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

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement and prospective authorization and coverage for intensive outpatient program (IOP) level of care services. The records provided for review do not support the IOP level of care services provided. The documentation reported that the patient was progressing with controlling her symptoms. The patients mood was euthymic and she was interactive with others. The patient was able to stop a binge eating episode. The patient was compliant with her Lamictal and Wellbutrin. The records indicate the patient has been able to function and attend to her activities of daily living. The patient was engaged in treatment and motivated for recovery. Therefore, the patient was a candidate for treatment in a less restrictive environment in a routine outpatient setting. Accordingly, the IOP services provided were not and are not medically necessary. Final Result: The reviewer determined that the services at issue were not and 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 psychiatry and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested cervical artificial intervertebral disc surgery for treatment of his medical condition. Findings: Three physician reviewers found that the requested services are not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The evidence based medical literature does not support single-level artificial disc replacement in the setting of multilevel cervical degenerative disc disease. This patient presents with cervical pain radiating into the left arm with numbness and complaints of balance issues. Clinical exam findings evidenced decreased bilateral C5, C6, and C7 reflexes with no significant sensory or motor loss. Imaging demonstrated multilevel significant degenerative disc disease with cord compression at the C4-5 level, according to both the radiologist and treating physician. There is a lack of compelling rationale presented to support the proposed C4-5 artificial disc replacement over standard anterior cervical discectomy and fusion for this patient in the setting of multilevel cervical degenerative disc disease. Therefore, the requested cervical artificial intervertebral disc surgery is not likely to be more beneficial for treatment of the patients medical condition than any available standard treatment.  Final Result: Three reviewers determined that the requested services are not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld.  Credentials/Qualifications: All three physician reviewers are board certified in orthopedic surgery 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 47-year-old female enrollee has requested for Botox injections for treatment of her intractable migraine headaches.   Findings:  Two physician reviewers found that Botox therapy has been widely accepted in specialty headache centers as a useful headache preventive regimen, based on published data as well as completed, but not yet published pivotal trial data from treatment of chronic migraine patients.
Appeal type: Experimental/Investigational
Decision: Upheld

 Nature of Statutory Criteria/Case Summary:   An enrollee has requested Familial Adenomatous Polyposis (FAP) and/or Lynch Syndrome gene testing for evaluation of her medical condition. Findings:  Two physician reviewers found that the requested FAP and Lynch Syndrome gene testing is not likely to be more effective for this patient than other available options. This patient does not meet the definition of high risk colorectal cancer syndromes according to the National Comprehensive Cancer Network (NCCN) guidelines. She also does not meet Amsterdam or Bethesda criteria. Thus, the requested gene testing is not likely to be more beneficial than her current standard therapy of increased surveillance with colonoscopy. Final Result: Two reviewers determined that the requested services are 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:  All three reviewers are board certified in internal medicine with sub-specialty certification in medical oncology 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: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Repatha Sureclick pen injector. Repatha (evolocumab) is a proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitor studied in and approved for patients with heterozygous familial hypercholesterolemia or for patients with documented atherosclerotic heart disease who require additional lowering of LDL cholesterol. This patient fits the latter criteria. In this setting, several prospective randomized trial have demonstrated safety, significant reduction in LDL cholesterol and outcomes improvement with the addition of PCSK9 inhibitors. Therefore, Repatha Sureclick pen injector is medically necessary for the treatment of this patient.  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 cardiovascular disease and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary:  An enrollee has requested Viekira Pak for treatment of his hepatitis C.  Findings: The physician reviewer found that according to the most recent joint guidelines issued by the American Association for the Study of Liver Diseases and the Infectious Diseases Society of America, all patients with chronic hepatitis C, regardless of fibrosis, should be treated except those with limited life expectancy due to non-liver-related comorbid conditions.  Per the guidelines, treatment-naive genotype 1a patients should be treated with Viekira Pak and ribavirin for 12 weeks. The recommendation applies regardless of fibrosis stage or viral load.  For these reasons, Viekira Pak is medically indicated for the treatment of this patient.  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 73-year-old man who experienced an intertrochanteric hip fracture five months ago underwent a DEXA scan, which suggested osteopenia in the opposite hip and probable osteoporosis of the spine. He has been taking calcium citrate. No workup for the etiology of his fragility fracture is presented in the information provided. The patients physician wishes to begin treatment with Forteo. The Health Plan has denied authorization and coverage for Forteo on the basis it is not medically necessary for treatment of the patients medical condition.The Health Plans recommendations are in line with most recommendations to reserve Forteo for patients who meet the following criteria: failed other treatments defined as statistically/clinically significant decreases in bone mineral density; occurrence or recurrence of fragility fractures while on treatment; intolerance to other treatments; severe osteoporosis usually defined as T-scores <-4.0; or other high risks for fractures such as old age, family history of hip fractures, or smoking or as assessed by various fracture risk indices. The submitted records do not demonstrate the patient meets any of these criteria. The patients physician does not document any etiology for the patients osteopenia or indicate whether the patient has any additional risk factors. The Health Plans recommendation of a formulary bisphosphonate is a medically reasonable alternative. Based upon the information set forth above, I have determined that the requested medication is not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld

