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

Nature of Statutory Criteria/Case Summary: An enrollee has requested Zepatier and ribavirin for treatment of his hepatitis C virus.  Findings:  The physician reviewer found that according to the joint guidelines issued by the American Association for the Study of Liver Diseases (AASLD) and the Infectious Diseases Society of America (IDSA), all patients with chronic hepatitis C should be treated except those with limited life expectancy due to non-liver-related conditions. Per guidelines, patients with HIV co-infection are high priority for treatment. The guidelines state that Testing for resistance-associated variants (RAVs) that confer decreased susceptibility to NS3 protease inhibitors and to NS5A inhibitors is recommended for patients with HCV genotype 1, regardless of subtype, in whom previous treatment with any HCV nonstructural protein 5A (NS5A) inhibitors has failed, and who have  reasons for urgent retreatment. The specific drugs used in the retreatment regimen should be tailored to the results of this testing. Based on HIV co-infection, urgent treatment is needed in this case. This patient has no NS5A RAVs. The guidelines further state that For patients with no NS5A inhibitor RAVs detected, retreatment with ledipasvir/sofosbuvir and [ribavirin] RBV for 24 weeks is recommended.  This is based on a 100% cure rate in RAV-free patients who have failed Harvoni. There is also robust data supporting Harvoni in patients who have failed peginterferon/ribavirin with telaprevir (LONESTAR) and Harvoni in HIV co-infection (ION-4 trial). In contrast, there is a lack of clinical data supporting use of Zepatier or Zepatier/ribavirin in patients who have failed Harvoni; furthermore, Zepatier is not recommended by AASLD/IDSA guidelines in patients free of NS5A RAVs.  For these reasons, treatment with Zepatier and ribavirin for 16 weeks is not supported by current medical guidelines and clinical evidence as medically necessary for the treatment of this patients hepatitis C infection.Final Result: The reviewer determined that the requested medications 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 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

The patient is a 42-year-old female who is 59 weighing 238 pounds with a body mass index (BMI) of 35. She has comorbid conditions including diabetes, obstructive sleep apnea, gastroesophageal reflux disease (GERD), and hypertension. The patient has requested authorization and coverage for gastric bypass surgery. The Health Plan has determined gastric bypass surgery is not medically necessary for treatment of the patients condition.With a BMI of 35 and her comorbid conditions, the patient does not meet medical necessity criteria for weight loss surgery. There is potential that conservative care including dietary regimen, appropriate exercise, and behavioral support and modification could be effective in assisting the patient in weight loss. Therefore, given the risks and morbidity associated with gastric bypass surgery, further attempts at weight loss should be undertaken prior to consideration of surgery. Accordingly, I have determined that the requested procedure is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld

A 57-year-old male enrollee has requested for enhanced external counterpulsation for treatment of his chest pain. Findings:  The physician reviewer found that the documentation is not supportive of coronary ischemia or angina. An electrocardiogram revealed normal left ventricular systolic function. Based on these findings, clinical indications for enhanced external counterpulsation have not been met.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Harvoni tablets for treatment of the enrollees hepatitis C virus. Findings:  The physician reviewer found that according to the most recent joint guidelines issued by the American Association for the Study of Liver Diseases (AASLD) and the Infectious Diseases Society of America (IDSA), all patients with chronic hepatitis C should be treated except those with limited life expectancy due to non-liver-related conditions. The guidelines recommend that all patients should be treated, regardless of fibrosis stage. The guidelines recommend that treatment naive genotype 1 patients should be treated with Harvoni for 12 weeks. These guideline recommendations are based on multiple randomized clinical trials, and the medication is U.S. Food and Drug Administration approved for all patients with chronic hepatitis C genotype 1 regardless of fibrosis stage. AASLD/IDSA guidelines cite data showing reduced survival with delayed treatment. Final Result: The reviewer determined that the requested medication regimen 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

A thirty-four year-old female with injury to the low back is requesting reimbursement for the chiropractic services and prospective authorization for additional chiropractic treatments.Reviewers Findings:  The reviewing physician found that the record indicate that the patient improved with one treating session and the provider has requested only two additional treatments for this condition.  The reviewing physician found that the Health Plan denial should be overturned.
Appeal type: Medical Necessity
Decision: Overturned

