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

Nature of Statutory Criteria/Case Summary: An enrollee has requested Forteo for treatment of the enrollees low density for age. Findings: The physician reviewer found that the review of the submitted documentation and relevant literature demonstrate the medical necessity of the requested medication. According to the National Osteoporosis Foundation guidelines for severe osteoporosis, sequential treatment with anabolic therapy followed by an antiresorptive agent is generally preferred to concomitant combination therapy (Cosman, et al). Teriparatide is an anabolic agent approved by the U.S. Food and Drug Administration (FDA) for the treatment of osteoporosis in postmenopausal women and men at high risk for fracture. Teriparatide reduces the risk of vertebral fractures by about 65% and non-vertebral fragility fractures by about 53% in patients with osteoporosis, after an average of 18 months of therapy (Cosman, et al). Denosumab is an antiresorptive agent that decreases the risk of spinal fractures by 68% and hip fractures by 40% and is indicated for the treatment of osteoporosis in men and women at high risk for fracture (Cosman, et al). Early studies have shown that the use of antiresorptive agent prior to or concomitant to teriparatide blunt the beneficial effects of teriparatide. It has been demonstrated that sequential monotherapy of teriparatide followed by an antiresorptive agent is more effective than monotherapy with an antiresorptive agent alone. It has been shown that the greater effect of teriparatide occurs after one year of therapy, and the benefit is maintained when followed by an antiresorptive agent (Black, et al). If teriparatide is not followed by an antiresorptive agent, all effect may be lost (Cosman, et al; Black, et al). In addition, the mechanism of osteoporosis in a person with anorexia includes a decrease in bone resorption (Fazeli, et al), therefore an antiresorptive agent may not be as effective as an anabolic agent such as teriparatide. Teriparatide has been shown to be effective in women with anorexia and men with secondary osteoporosis (Fazeli, et al; Orwoll, et al). In sum, treatment with teriparatide is medically necessary for this patient for one or two years followed by antiresorptive agent such as denosumab. The reverse order may have blunted results. All told, the request for Forteo has been established as medically necessary for treatment of the patients medical condition.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: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/ Case Summary:  The enrollee requested coverage for Laparoscopic Anti-Reflux Procedure Utilizing LINX Reflux Management System. According to the medical literature, experience with the LINX Reflux Management System confirms the initial safety profile that led to FDA approval of the device. The LINX results in long-term gastroesophageal reflux disease (GERD) control based on symptomatic outcomes, proton pump inhibitor utilization, and pH studies. The current medical literature shows LINX results in similar objective control of GERD, symptom resolution, and improved quality of life. LINX, by the medical literature, has less of the common side effects from which fundoplication patients often suffer and results in improvement in health outcomes.Final Result: Three of the three reviewers determined that the requested service was likely to be more beneficial than any available standard therapy for treatment of the enrollees medical condition. Credentials/Qualifications: Three reviewers are board certified in 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: Medical Necessity
Decision: Overturned

A 41-year-old female enrollee has requested coverage for acute inpatient psychiatric treatment for treatment of her bipolar disorder and bulimia.  Findings:  The physician reviewer found that modern psychiatric practice aims to place patients in the least restrictive treatment setting. In general and if feasible, community intervention settings are thought to offer optimization of treatment gains; however, placement in more restrictive settings is often clinically appropriate.  In this particular case, acute hospitalization was indicated.  Discharge on the date in question would have more than likely burdened the patient with undue morbidity and an elevated risk for readmission. On that date the patient was described as hopeless and suicidal per nursing, while the physician reported near constant suicidal thoughts and the patients fear that she might act on them. To release a patient from the acute setting under such circumstances would be inconsistent with the standards of good medical practice in this country.  Since that time, the patient has remained symptomatic with acute suicidal ideation and eating disordered behavior.  Per the medical records, the patient has not consolidated the treatment gains necessary to succeed at a lower level of care. Further, three days later, the patient stated she was all good with the exception of other patients triggering her while nursing notes reported no suicidal ideation and positive mood reactivity to visitors. The complexity of the medication regimen has not exceeded a threshold of unsuitability for a less restrictive treatment setting and there is no evidence of an acute medical issue that warrants inpatient medical care. Finally, on a subsequent date at issue, the patient began to explore core conflictual issues in therapy which represents a critically meaningful pursuit, but one that is inappropriate for the acute setting.  Accounting for the patients history, hospital course and documentation provided, and acknowledging the enduring unresolved intrapsychic conflicts, distorted sense of self and chronic suicidality, the patient has reached maximal hospital benefit. Thus, mobilization to a less restrictive setting is indicated. In order for the patient to consolidate her treatment gains, the inpatient services at issue were and are medically necessary for seventeen of the dates at issue. Any inpatient psychiatric services provided from the seventeenth day at issue onward are not medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned

A 61-year-old male has requested treatment including left radial approach cardiac catheterization, attempted percutaneous coronary intervention of the diagonal branch, and physiologic measurement of pressure loss across the tandem right coronary artery lesions, with stenting if fractional low reserve is positive for treatment of his two vessel coronary artery disease, total occlusion of diagonal artery, persistent angina and hypercholesterolemia.   Findings:  The physician reviewer found that this patient presents with coronary artery disease, persistent limiting angina, and provocable coronary ischemia in the territory of a known occluded diagonal branch.  In this circumstance of limiting angina despite a trial of adequate medical therapy, an attempt at opening up the occluded diagonal artery is medically indicated.  Persistent limiting angina that has failed medical therapy is an accepted indication for coronary revascularization.  However, there is no provocable ischemia in the distribution of the right coronary artery by stress echocardiography.  Thus, these asymptomatic right coronary lesions are best managed by risk factor modification without revascularization.  Fractional flow reserve measurement in the right coronary artery would not be expected to provide incremental information about right coronary ischemia beyond that already obtained from stress echocardiography.  Finally, while a radial approach to percutaneous revascularization may offer some potential mild advantages, a femoral approach has similar outcomes and has been a standard approach since the advent of percutaneous revascularization. The submitted medical records fail to demonstrate the medical necessity of the radial approach in this patients case.  All told, attempted percutaneous intervention of the diagonal branch is medically indicated in this patients case.  However, left radial approach cardiac catheterization and physiologic measurement of pressure loss across the tandem right coronary artery lesions, with stenting if fractional low reserve is positive, are not medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld

The patient has requested authorization and coverage for Lynparza (olaparib) 150 mg tablets, two tablets twice a day. Poly ADP ribose polymerase (PARP) inhibitors have shown promise for the treatment of certain cancers related to BRCA1 and BRCA2 mutations. There is a paucity of data in the current medical literature to support the use of PARP inhibitors, such as Lynparza, in the treatment of colon cancer. There are ongoing clinical trials evaluating the safety and efficacy of PARP inhibitors in combination with other drugs for the treatment of solid tumors. Although this patient has a somatic BRCA2 mutation, the available data do not support an indication for treatment with a PARP inhibitor. Based on these findings, the requested Lynparza (olaparib) 150 mg tablets, two tablets twice a day, is not medically necessary for treatment of this patient.Final Result: The reviewer determined that the requested medication is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in internal medicine with subspecialty certifications in medical oncology and hematology 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

An enrollee has requested authorization and coverage for hypoglossal nerve stimulator surgery. Findings:  The physician reviewer found that the patienthas a history of obstructive sleep apnea (OSA). He was treated with continuous positive airway pressure (CPAP) but he became intolerant to the therapy. The patient reported daytime somnolence. The patients provider recommended a surgical implantation of hypoglossal nerve stimulator. The Health Plan denied the requested services as investigational for the treatment of this patient. The hypoglossal nerve stimulator can be an effective therapy for certain patients diagnosed with OSA. However, in this patients case, the procedure is not likely to be superior to other methods of treatment for his medical condition. Although this patient has failed CPAP therapy, there was no documentation of nonconcentric airway collapse confirmed by sleep endoscopy.  As such, while hypoglossal nerve stimulator can be effective therapy for certain OSA patients, the requested services are not effective for this patient. Therefore, the requested hypoglossal nerve stimulator is not likely to be superior to other available modalities for treatment of this patient. Final Result: 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: the physician reviewers are board certified in otolaryngology 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 52-year-old female has requested a DEXA scan for the evaluation of her osteoporosis. Findings:  The physician reviewer found that DEXA scans at two-year intervals are satisfactory in following progress even taking into account this patients higher risk based on her mothers osteoporosis as well as the patients history of radiation and chemotherapy to treat her breast cancer. There is no data supporting yearly DEXA scans in this setting.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for CPT code 15877 (suction lipectomy trunk) and CPT code 17999 (skin tissue procedure) for treatment of her abdominal and flank lipodystrophy. Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the services at issue.  The medical records document significant weight loss following bariatric surgery.  The patient was noted to have mild to moderate soft tissue excess of the abdomen and flanks, for which she underwent abdominoplasty with liposuction of the upper abdomen and flanks. However, the submitted photograph shows evidence of only mild excess in the abdomen and flanks.  Further, the records do not document a functional deficit (e.g., disabling rashes, pain, physical limitation, back strain, etc.) that failed reasonable conservative management.  Therefore, CPT code 15877 (suction lipectomy trunk) and CPT code 17999 (skin tissue procedure) were not medically necessary for the treatment of this patient. With regard to whether the services at issue were reconstructive in nature, based on the records provided, the patients condition does not constitute an abnormal structure of the body.  The photograph shows evidence of only mild excess skin of the upper abdomen and flanks.  The patients appearance was consistent with a normal appearance of the upper abdomen and flanks.  In sum, the services at issue were not reconstructive in nature. Final Result: The reviewer determined that the services at issue were not medically necessary for treatment of the patients medical condition and were not reconstructive in nature. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in plastic surgery and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

