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

A 59-year-old male enrollee has requested a power operated wheelchair for the treatment of his symptoms associated with multiple sclerosis. Findings:  The physician reviewer found that the patient does not have a documented mobility deficit that affects his ability to perform mobility related activities of daily living (ADL) within his home. Although he appears to feel weaker at times, there is no documentation that he is unable to perform normal ADLs within his home at those times. It appears that the patient is requesting a power wheelchair mainly for use outside the home. He does not meet the criteria for a power operated vehicle as he does not have a mobility related deficit that keeps him from performing or completing ADLs within his home. If he does indeed have intermittent mobility related deficits that affect his ability to perform ADLs, there is no documentation that his deficits cannot be ameliorated with the use of a walker or cane. Lastly, there is no documentation that the patient is not able to propel a manual wheelchair. Hence, he does not meet the criteria for a power operated vehicle. If he is at increased morbidity risk due to his mobility deficit, a cane, walker or manual wheelchair must have failed to correct this deficit before guidelines for a power operated vehicle are met.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/ Case Summary:  The enrollee requested reimbursement, and authorization and coverage for a CPAP machine. The enrollee has a history of obesity, with a body mass index of 34.45 and obstructive sleep apnea (OSA). At a follow up visit with his pulmonologist for hypersomnia, the enrollee indicates he feels better when he uses the CPAP machine all night, but he has problems with his CPAP mask. Physical exam showed a small blister on the left side of the bridge of the enrollees nose, so a referral for mask fitting by respiratory therapist was made. The enrollee indicates his compliance with more regular CPAP use has been affected because of the facial blister caused by the CPAP mask. Clinical practice guidelines strongly recommend the use of positive airway pressure (PAP), compared to no therapy, to treat obstructive sleep apnea (OSA) in adults with excessive sleepiness. The guidelines also recommend adequate follow-up, including troubleshooting and monitoring of objective efficacy and usage data to ensure adequate treatment and adherence, at PAP therapy initiation and during treatment of OSA. Consistent with the enrollees facial blister, literature indicates nasal skin lesions, including erythema, and ulcers at the site of mask contact, increases with longer CPAP durations, and is a common adverse effect that discourages enrollee compliance to CPAP use. As a result, the literature indicates the choice and application of the CPAP mask in patients with OSA is a challenge that greatly affects long-term compliance to PAP therapy. As per a study in the medical literature, the best mask is the one the enrollee will wear. It is unclear which type of CPAP mask the enrollee currently uses. However, regardless of the type, the enrollees record indicates non-compliance with CPAP use is because of the mask fitting. Current guidelines strongly recommend CPAP use for patients with OSA and hypersomnia, as is the case with this enrollee.Final Result: The reviewer determined that the requested services were and are medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The physician reviewer is licensed in sleep 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 similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