A 55-year-old female enrollee has requested for an in vitro chemo-sensitivity test for evaluation of her breast cancer. Findings:  The physician reviewer found that there is a lack of peer-reviewed, randomized clinical trials showing the clinical benefit of using this technology to decide on the chemotherapy regimen to be used. As per the American Society of Clinical Oncology guidelines, use of these tests has not been shown to improve survival or quality of life.
Appeal type: Experimental/Investigational
Decision: Upheld

A 26-year-old female enrollee requested a blood test for measurement of serum concentration of infliximab and antibodies to infliximab for medical evaluation of the enrollees ulcerative colitis.  Findings:  Two physician reviewers found that the requested services were not likely to have been more effective than other methods of evaluation.  There is a lack of support for the measurement of infliximab levels and antibodies to infliximab in this clinical setting.  The appropriate drug level to target has not been clearly established.  The incremental benefit of this testing beyond clinical care has not been demonstrated when assessing efficacy.  Although high levels of antibody have been associated with lower drug levels and infusion reactions, these antibodies have not been consistently demonstrated to have neutralizing capabilities in vitro.  All told, the blood test for measurement of serum concentration of infliximab and antibodies to infliximab was not likely to have been of greater benefit than other modalities for evaluating this patient.
Appeal type: Medical Necessity
Decision: Upheld

A 46-year-old female enrollee has requested a bariatric surgery consultation for treatment of her obesity.  Findings:  The physician reviewer found that this patients records of last year document a BMI of less than 40 without serious comorbid conditions. After her previous bariatric procedure, she maintained roughly 50 of the 80 pounds lost, without evidence of any anatomical complication of the prior gastric bypass. Thus, revisional surgery with placement of a Lap-Band would not likely improve or affect her condition (Patel, et al). In general, revisional bariatric surgery is not without risk and there should be documentation of failure of maximal conservative treatment with aggressive dietary and behavioral efforts prior to consideration for the procedure (Bessler, et al). This is particularly relevant if there are no documented complications that need to be corrected (Chin, et al). As in this patients case, there are no suspected or documented complications of the original gastric bypass procedure. In addition, there is inadequate evidence of compliance with dietary and behavioral follow-up since her surgery or recent dietary or behavioral evaluations. For these reasons, the requested consultation for possible revisional bariatric surgery has not been established as medically necessary for the management of this patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for removal of myelolipoma from the right adrenal gland for the treatment of the enrollees myelolipoma. Fulfills requirements of (1374.33) (h)(1)(A), (B), and (C).Findings:  The physician reviewer found that the physician reviewer determined that angiomyolipoma of the adrenal gland is a benign tumor that may cause symptoms due to the mass effect on adjacent organs or the retroperitoneum. It does not appear to either have biochemical/functional consequences, nor does it appear to have malignant potential. Therefore, therapy can be observation when the diagnosis is clear. If the diagnosis is unclear, then resection may be indicated to eliminate the possibility of a soft tissue lipomatous tumor. In selected cases, surgical resection may be indicated for relief of symptoms. In this patient's case, the diagnosis was clearly made on a core biopsy. Although the patient is complaining of abdominal pain, it is unclear if it is directly related to this tumor, as the patient also has a recurrent hernia. In addition, the pain is only of two months duration, and the tumor has been present for at least four years. Based on the records, the tumor does not appear to be rapidly enlarging in which imminent symptoms may prompt surgical resection. All told, the requested removal of myelolipoma from the right adrenal gland is not medically necessary for the treatment of this patient. Fulfills requirements of (1374.33)(h)(1)(H) and (K).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. Fulfills requirement of 1374.33(h)(1)(I)Credentials/Qualifications: The reviewer is board certified in 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. Fulfills requirement of (1374.33)(h)(1)(G)
Appeal type: Experimental/Investigational
Decision: Upheld

