Persius/imr-appeals huggingface dataset:
Appeal type: Experimental/Investigational
Decision: Upheld

A 37-year-old female enrollee requested oral chemotherapy with Afinitor for medical treatment of the enrollees recurrent highly anaplastic pinealoblastoma.  Findings:  Two physician reviewers found that there is a paucity of clinical evidence supporting the use of Afinitor in the treatment of pinealoblastoma. The National Comprehensive Cancer Network (NCCN) treatment guidelines have not included Afinitor in its recommendations for patients with pinealoblastoma. All told, the peer-reviewed medical literature has not demonstrated that treatment with Afinitor is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary:  An enrollee has requested Sovaldi and ribavirin for 12 weeks for treatment of his hepatitis C.  Findings:  Three physician reviewers found that the current medical evidence supports the requested medications in this clinical setting.  Per the American Association for the Study of Liver Diseases and Infectious Diseases Society of America guidelines, all patients with chronic active hepatitis C should be treated regardless of fibrosis score.  The guidelines note that the medical evidence supports treatment in all patients with chronic hepatitis C, except those with limited life expectancy less than 12 months due to non-liver-related comorbid conditions.  Per the guidelines, daily Sovaldi and weight-based ribavirin are recommended for treatment-naive and treatment-experienced patients with hepatitis C, genotype 2 infection.  All told, Sovaldi and ribavirin for 12 weeks are medically indicated for the treatment of this patient. Final Result: Three reviewers determined that the requested medications are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: All 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

A 56-year-old female enrollee has requested total hip resurfacing arthroplasty for treatment of her osteoarthritis.  Findings:  Two physician reviewers found that total hip resurfacing arthroplasty is medically reasonable and has certain advantages.  In theory the resurfacing arthroplasty will preserve bone stock of the femoral neck and make femoral revision surgery more predictable.  In an active young individual these advantages are not insignificant. Regarding the socket side of the surgery, there have been issues historically pertaining to longevity of this implant, but considerable modification has been made to optimize longevity. Furthermore, the proposed procedure has distinct advantages over a traditional arthroplasty. The risk of dislocation is reduced, bone stock is preserved so that future revision surgery is possible, and other common problems and accommodations are decreased with this surgery as compared to traditional total hip replacement.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested laboratory testing for liver scar tissue (fibrosis)  CPT code 81599 unlisted Maaa for evaluation of her hepatitis C virus (HCV).  Findings:  Two physician reviewers found that noninvasive testing for fibrosis is accepted by national guidelines to assess the stage of fibrosis to be treated for HCV. Although liver biopsy is the diagnostic standard, sampling error and observer variability limit test performance, particularly when inadequate sampling occurs. In addition, the liver biopsy is invasive and minor complications are common, limiting patient and practitioner acceptance. Serious complications such as bleeding, although rare, are well recognized. Recently, noninvasive tests to stage the degree of fibrosis in patients with chronic HCV infection include models incorporating indirect serum biomarkers (routine tests such as aspartate transaminase (AST), alanine transaminase (ALT), and platelet count), direct serum biomarkers (components of the extracellular matrix produced by activated hepatic stellate cells) and vibration-controlled transient liver elastography. Therefore, the services at issue were likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Final Result: Two reviewers determined that the services at issue were likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned.  Credentials/Qualifications: All three reviewers are board certified in 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: Upheld

A 29-year-old female enrollee has requested a bariatric sleeve gastrectomy for the treatment of her morbid obesity. Findings:  Three physician reviewers found that this patient is a morbidly obese 29-year-old female who is seeking authorization for sleeve gastrectomy. The Health Plan considers this procedure investigational and has denied authorization. The Health Plan has recommended Lap-Band or gastric bypass for treatment of the patient's condition. The patient has an increased CRP, which is likely a result of her obesity. There are no data demonstrating that increased CRP is a contraindication to Lap-Band. In fact, the Lap-Band would be preferred in this patient, since it gives the ability to deflate the band if she becomes pregnant. Furthermore, there is no indication for sleeve gastrectomy for treatment of this patient, as her obesity is not extreme, and she does not have a need for chronic NSAIDs or significant hepatomegaly.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for monitored anesthesia care (MAC) services provided during a colonoscopy. The records provided for review indicate that this patient presented to their provider for a routine colonoscopy. The patients records include documentation of obstructive sleep apnea (OSA) and gastroesophageal reflux disease (GERD). Preoperatively, the patient was given an ASA classification score of 2. As noted by the American Society for Gastrointestinal Endoscopy (ASGE), the presence of OSA represents a risk for difficulty with moderate sedation (Early, et al.). The ASGE further noted that anesthesia provider-administered sedation be considered for complex endoscopic procedures or patients with multiple medical comorbidities or at risk for airway compromise. Per the ASGE, the medical conditions which represent clinical risk include potentially difficult airway and airway anatomy associated with difficult intubation. Given this patients ASA score of 2 and diagnosis of OSA, the use of MAC services during evaluation with colonoscopy were appropriate and consistent with ASGE recommendations. Therefore, the MAC services provided during a colonoscopy were medically necessary for treatment of this patient. Final Result: The reviewer determined that the services at issue were 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 anesthesiology with subspecialty certification in pain 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 37-year-old female enrollee has requested radiofrequency ablation for treatment of her lung cancer metastasized to the liver. Findings:  Two physician reviewers found the medical records indicate the patient is currently symptomatic from her liver metastases, which has progressed while on crizotinib. Thus, the goal of her therapy is not to improve overall or progression-free survival, which is the usual endpoint in clinical trials of RFA, but to palliate her pain and improve quality of life. Moreover, second-line chemotherapy has a less than 10% chance of helping her with her pain. In comparison, the expected control rate of a metastatic liver lesion is up to 97% with RFA (Tanis, et al). Therefore, the request for RFA is likely to be more beneficial than other modalities for the treatment of the patients medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld

A 47-year-old male enrollee has requested an implantable brain stimulator for treatment of his major depressive disorder. Findings:  Three physician reviewers found that the current medical evidence has not established the superior efficacy of the requested device in this setting.  There is a lack of adequately powered, well-designed or statistically meaningful studies in the medical literature to support this intervention in the treatment of major depressive disorder.  Further, deep brain stimulation is not endorsed by the American Psychiatric Associations current practice guideline for treatment of individuals with depression.  Additionally, based on review of the documentation provided, it does not appear that the patient has exhausted standard interventions, such as community programming or augmentative medication management strategies.  All told, the requested implantable brain stimulator is not likely to be superior over other available treatment modalities.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary:An enrollee has requested reimbursement and prospective authorization and coverage for electrical bone growth stimulator for treatment of the enrollee who had a right bunionectomy.  Findings:  The physician reviewers found that there is support in the medical literature for the efficacy of the services at issue in this clinical setting. This patient underwent a first metatarsal first cuneiform joint fusion/bunionectomy right foot. It was noted that patient continued to have pain and swelling to the surgical area. Subsequently, hardware was removed and the surgical site was found not to be fused. The literature advises that noninvasive electrical bone growth stimulators are considered effective for the treatment of nonunion or congenital pseudarthrosis of the appendicular skeleton. It is recommended that 45 days must have passed since the date of fracture and or surgical treatment. In this patients case, the fracture gap is less than 1 cm and serial radiographs or appropriate imaging studies confirm that no progressive signs of healing have occurred. In this case surgical intervention and visualization of the joint indicated that the first metatarsal first cuneiform joint had not fused in over seven months. Therefore, electrical bone growth stimulator was and is likely to be more beneficial for treatment of the patients medical condition than the available therapy options. Final Result: Two of three reviewers determined that the  services at issue were and are likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: Physician reviewers number one, two, and three are board certified in podiatry and 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 56-year-old female enrollee has requested Hycet  liquid hydrocodone 2.5mg/acetaminophen 108 ml for treatment of her osteoarthritis.  Findings:  The physician reviewer found that the current standard of care for chronic pain due to osteoarthritis is treatment in a multidisciplinary practice to include physical therapy, massage therapy, behavioral therapy, and injections to help reduce pain. There are a variety of anti-convulsants and anti-depressants considered adjunctive to this therapy. Short release and short acting opioids are associated with a high risk of dependence and tolerance. Thus, long-term administration is not recommended (Fishman). Further, Baron and McDonald reported that high dose and short acting opiates might contribute to pain sensitization via opioid-induced hyperalgesia, decreasing patient pain threshold, and potentially masking resolution of a preexisting pain condition. In this retrospective study, the majority of patients undergoing detoxification of high dose opiates for chronic pain reported a significant decrease in pain at the end of the study, further supporting the theory of opioid-induced hyperalgesia. Similarly, Ballantyne and Mao reported that prolonged use of high dose, short-acting opiates might induce tolerance, and abnormal pain sensitivity. For these reasons, it is in the patients best interest to wean off of opioids. Therefore, Hycet as requested by the patient is not supported as medically necessary for treatment of her medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld

At issue is whether the 4Kscore protein biomarker testing that was performed was likely to have been more beneficial for evaluation of the enrollees condition than any available standard therapy. The enrollee has a history of an elevated prostate specific (PSA) antigen level. He was diagnosed with benign prostatic hyperplasia, elevated prostate specific antigen, and a family history of malignant neoplasm of the prostate.Three out of three medical experts decided that the 4Kscore protein biomarker testing performed was not likely to have been more beneficial for you than any available standard therapy. The National Comprehensive Cancer Network (NCCN), European Association of Urology (EAU), and American Urological Association (AUA) guidelines recommend considering a 4Kscore protein biomarker for certain patients.  The guidelines do not consider the test as a standard of care for all patients with elevated PSA. There is insufficient data on clinical outcomes to currently support routine use in screening men for prostate cancer.Final Result: The reviewers determined that the requested test was 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 urology 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 the compound medication levothyroxine sodium 100%, microcrystalline cellulose, liothyronine sodium 100%, capsule coni-snap and hypromellose for treatment of the enrollees hypothyroidism. Findings:  The physician reviewer found that the medical records fail to demonstrate the medical necessity of the requested medication compound in this clinical setting. The patients vitals appeared stable with a heart rate of 70 and blood pressure of 116/81. The patients body mass index was noted as 30.6. The records did not provide a clinical reason as to why this patient could not try preparations T4 and T3 as treatment options. The records do not indicate treatments or objective data to support the patients request for the medication compound. Therefore, the records provided have not established that the requested medication compound is medically indicated in this patients case.  Instead, preparations T4 and T3 should be tried as first line therapies in the treatment of this patients hypothyroidism. In sum, the compound medication levothyroxine sodium 100%, microcrystalline cellulose, liothyronine sodium 100%, capsule coni-snap and hypromellose is not medically necessary for treatment of this patients medical condition. Final Result: The reviewer determined that the medication compound 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 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.
Appeal type: Medical Necessity
Decision: Upheld

The parent of a 14-year-old male enrollee has requested a Xopenex inhaler for treatment of the enrollees asthma. Findings:  The physician reviewer found that levalbuterol, the R-isomeric form of albuterol, was developed to increase the efficacy of bronchodilation while decreasing side effects such as tachycardia and loss of potency. However, in head-to-head studies, levalbuterol has not consistently been shown to be more efficacious, nor has it demonstrated decreased unwanted effects, when compared to racemic albuterol. In the case of this patient, the provider decided to change rescue bronchodilator therapy from albuterol to levalbuterol, without introduction of a preventive medication such as inhaled corticosteroid. There is no documentation that the patient was experiencing unwanted side effects from racemic albuterol, and no objective data to demonstrate better asthma control with levalbuterol. Therefore, in the absence of clear documentation of a contraindication to the use of racemic albuterol, the use of levalbuterol is not medically necessary in this patient.
Appeal type: Medical Necessity
Decision: Overturned

A 21-year-old male enrollee requested authorization and coverage of an insulin pump and related supplies. The Health Plan denied the request indicating that the requested equipment is not medically necessary for treatment of the enrollees type I diabetes.One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer overturned the Health Plans denial on the basis that the requested equipment is medically necessary.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for transcatheter closure of the left atrial appendage and one day inpatient stay for treatment of the enrollees atrial fibrillation. Findings:  2/3 of the physician reviewers found that the Watchman device is U.S. Food and Drug Administration (FDA) approved and has been shown to be safe and successful in a high percentage of patients. However, the guidelines suggest use of the device in patients with contraindications to anticoagulants. Randomized studies have not shown that the use of the Watchman device is superior to medical treatment. The clinical documentation submitted for review fails to demonstrate that the patient has a contraindication to anticoagulants. Therefore, the request for transcatheter closure of the left atrial appendage and one day inpatient stay are not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Final Result: 2/3 of the 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: Physician reviewer number one is board certified in internal medicine with sub-specialty certification in cardiovascular disease and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.Physician reviewer number two is board certified in internal medicine with sub-specialty certification in cardiovascular disease and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.Physician reviewer number three is board certified in internal medicine with sub-specialty certification in cardiovascular disease and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

A 66-year-old male enrollee requested authorization and coverage of enhanced external counterpulsation (EECP). The Health Plan denied the request indicating that the requested therapy is not medically necessary for treatment of the enrollees coronary artery disease.One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer upheld the Health Plans denial on the basis that the requested therapy is not medically necessary.
Appeal type: Experimental/Investigational
Decision: Overturned

The parent of an 11-month-old female enrollee has requested evaluation and treatment of swallowing dysfunction and manual electrical stimulation (e-stim) therapy for the treatment of the enrollees dysphagia. Findings:  Two physician reviewers found that this female patient has complex medical problems and disabilities resulting in significant feeding difficulties. She is currently receiving comprehensive feeding therapy, involving multiple modalities, including the use of e-stim. She has shown improvement as a result of this intensive therapy. The literature supports the use of e-stim for patients with dysphagia and feeding difficulties. Carnaby-Mann and Crary (2007) noted, Transcutaneous electrical stimulation involves the application of electrical current across the skin to excite nerve or muscle tissue during a functional task and concluded, this preliminary meta-analysis revealed a small but significant summary effect size for transcutaneous NMES [neuromuscular electrical stimuation] for swallowing.  Numerous speech and language pathologists utilize this modality in their treatment of patients with dysphagia. The same authors in 2008 noted that, a systematic therapy for chronic pharyngeal dysphagia using adjunctive neuromuscular electrical stimulation (e-stim) produced improvement in clinical swallowing ability and functional oral intake without significant weight loss or complications. Finally, Shaw and colleagues concluded, VitalStim therapy clearly has a place in the management of dysphagia. In sum, the literature supports the adjunctive use of e-stim in the treatment of patients with dysphagia and feeding difficulties in this patient population.