A 45-year-old male enrollee has requested an out-of-network referral for a second opinion as well as proton beam radiation therapy for treatment of the enrollees chordoma. Findings:  The physician reviewer found that the submitted documentation supports the medical necessity of a portion of the requested services.  Chordomas are rare tumors arising along the central nervous system axis anywhere from the cranium/base of skull to the sacrum, derived from notochord cells. These tumors are relatively radiation resistant and efforts are needed to escalate the dose to achieve a reasonable likelihood of tumor control.  As chordomas are rare tumors, and cervical location relatively uncommon, the quantity and quality of studies is low.  Specifically, there is a lack of comparison studies of outcomes after proton beam radiation therapy versus photon therapy specifically for cervical chordomas.  The primary advantage of proton therapy is the ability to escalate the dose to the target while maintaining acceptable dose delivery to the normal critical tissues of the central nervous system. In this case, given the relative resistance of chordomas to radiation and the cervical spine location of the tumor, there is some support for proton beam radiation therapy.  However, based upon the submitted records, the relative efficacy of the in-network versus out-of-network treatment plans is not clear.  Evaluation by an out-of-network provider is needed to allow for comparison of dosimetric plans.  Thus, the medical necessity of the requested proton beam radiation therapy has not been established, as quantitative dosimetric values are needed.  All told, the requested out-of-network referral for a second opinion is medically necessary in this clinical setting, and the medical necessity of proton beam radiation therapy has not been established at this time.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/ Case Summary:  The enrollee is requesting authorization and coverage for a procedure to repair ventral hernia(s) and remove excessive and redundant skin and subcutaneous tissue of the abdomen and pannus. The enrollee has panniculitis. At an office visit, her general surgeon noted she had a ventral hernia and two umbilical hernias. The enrollee complained of excess skin that impeded her ability to undergo repair of her hernias. She also complained of a left groin bulge with associated pain. The enrollee previously weighed 445 pounds and now weighs 254 pounds. She has maintained this weight for the past three years with minor fluctuations. She was referred to a plastic surgeon, who noted the enrollee had a significant abdominal pannus, which may interfere with the hernia repairs due to the redundant skin and soft tissues. She has a history of recurrent skin breakdown and skin infections underneath the overhanging pannus, which have required topical and oral antibiotic treatments. Documentation shows a 43% body weight loss and a significant abdominal pannus, with a recurrent history of skin breakdown and infections underneath the overhanging pannus.  This condition constitutes an abnormal structure of the body, which has been caused by the disease of obesity. The review of systems is positive for skin rash.  The concurrent ventral hernia repair and panniculectomy will decrease dermatitis, and improve hygiene, mobility, and overall quality of life. The medical literature notes panniculectomy can be safely performed when indicated. A study shows the addition of a panniculectomy to ventral hernia repair does not increase complications that require an intervention. Ventral hernia repair with concurrent panniculectomy can be considered in obese patients with a symptomatic panniculus who wish to have a single-stage operation. This procedure is medically necessary for this enrollee because, based on photography in the record, the enrollees pannus is hanging below the pubis; there is documentation of recurrent skin infections and breakdown; the enrollee has had a weight loss of 191 pounds, which has remained stable over the last three years, and the procedure will be performed concurrently with ventral hernia repairs. The procedure will improve the functional impairment caused by the chronic rashes and will create a more normal appearance. Additionally, the requested procedure would provide more than a minimal improvement in the appearance of the enrollee.  Final Result: The reviewer determined that the requested services are medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The physician 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 similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

The patient is a 49-year-old male who is paraplegic with a history of polio quadriplegia who is requesting authorization for a manual wheelchair. He indicates he has a power-operated vehicle (POV) and a manual wheelchair and is seeking a replacement for his manual wheelchair. The patient states he only utilizes the POV for work and cannot use the POV at home. The Health Plan indicates that because the patient already has a POV, a manual wheelchair is not medically necessary. A review of the information provided indicates the patient has requested a manual wheelchair because his current manual wheelchair needs to be replaced and he cannot utilize his POV in his home secondary to access issues. Generally, two wheelchairs are not considered medically necessary. In this instance it is unclear why this patient has a POV for work only and why the POV was authorized if there were access problems in the patients home. Further, the information provided does not demonstrate why a new manual wheelchair is necessary. Therefore, this patient requires an updated physical therapy and access evaluation to determine what equipment this patient requires. As such, I have determined the requested equipment is not medically necessary at this time. The Health Plans denial should be upheld at this time. However, the patient should be provided an updated physical therapy and access evaluation to appropriately determine the patients equipment needs.
Appeal type: Medical Necessity
Decision: Overturned

