in perceived orthotic mobility and safety. However, there is limited literature that demonstrates that a computerized knee ankle foot orthosis would be of proven additional benefit over the standard knee ankle foot orthosis brace. Notwithstanding several studies that show the promise of the requested equipment, there is limited literature that demonstrates the safety and long-term effectiveness of computerized knee ankle foot orthoses.In this case, the patient notes that he can walk with a walker at home but does not walk in the community. Overall, there are well-documented clinical findings to support right lower extremity weakness as well as ambulation deficits. However, there is limited published, large-scale, long-term peer-reviewed literature that shows the request to be an effective and/or safe treatment for the noted pathology. Therefore, the requested computerized knee ankle foot orthosis (HCPCS L2006) is not likely to be more beneficial than any other available standard therapy for patients medical condition.Final Result: The reviewers determined that the requested device is not likely to be more beneficial than any available standard treatment for the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer 1, reviewer 2, and reviewer 3 are board certified in orthopedic surgery. All reviewers 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

A 44-year-old female enrollee has requested laparoscopic adjustable gastric banding (Lap Band) for treatment of her morbid obesity. Findings:  The physician reviewer found that the Lap Band is presently the most common bariatric surgical procedure performed in the world, and the second most common bariatric surgical procedure performed in the United States (US). The procedure is undisputedly safer than other bariatric procedures in that it involves shorter operative time, no chance of anastomotic leaks, no dumping syndrome and no serious nutritional deficiencies. Current data indicates the Lap Band is at par with other operative procedures for weight loss and the patient should be free to choose among the generally accepted bariatric procedures.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement and prospective authorization and coverage for denosumab (Xgeva) injections provided for treatment of the enrollees prostate cancer. Findings: Three physician reviewers found that Xgeva is a monoclonal antibody that binds to osteoclasts in bone. Along with zoledronic acid (Zometa), Xgeva has been approved by the U.S. Food and Drug Administration (FDA) for use in patients with bone metastases from prostate cancer. The goal of such therapy is to delay or prevent the worsening of the bone metastases producing clinical symptomatology and the need for radiation therapy. In one direct comparative study, Xgeva was found to be superior to Zometa. Moreover, Xgeva has been demonstrated to be beneficial in this clinical setting. Final Result: Three reviewers determined that the medication at issue was and is likely to be more benefitical for the 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 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 left knee surgery (arthroscopy with meniscectomy). Magnetic resonance imaging (MRI) of the left knee demonstrated tricompartmental osteoarthritis of the knee, particularly severe in the medial compartment, where a complex tear of the medial meniscus was also present. This is a typical degenerative tear that is usually not helped by a partial meniscectomy. Researchers noted a three-fold increase in the risk for knee replacement surgery after arthroscopic surgery for degenerative meniscal tears. Researchers recommended against arthroscopic knee surgery for degenerative knee disease. The medical evidence does not support arthroscopy in the presence of a degenerative medial meniscal tear and osteoarthritis. Therefore, left knee surgery (arthroscopy with meniscectomy) is not medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested services are not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is board certified in 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: Overturned