A 23-year-old female enrollee has requested inpatient care for the treatment of her bulimia nervosa. Findings:  The physician reviewer found that this patient was suffering from both significant bulimia nervosa as well as major depression, and five days of inpatient treatment would have been insufficient for treatment of this patient.  The treatment notes demonstrate the extent of both of these problems for the patient.  Her psychiatrist approached her care with relevant and current pharmacologic considerations, although any of these medications take time to work.  The patients level of medical morbidity was substantial, and she warranted inpatient treatment.
Appeal type: Medical Necessity
Decision: Upheld

A 22-year-old female enrollee has requested for jaw surgery for treatment of her craniofacial abnormality. Findings:  The physician reviewer found that the documentation fails to establish the medical necessity of the requested jaw surgery.  The patient has not been diagnosed with a significant obstructive sleep apnea which would benefit from maxilla mandibular advancement.  The current medical evidence does not support the requested surgery in this clinical scenario.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the digital breast tomosynthesis for evaluation of the enrollees breast cancer screening. Findings:  2/3 of the physician reviewers found that the digital breast tomosynthesis performed was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The American College of Radiology (ACR) has urged tomosynthesis be removed from the investigational category due to the advantages it brings radiologists interpreting mammograms. Tomosynthesis allows the radiologist to separate dense glandular elements from underlying mass and architectural distortion resulting in an increase in accuracy, increase in detection of small cancers and decrease in callbacks compared to when imaging is done using the two-dimensional technique only. Thus, the digital tomosynthesis was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.  Final Result: 2/3 of the reviewers determined that the diagnostic procedure 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: Physician reviewer number one 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.Physician reviewer number two 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.Physician reviewer number three 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

Nature of Statutory Criteria/Case Summary:  An enrollee has requested a vascular surgery evaluation for treatment of her bilateral lower extremity varicose veins.  Findings:  The physician reviewer found that based on the available documentation, the requested vascular surgery evaluation is medically necessary to manage this patients compression hose, to rule out other causes for pain other than varicose veins, and to interpret diagnostic imaging in the presence of varicose veins. Further, the requested evaluation is consistent with the recommended management and treatment guidelines in the current medical literature. Thus, the requested evaluation with a vascular surgeon is supported as medically necessary for evaluation of this patients painful varicose veins.  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 surgery with sub-specialty certification in vascular 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: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for facial feminization surgery performed on 6/25/20. Findings:  The physician reviewer found that facial feminization surgery relieves gender dysphoria through harmonization with regard to other modified structures...achieving an aesthetic result beyond gender difference. Ainsworth and Spiegel demonstrated that facial feminization surgery, like genital surgery, improved mental health-related quality of life. The World Professional Association for Transgender Healths (WPATH) Position Statement on Medical Necessity of Treatment noted that non-genital surgical procedures, including facial feminization surgery, is often of greater practical significance in the patients daily life than reconstruction of the genitals. WPATH noted, These reconstructive procedures are not optional in any meaningful sense, but are understood to be medically necessary for the treatment of the diagnosed condition. In this case, the patient has been diagnosed with gender dysphoria and, as a result, had symptoms of chronic anxiety, depression, low self-esteem, agoraphobia, and overall severe distress. The medical evidence supports the services at issue in this clinical setting. Therefore, facial feminization surgery performed on 6/25/20 was medically necessary for the treatment of the patients medical condition.Final Result: The reviewer determined that the service at issue was 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 psychiatry with expertise in transgender 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: Medical Necessity
Decision: Upheld

The parent of a 12-year-old male enrollee has requested authorization and coverage for Protopic 0.1% ointment.  The Health Plan has denied this request indicating that the requested medication is not medically necessary for treatment of the enrollees atopic dermatitis.  Findings:  The physician reviewer found that the patient has a history of severe atopic dermatitis.  While the topical calcineurin inhibitors are successful in treatment of atopic dermatitis with minimal side effects, the higher strength form of Protopic (0.1%) has not been FDA approved for 12-year-old patients.  The information provided does not indicate that the approved lower strength form (Protopic 0.03% ointment) would be ineffective for this patient.  While it has been tried in the past, the documentation does not demonstrate that prescriptions have been written for Protopic in the six-year interim between 2005 and 2011.   The submitted medical records do not demonstrate that Protopic 0.03% would be ineffective at this time, given that the severity of atopic dermatitis can change considerably with age.   The medical records do not show that intermittent topical steroid use has been ineffective recently.  In this patients case, the medical documentation provided does not demonstrate the medical necessity of the requested Protopic 0.1% ointment.  All told, the requested Protopic 0.1% ointment is not medically indicated for the treatment of this patient.
Appeal type: Experimental/Investigational
Decision: Overturned