 The records indicate the patient has failed first-line therapies with high potency topical steroids, Humira, and methotrexate. Additional treatment has included triamcinolone and clobetasol. Psoriasis was noted to cover 10 percent of his body surface area. The patient began taking Otezla on 6/25/18 and was noted to have good therapeutic effect. The patient has requested coverage for Otezla 30mg. The Health Plan denied the requested and reported the requested medication is not medically necessary for the treatment of this patient. At issue in this case is whether Otezla 30mg is medically necessary for treatment of this patients medical condition. Psoriasis is a chronic inflammatory skin disease that presents with sharply demarcated, inflammatory, erythematous plaques with characteristic silver-white scaling due to epidermal hyperproliferation and parakeratosis secondary to the inflammation. Psoriasis has a high negative impact on the quality of life, especially in patients moderately or severely affected by the disease. Approximately 20 percent of patients require treatment with systemic drugs and up to 30 percent of psoriatic patients develop psoriatic arthritis. The long-term use of traditional systemic therapies is not recommended due to renal, hepatic, pulmonary toxicity and limited efficacy. Moreover, traditional systemic therapies for psoriasis, including methotrexate and cyclosporine, as well as anti-tumor necrosis factor (anti-TNF) drugs may develop adverse events. Otezla, an oral phosphodiesterase-4 (PDE4) inhibitor, is a U.S. Food and Drug Administration (FDA) approved therapeutic option for the treatment of patients with moderate to severe plaque psoriasis. Adequate data from the first phase III study demonstrated the efficacy of Otezla in patients with plaque psoriasis (Papp, et al; Gottileb, et al.; Crowley, et al.). Otezla demonstrated significant improvements in mean percentage change in psoriasis area, severity index (PASI) score, and in pruritus. Furthermore, PASI response was maintained over 52 weeks with continued Otezla treatment (Gottileb, et al.). The records indicate that this patient has failed first-line therapies with high potency topical steroids, Humira, and methotrexate, in addition to triamcinolone and clobetasol. Given the support in the medical literature, Otezla 30mg is medically necessary for treatment of this 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 dermatology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

The patient is a 20-year-old male who was rendered a paraplegic as a result of a pool dive. He is involved in appropriate rehabilitation. The patients physician has recommended a standing frame for the purpose of attaining weight bearing on his lower extremities. The Health Plan has denied this request indicating the requested equipment is not medically necessary for treatment of the patients medical condition.The standing wheelchair was developed for patients such at this patient to improve their quality of life and maintain reasonable health. Considering the patients young age, every strategy and modality has to be applied to ensure that he can survive without major medical complications and lead a reasonably productive life. The standing frame is essential to the welfare of this patient and should be authorized. Therefore, I have determined that the requested equipment is medically necessary for treatment of the patients medical condition. The Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a two-year-old male enrollee has requested for speech therapy for treatment of the enrollees expressive speech delay.  Findings:  The physician reviewer found that there is robust medical literature supporting speech therapy in this speech delayed population including the meta-analysis from Law and colleagues that reported that children with speech delay can be readily treated. Goorhuis-Brouwer and Kniff specifically deals with speech-delayed children, such as this possibly cognitively normal child, and points out that such normal, as well as cognitively delayed, children are candidates for successful speech therapy. Emanuel and colleagues specifically addressed the accuracy of speech testing in a two-year-old population.  Speech therapy is medically indicated in this patients care.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Harvoni for treatment of the enrollees chronic hepatitis C virus genotype 1a. 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. This applies regardless of fibrosis stage or viral load, and advanced fibrosis is not required for treatment. 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. The AASLD/IDSA guidelines cite data showing reduced survival with delayed treatment. 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: Overturned

Nature of Statutory Criteria/Case Summary:  An enrollee requested radiofrequency ablation of the tongue base for treatment of his obstructive sleep apnea.  Findings:  The physician reviewer found that according to the documentation submitted for review, this patient has documented obstructive sleep apnea and has tried and failed CPAP and an oral appliance. According to the medical literature Radiofrequency ablation (RFA) can be considered as a treatment in patients with mild to moderate obstructive sleep apnea who cannot tolerate or who are unwilling to adhere to positive airway pressure therapy, or in whom oral appliances have been considered and found ineffective or undesirable. Furthermore, the medical literature shows that treatment to the base of the tongue is the most effective in improving the quality of life and reducing obstructive sleep apnea symptoms. Based on the medical literature and clinical documentation provided, radiofrequency ablation of the tongue base is medically necessary for treatment of the patients medical condition. Final Result: The reviewer determined that the requested services are medically necessary for evaluation of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in otolaryngology with sub-specialty certification in sleep 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: Urgent Care
Decision: Upheld