A 41-year-old male enrollee has requested surgery by a colorectal cancer specialist for the treatment of his colon and rectal cancer. Findings:  The physician reviewer found that the relationship of surgical specialization to cancer outcomes remains controversial. In the management of colon and rectal cancer, there are publications to support improved outcomes when patients are treated by specialists, but more recent papers have demonstrated that the improvement is likely related to surgeon and/or hospital volume rather than specialization (Borowski, et al. and Martinez-Ramos, et al.). That is, equivalent outcomes can be obtained by non-specialists who perform a high volume of the procedure and conversely, a specialist who performs a low volume of an index procedure can have inferior outcomes. In this case, no evidence has been provided that the practice volume of the in-network physician is inferior to that of the out-of-network physician. Thus, it should not be assumed that the specialization of the out-of-network physician will ensure better outcomes (operative morbidity, mortality, or cancer-related survival). Therefore, given the lack of evidence to directly support specialization as an independent predictor of improved outcome, and the availability of an in-network surgeon who appears to understand the management of rectal cancer (through the decision to refer the patient for preoperative therapy), the medical necessity of a colon and rectal surgeon is not established.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for positron emission tomography (PET) scan with computed tomography (CT), skull to thigh for evaluation of the enrollee, who has a history of fatigue, palpitations, chest pain, shortness of breath and intermittent pain in the right shin and upper thighs. Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity for the requested services. In this patients case, the guidelines do not support the efficacy of the PET/CT. In recent years, PET/CT scanning has become increasingly common, primarily as a tool to evaluate the presence or extent of malignancy.  There are non-oncologic indications, such as evaluating fevers of unknown origins and dementias, but these are far less common. For this particular patient, the records do not demonstrate a clear indication for a PET/CT scan. The tiny pulmonary nodules that were noted are too small to be conclusively visualized on PET scans. The residual thymic tissue is not an unusual finding in this clinical setting, and there are no signs or symptoms in the legs that would warrant a PET/CT scan. The American College of Radiology (ACR) Appropriateness Criteria has published over 50 appropriateness criteria for various clinical presentations.  Under the heading of chronic extremity pain, PET/CT scanning is not mentioned as a possible tool. Additionally, there is no clinical information submitted to support the use of a PET/CT scan to evaluate the patients head.  There was some mention of fevers following a dental procedure two years earlier, but dental issues are not routinely evaluated by PET/CT scans. In sum, without a diagnosis of tumor, or without a recognizable abnormality that is likely to be considered a tumor, and for the other non-specific constitutional symptoms, there does not appear to be a clinical indication for PET/CT.  As such, PET/CT skull to thigh is not medically necessary for the evaluation of this patients medical condition. Final Result: The reviewer determined that the requested services are not medically necessary for evaluation of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in 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: Overturned

A female enrollee requested transcranial magnetic stimulation (TMS) therapy for medical treatment of her major depressive disorder.  Findings:  The physician reviewer found that the American Psychiatric Association has endorsed transcranial magnetic stimulation for the acute phase treatment of major depressive disorder after failure of at least one antidepressant trial.  In this case, the patient was experiencing symptoms consistent with an acute major depressive episode that was causing significant morbidity and functional impairment.  She had pursued standard therapies used to combat depression.  All told, the requested transcranial magnetic stimulation is medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Overturned

The parent of an eight-year-old female enrollee has requested continued speech therapy for the treatment of the enrollees congenital muscular dystrophy. Findings:  The physician reviewer found that the patients speech issues result from a congenital abnormality, as she has been diagnosed with congenital muscular dystrophy with dysarthria. The patients dysfunction is not self correcting. Based on the documentation provided, speech therapy has resulted in practical improvement within a reasonable time. The patient is likely to benefit from continued therapy and meets criterion for medical necessity.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested Subsys for treatment of her medical condition. Findings: The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested medication.  The current standard of care for chronic pain in this setting 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 anticonvulsants and antidepressants considered adjunctive to this therapy.  The reviewers 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.  Long-term opiates are more likely to cause adverse outcomes. Ballantyne and Mao reported that prolonged use of high-dose opiates might induce tolerance and abnormal pain sensitivity.  The current medical evidence does not support the requested medication in this clinical setting.  All told, the requested Subsys is not medically indicated for the treatment of this patient.  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 anesthesiology with sub-specialty 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.