Findings:  The physician reviewer found that An enrollee has requested reimbursement for FoundationOne CDx. Soft tissue sarcomas, which include Ewing sarcomas, are rare and include a diverse group of tumors with differing treatments. Italiano and colleagues report that advances in molecular genetics of sarcoma have enabled the identification of type-specific aberrations and that molecular genetic testing assists in the diagnostic accuracy of sarcoma and appropriate clinical management. Given that the results of molecular profiling may be used to help guide treatment decision making, especially after exhaustion of standard therapies, including targeted therapies and clinical trials, the service at issue was likely to have been more beneficial than any available standard therapy. Therefore, FoundationOne CDx was likely to have been more beneficial for evaluation of the patient's condition than any available standard therapy.Findings:  Two of the three physician reviewers found the FoundationOne CDx was likely to have been more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the service at issue was likely to have been more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested Epclusa 400 mg-100 mg for the treatment of the enrollees hepatitis C.  Findings: The physician reviewer found that the current medical evidence supports the requested medication regimen in this clinical setting.  According to 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 should be treated, except those with life expectancy less than 12 months due to non-liver-related conditions.  This applies regardless of fibrosis stage.  Per the guidelines, Epclusa is recommended as first-line for treatment-naive genotype 2 patients. Delay in treatment may result in decreased survival.  All told, Epclusa 400 mg-100 mg is medically indicated for the treatment of this patient.Final Result: The reviewer determined that the requested medication regimen 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 has requested surgery using microdissection and image guidance using neuronavigation to remove all of the remaining chordoma cancer in the pharyngeal prevertebral region near the C2 vertebrae, or surgery to remove all of the remaining chordoma cancer in the pharyngeal prevertebral region near the C2 vertebrae.  Findings: The physician reviewer found that the Health Plan has denied this request indicating that the requested services are not medically necessary for treatment of the enrollees cervical chordoma.  The current medical evidence supports the requested services in this clinical setting.  There are several well-known characteristics of chordomas.  First, and foremost, complete surgical resection is the only way to cure this disease.  This should be done by a surgeon well versed in chordoma surgery. This surgery should be performed with intraoperative navigation by highly trained neurological surgeons and/or spine surgeons.  The requested services are standard of care in this patients case. In sum, the requested surgery using microdissection and image guidance using neuronavigation to remove all of the remaining chordoma cancer in the pharyngeal prevertebral region near the C2 vertebrae is medically indicated for the treatment of this patient.Final Result: The reviewer determined that the requested services are 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 neurological 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

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for additional physical therapy. Researchers note that management of adhesive capsulitis is based on the underlying cause of pain and stiffness, and determination of the etiology is essential. The authors further note that management of true capsular restriction of motion begins with gentle, progressive stretching exercises. While range of motion programs may be started in a formal setting by physical therapists, they can be transitioned to an independent program over time and frequent range of motion exercise in the home setting may play a larger role in effectuating positive outcomes than in a formal therapy setting. Researchers note that interventions such as steroid injections or other analgesic measures can be considered during the painful stages of initiating mobilization to expedite recovery. In this case, the patient has neck pain radiating down the right arm and shoulder with limited range of motion in the right arm, and has been diagnosed with full thickness right rotator cuff tears. In this clinical setting, the limited active right shoulder range of motion is not rectifiable by physical therapy due to the underlying rotator cuff pathology. The documentation reports that the patient has already undergone physical therapy without significant benefit. Given that the records do not support that continued formal therapy would confer a meaningful benefit to the patient in this clinical setting, the requested services are not medically indicated. Therefore, additional physical therapy is not medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested services are not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is board certified in physical medicine and rehabilitation and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary:  An enrollee has requested skilled nursing care for the treatment of his medical condition.   Findings:  The physician reviewer found that the current medical evidence supports the services at issue in this clinical setting.  Functional impairments due to acquired brain insults, including severe ischemic hemispheric cerebral strokes, can improve with time, but are also amenable to rehabilitation interventions.  In this case, the patient had very profound initial functional deficits.  He has been receiving rehabilitation care for a prolonged period of time.  However, more recently, he has been making significant functional gains.  Based on the records, additional gains in the near future were and are reasonably expected given the gains in self-care and ambulation.  Further skilled nursing care was and is medically appropriate to optimize his recovery.  All told, skilled nursing care was and is medically indicated for the treatment of this patient. Final Result: The reviewer determined that the services at issue were and are 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 physical medicine and rehabilitation and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.