A 48-year-old male enrollee has requested emergency room services for the treatment of his medical condition. Findings:  The physician reviewer found that the prudent layperson standard for an emergency requires that the patients condition be of acute onset and of such severity that a prudent layperson would believe the patients health to be in jeopardy without immediate medical attention. Based on the medical records provided for review, the patient did not have exhibit any symptoms or signs that would constitute an emergency. Upon presentation to the emergency room, the patients condition was stable. His vital signs and physical examination were normal. His symptoms of mild dysuria and penile discharge had been present for one week. It is not likely that these circumstances would cause a prudent layperson to reasonably believe that his health would be in serious jeopardy in the absence of immediate medical attention. It appears that a prudent layperson in this situation would make the decision that this was a non-emergent presentation.
Appeal type: Medical Necessity
Decision: Overturned

A 45-year-old male enrollee has requested Cialis for treatment of his age-related erectile dysfunction. Findings:  The physician reviewer found that Cialis is an accepted treatment and primary therapy for erection failure. The treatment of erectile dysfunction is goal-directed. Cialis is a phosphodiesterase (PDE) type 5 inhibitor, which is a class of drug that has been shown to be safe and effective. There are only a few particular clinical situations in which PDE type 5 inhibitors cannot be used safely. In this patients case, the underlying cause of his erectile dysfunction (ED) has been related to his age alone, and not due to other underlying factors. After the age of 40, there is a progressive loss of erectile ability which is presumed to be caused by early vascular disease. The studies by Laumann, et al., Chew, et al. and Johannes, et al. show that age alone is a significant risk factor for ED, with the risk being 2% to 8% in patients aged 40 to 49 years. The degree of the ED varies from partial to complete in such patients. Therefore, individuals in the patients age group are appropriate candidates for ED therapy using PDE type 5 inhibitors. In addition, this patients prior positive clinical response to Cialis is additional support to justify its medical necessity for treatment of this patients ED.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary:  An enrollee has requested authorization and coverage for matrix associated autologous chondrocyte implantation (MACI) for a derangement of the left knee.Findings: Two out of three physician reviewers found that matrix associated autologous chondrocyte implantation (MACI) for a derangement of the left knee is likely to be more beneficial for the enrollee than any available standard therapy.MACI is a well-established treatment for full-thickness cartilage defects. Favorable MACI outcomes have been demonstrated in several significant studies. A study by Saris and colleagues found statistically significant improvements in pain, function, and quality of life for patients who underwent MACI compared with microfracture surgery. The improvements that were noted in patients that underwent MACI were sustained at a minimum of two years with the MACI technique. A five-year follow-up study published by Brittberg and colleagues further demonstrated clinical durability when compared with microfracture treatment. MACI was approved by the U.S. Food and Drug Administration (FDA) for symptomatic, single or multiple full-thickness cartilage defects of the knee with or without bone involvement in adults with no size restriction and for any surface of the knee, including patellofemoral joint. A study by Ebert and colleagues concluded, MACI provided high satisfaction levels and tissue durability beyond 10 years. The outcomes of this randomized trial demonstrate a safe 8-week weight-bearing rehabilitation protocol without jeopardizing longer-term outcomes. In this case, the patient has several full-thickness chondral defects following a severe knee injury. The patients condition has been shown by the medical literature to be effectively managed by MACI. Per the records, severe pain and disability not responding to conservative treatment persisted. The patients BMI of 31.8 is not a contraindication for MACI. According to FDA guidelines, the BMI cut-off is 35. Therefore, MACI for a derangement of the left knee is likely to be more beneficial than any other available standard therapy for the patients condition.Final Result: The reviewers determined that the requested service is likely to be more beneficial than any available standard treatment for the patients medical condition. Therefore, the Health Plans denial should be overturn.Credentials/Qualifications: The reviewer 1, reviewer 2, and reviewer 3 are board certified in 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.