A 64-year-old female enrollee requested magnetic resonance imaging (MRI) of the breasts for medical evaluation and treatment.  Findings:  Three physician reviewers found that the patient underwent removal of bilateral breast implants and replacement of the implants due to right implant rupture. According to the provider, a breast ultrasound demonstrated rupture of right breast implant and free silicone. Magnetic resonance imaging (MRI) of the breasts revealed evidence of right breast intracapsular rupture and free extracapsular silicone within the left lateral breast and right axillary lymph nodes. Subsequently, the patient underwent surgery to remove the implants and some of the silicone. Bilateral diagnostic mammogram and targeted breast ultrasound showed right axillary silicone containing lymph nodes. The patient was noted to have continued right breast pain and a follow-up MRI was recommended. The patient was evaluated with MRI and determined to have right axillary reactive silicone infiltrated lymph nodes that were also present on MRI earlier. In the peer-reviewed medical literature, Samuels and colleagues noted that mammography supplemented with ultrasonography constitutes the most cost-effective initial study, followed by MRI if these are equivocal. MRI is the most sensitive and specific study to evaluate breast implant rupture. Ahn and colleagues concluded that the most reliable imaging modality for implant rupture detection is MRI, followed by sonogram. Mammogram is the least reliable. Our study supports the clinical indication and diagnostic value of sonogram and MRI in the evaluation of symptomatic breast implant patients. All told, the use of the follow-up breast MRI was indicated to provide information relevant to this patients evaluation and treatment and was likely to have been more beneficial than any available standard modality.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary:  An enrollee has requested a 12 week course of Harvoni for treatment of her chronic hepatitis C virus genotype 1a.  Findings:  Two physician reviewers found that as per the American Association for the Study of Liver Diseases (AASLD) and Infectious Diseases Society of America (IDSA) guidelines, all patients with chronic active hepatitis C are eligible for treatment and should be treated with U.S. Food and Drug Administration (FDA) approved antiviral therapy regardless of fibrosis score. Successful hepatitis C treatment results in sustained virologic response (SVR), which is tantamount to virologic cure, and is expected to benefit nearly all chronically infected patients. The fixed dose combination ledipasvir-sofosbuvir (Harvoni) is FDA approved for the treatment of chronic hepatitis C genotype 1 in both treatment-naive and treatment-experienced patients. Given this support, the requested 12 week course of Harvoni is medically necessary for treatment of this patients hepatitis C virus.  Final Result:  Two reviewers 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 three reviewers are board certified in internal medicine with sub-specialty certification in gastroenterology 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

The parent of a seven-month-old female enrollee has requested a cranial orthotic for treatment of the enrollees brachycephaly.  Findings:  Two physician reviewers found that this young patient had a misshapen skull which did not respond to conventional treatment of avoiding the back of her head to lie flat down. As reshaping of the skull is generally only successful during the rapid growth of the head during the first six months of life, the patient was referred by her fourth month for an external molding orthotic device. Research reports success and recommend utilizing an external molding device in reshaping skull deformities in infants. The cranial orthotic devices are not considered investigational however, as the technique has been a viable alternative to extensive cranoisyostosis surgery for at least 30 years. According to the information supplied by the manufacturer, orthotic bands and head molding helmets have been approved by the FDA since 1998. Thus, the argument that the device at issue is investigational in unfounded and the utilization of the orthotic band is clearly the treatment of choice for this patient. It is therefore medically necessary for this young patient to be fitted and to wear this orthotic device to prevent permanent skull deformity.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a 17-year-old female enrollee has requested continued residential treatment services for treatment of the enrollees behavioral health condition. Findings:  The physician reviewer found the submitted documentation demonstrates the medical necessity of the services at issue.  Modern psychiatric practice aims to place patients in the least restrictive treatment setting as community interventions optimize treatment gains.  However, patients with anxiety, character pathology, substance use, and mood symptoms may episodically require treatment in a more restrictive setting. This patient is at risk for a poor outcome in the absence of specialized care in a 24-hour setting.  Her family environment remains a prominent stressor for affective dysregulation and cognitive distortions.  Additionally, the patient has required multiple acute admissions and failed less restrictive alternative interventions.  The progress notes document aggressive thoughts aimed towards her family and an inability to self-soothe.  Somatic symptoms were prominent and a new medication, aripiprazole, was added to the regimen for depression, anxiety, mood lability and recurrent interpersonal strife.  Although the patient has made some progress, she has not consolidated the treatment gains necessary to succeed in a less restrictive setting.  The services are for active treatment which is reasonably expected to prevent a more serious clinical situation and improve her current condition.  All told, continued residential treatment services are medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for the following services: massage therapy as part of his physical therapy treatment plan; electrical stimulation as part of his physical therapy treatment plan; physical therapy once per week; and physical therapy performed by a physical therapist that physically assists with the assigned stretches and other exercises, as opposed to giving the enrollee a printout with instructions for home exercises for treatment of the enrollees dislocated right shoulder. Findings:  The physician reviewer found that the standard of care for a primary anterior dislocation is managed with acute reduction of the dislocation using one of many available techniques: A short period of immobilization, typically in internal rotation; and conservative non-surgical management of exercise and gradual return to activity. There is a lack of support in the medical literature as to the benefit of massage, electrical stimulation or long-term regular supervised physical therapy for the patients medical condition.  Exercises and activities can be gradually resumed with intermittent formal therapy assessments and basic exercises performed independently. Final Result: The reviewer determined that the requested services are not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.  Credentials/Qualifications: Physician reviewer number one is board certified in physical medicine and rehabilitation 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.