A 54-year-old male enrollee has requested three platelet rich plasma injections for medical treatment of his medical condition. Findings:  Three physician reviewers found that there is a lack of support for the use of platelet rich plasma injections for the treatment of the tissue injury sustained by this patient.  While platelet rich plasma injections have been utilized in a variety of applications, including lateral epicondylitis, rotator cuff tears and a number of other tendinopathies, the evidence for efficacy is limited.  Specifically, there is an absence of randomized studies with sufficient size to control for unknown variables.  Thus, due to the lack of documentation of efficacy, the requested platelet rich plasma injections are not likely to be of greater benefit for the treatment of this patients condition than other treatment options.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a 17-year-old male enrollee has requested  residential treatment center (RTC) level of care services for treatment of the enrollees behavioral health issues.  Findings:  The physician reviewer found that the providers who evaluated this young patient at the time of admission documented that he required long-term treatment in an inpatient setting, with an eye towards gradually stepping him down through levels of treatment. The patient presented with questionable psychotic symptoms intermittently. The psychologist who evaluated and treated this patient over a period of months stated that the patient, presented with one of the most serious cases of major depression I had ever treated during his 17 years of practice. In addition, the patients medications were still being titrated during his inpatient stay, and events were further complicated by the evolution of tics, necessitating holding his medication, treating the tics, and resuming his medications. Moreover, he continued to have intermittent, recurring sleep disturbance, suicidal ideation, and a desire to use substances throughout his inpatient hospitalization. Thus, it was reasonable for the patients providers to have expected that any attempts at treatment would require long-term therapy with gradual advancement in order to best serve the patients interests. Given the gravity of his symptoms, a lesser level of care would not likely have been adequate for managing the patients condition. For these reasons, the RTC services at issue have been demonstrated as medically necessary and appropriate for treatment of his condition on the said dates.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested digital breast tomosynthesis for evaluation of the enrollees medical condition.  Findings: Three physician reviewers found that the digital breast tomosynthesis was likely to be more beneficial for evaluation of the patients medical condition than available standard modalities. Ciatto and colleagues investigated the effect of integrated two-dimensional (2D) and three-dimensional (3D) mammography in the breast cancer screening population. The authors found that Integrated 2D and 3D mammography improves breast cancer detection and has the potential to reduce false positive recalls. Based on the medical literature cited above, the use of breast tomosynthesis was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Final Result: Three reviewers determined that the service at issue was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: All three physician reviewers are board certified in diagnostic radiology 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

A 61-year-old male enrollee has requested for Tarceva, Tykerb, Nexavar and sodium phenylbutyrate for treatment of his squamous cell carcinoma. Findings:  Three physician reviewers found that NCCN guidelines for the treatment of squamous cell cancer of the head and neck suggest clinical trial, as no optimal treatment regimen has been identified. In the absence of a trial, cisplatin-based chemoradiation is considered the standard treatment. In this case, the patient declined radiotherapy and was given a platinum-based combination using the biological agents Tarceva and Avastin along with sodium phenylbutyrate. Since his progression, he has received additional biologics, but he has never received radiotherapy. None of the agents in question are considered appropriate for the treatment of head and neck cancers outside of a clinical trial. There is some date for Erbitux (cetuximab), an EGFR inhibitor similar to Tarceva, as a systemic therapy, particularly in unresectable disease. Other standard therapies that hold promise for this type of cancer include taxanes (docetaxel or paclitaxel) and gemcitabine.
Appeal type: Experimental/Investigational
Decision: Upheld

A 58-year-old female enrollee has requested photodynamic therapy used in conjunction with aminolevulinic acid hydrochloride for the treatment of her actinic keratoses. Findings:  Two physician reviewers found that the treatment of actinic keratosis can be achieved with both surgical and medical modalities. A commonly used treatment is surgical (i.e., cryotherapy). A study by Kaufmann and colleagues comparing photodynamic therapy to cryotherapy showed photodynamic therapy had inferior efficacy for treatment of non-face/scalp actinic keratosis. With regard to non-surgical treatment, topical medication such as fluorouracil is often used with good results. The submitted documentation does not establish the patient has received adequate trials of standard topical agents. Furthermore, the available published studies do not support the contention that photodynamic therapy is better than the standard therapies used in this setting.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Saxenda pen 3 mg/0.5 mL. Findings:  The physician reviewer found that clinical practice guidelines recommend diet, exercise, and behavioral modification in all obesity management approaches. The authors further note that patients with a history of being unable to successfully lose and maintain weight and who meet label indications are candidates for weight loss medications. The guidelines recommend continued use of weight loss medication if the patients response is deemed effective, with 5% or more body weight loss at three months, and safe. In this case, the patient has a history of obesity and has been unable to lose and maintain weight with diet and exercise alone. He has responded well to Saxenda, with 9% weight loss over the past three months. Given the current medical literature and the providers recommendation that the patient continue on weight loss medication, the requested medication is medically indicated. Therefore, Saxenda pen 3 mg/0.5 mL is medically necessary for the treatment of this patient.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 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: Overturned

The parent of a 13-year-old female enrollee has requested speech therapy for the treatment of the enrollees autism. Findings:  The physician reviewer found that children with autism have deficits in speech and language, as well as social communication. Therapists with experience working with children on the spectrum, handling the myriad of communication challenges that face these children, are most appropriate. While school services are essential, they are not sufficient for children with the severity of deficits as seen in this patient. The more aggressively these deficits are targeted, the better chance this patient has for developing adequate skills to function in the community.