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

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for balloon sinus ostial dilation for treatment of the enrollees sinusitis.  Findings:  Three physician reviewers found that at present, functional endoscopic sinus surgical techniques for the management of chronic rhinosinusitis refractory to medical management are still considered the surgical treatment of choice. Balloon sinus ostial dilation is a technique to improve patients symptoms of recurrent acute rhinosinusitis to help widen and dilate the sinus pathways.  Some data report improvement in patient symptoms with this technique. However, this patient does not meet clinical medical criteria for surgical treatment of the paranasal sinuses based on the findings documented in the medical reports. Final Result: The reviewers determined that the requested procedure is 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: Reviewers 1, 2 and 3 are board certified in otolaryngology and are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

A 44-year-old female enrollee has requested SAVI radiation therapy (internal radiation therapy) for treatment of her breast cancer. Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the services at issue in this patients case.  Based upon American Society for Radiation Oncology guidelines, partial breast irradiation is an emerging standard of care for women with low risk of recurrence.  Per these guidelines, suitable candidates for accelerated partial breast irradiation are older than 60 years of age, with small tumors, and negative margins.  As noted by Smith and colleagues, patients who are younger than 50 years of age are unsuitable for partial breast irradiation.  This patient is 44 years of age.  The current medical evidence has not established the long-term safety and efficacy of SAVI radiation therapy in this clinical setting.  Longer term follow-up is needed to ascertain if there is any risk or benefit with respect to late toxicity and long-term tumor control.  All told, SAVI radiation therapy (internal radiation therapy) was not medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Overturned

The patients parent has requested authorization and coverage for Zolgensma. In this patients case, Spinraza therapy has not prevented worsening of his scoliosis. This is indicative that Spinraza has been ineffective. As his disease progresses, it further compromises his respiratory function. U.S. Food and Drug Administration (FDA) approved Zolgensma as the first gene therapy to treat patients younger than two years of age with SMA. Children with SMA Type 1 typically have motor neuron death that manifests clinically between birth and six months of age. Since Zolgensma therapy can lead to a disease-modifying outcome by creating the production of normal SMN protein, it is possible to rescue motor neurons before they die at any point in an affected patients clinical course. Zolgensma can provide a disease-modifying outcome for this patient because there are still motor neurons that can be rescued that may have been preserved with Spinraza therapy, but not completely restored to a functional state, given the progression of scoliosis.Spinraza works by acting as an antisense oligonucleotide that targets SMN2, so that it creates more functional SMN protein. In contrast, Zolgensma delivers sustained expression of normal SMN protein, bypassing production of either mutated or absent SMN. Since Spinraza needs to be administered repeatedly via an intrathecal route, there is an additional risk of general anesthesia in infants/toddlers that may have respiratory compromise, while Zolgensma only needs to be given once. In this patients case, Spinraza has not halted the progression of scoliosis, and repeated intrathecal administrations may be associated with additional respiratory compromise from general anesthesia. Thus, the medical evidence supports Zolgensma therapy in this patients case. Therefore, the requested Zolgensma 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 neurology with special qualification in child neurology 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:   An enrollee has requested Otezla for treatment of her medical condition. Findings:  The physician reviewer found that review of the submitted documentation and relevant literature fails to demonstrate the medical necessity of the requested medication. Otezla (apremilast) is an orally administered phosphodiesterase-4 inhibitor U.S. Food and Drug Administration (FDA) approved for the treatment of psoriatic arthritis (PsA). However, Otezla is not currently known to be disease modifying at this time. As such, it is not a preferred agent for the treatment of PsA. Per researchers Treatment recommendations for peripheral arthritis include non-steroidal anti-inflammatory drugs (NSAIDs), intra-articular glucocorticoid injections, disease-modifying antirheumatic drugs (DMARDs) and [tumor necrosis factor] TNF inhibitors. Anti-TNF agents have been proven very effective for PsA and are disease modifying agents. Anti-TNF agents prevent progression of disease, erosions and disability and are thus the preferred agent for PsA. As noted above, anti-TNF agents are the preferred medication in this disease as they are known to be disease modifying which Otezla has not proven to be. In this case, the patient was in remission with her previous treatment regimen, although having gastrointestinal side effects. It would be reasonable to try another anti-TNF agent prior to authorizing Otezla as she may not have the same side effects and they have proven to work for her. Given that the patient has not failed other anti-TNF agents, the request for coverage of Otezla is not medically necessary for treatment of the patients medical condition. 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 rheumatology 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 reimbursement for diagnostic mammogram and SAVI placement of left breast. The enrollee who underwent routine mammography that showed new calcifications in the left breast. These were confirmed by magnification views and biopsied. Pathology showed low grade ductal carcinoma in situ (DCIS) of the left breast. The patient underwent SAVI placement followed by left breast lumpectomy and left axillary sentinel lymph node biopsy. The physician believed the procedure was the most appropriate and effective treatment for the patients cancer. Multiple studies have shown and confirmed evidence on the safety and effectiveness of SAVI SCOUT localization (SSL) surgical guidance system when compared to traditional methods, of wire localization (WL) to localized non-palpable breast lesions. SAVI SCOUT surgical guidance is a non-radioactive infrared (IR)-activated electromagnetic wave reflector that is implanted into the breast under ultrasound or mammographic (imaging) guidance. In addition to its safe and feasible use, literature supports SSL due to its comparable effectiveness, in terms of accuracy and reliability to localize and excise breast lesions with acceptable margin positivity to that of traditional methods including wire localization and radioactive seeds. SSL has the added advantages of not needing to use a wire or radioactive materials. Surgical outcomes with SSL were no different from that with wire localization. However, SSL is considered more beneficial than wire localization in terms of technical feasibility and avoiding the complications associated with wire localization. Final Result: Three of the three reviewers determined that the requested services are likely to be more beneficial than any available standard therapy for treatment of the enrollees medical condition. Credentials/Qualifications: One reviewer is board certified in diagnostic radiology and vascular and interventional radiology; another reviewer is board certified in general surgical oncology and; the third reviewer is board certified in medical oncology. All three reviewers are actively practicing and 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 male enrollee requested follow-up with a trauma surgeon for medical treatment of his 6th and 7th rib fractures status post motor vehicle accident. Findings:  The physician reviewer found that based on the available documentation, this patient has two non-displaced rib fractures without any other medical issues such as hemothorax. The treatment of non-displaced rib fractures does not require surgical intervention and can be managed medically without the services of a specialist. Primarily, the treatment is focused on pain control and prevention of atelectasis. Thus, the requested follow-up with a trauma surgeon is not supported as medically necessary for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned

A 51-year-old female enrollee requested Copaxone 40 mg/ml, 3 times per week injections for medical treatment of her relapsing multiple sclerosis.  Findings:  The physician reviewer found that a change in multiple sclerosis disease modifying medication is typically made in cases in which there is active disease, increase in disability or new MRI activity. Data suggests that 3 times per week Copaxone is as effective as daily injections (Khan, et al.), with less long-term lipoatrophy and higher patient satisfaction.   Current standard of care among multiple sclerosis specialists is to prescribe 3 times weekly Copaxone 40mg/ml rather than daily therapy, as the former is associated with better compliance, less injection site reactions and less long-term lipoatrophy.   Therefore, the requested medication is medically necessary for treatment of the patients relapsing multiple sclerosis.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: A female enrollee has requested reimbursement for the computed tomography (CT) scan of the heart without contrast for evaluation of the enrollees elevated cholesterol. Findings:  The physician reviewer found that based on the records provided, the patient presents with some coronary risk but no history of coronary disease. In this circumstance, guidelines for the management of cardiac risk and dyslipidemia are available and do not recommend performing coronary calcium scanning in this setting. Screening coronary calcium scoring is not considered the standard of care. Specifically, there is a lack of controlled evidence that treatment based on screening coronary calcium scanning provides outcome benefit that is incremental compared to treatment based on standard risk factor profiling and basic lipid analysis alone. Finally, though this patient has a mildly elevated total cholesterol it is largely due to a high HDL cholesterol. All told, the CT scan of the heart without contrast was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Final Result: Two of three reviewers determined that the service at issue was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: Physician reviewer number one is board certified in internal medicine with sub-specialty certification in cardiovascular disease and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.Physician reviewer number two is board certified in internal medicine with sub-specialty certification in cardiovascular disease and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.Physician reviewer number three is board certified in internal medicine with sub-specialty certification in cardiovascular disease and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for direct manipulation techniques, such as compression, trigger point pressure release, deep massage, spray and stretch, ultrasound transverse friction massage and/or laser therapy. Current evidence-based literature regarding the management of hypermobile Ehlers-Danlos syndrome and myofascial pain syndrome is limited in size and quality. A few studies have shown positive effects with physiotherapy. While the optimal rehabilitation program has not been identified, research supports that proprioception, strength, and motor control, in addition to education, physical activity, and fitness are important components. However, there is a limited body of high quality evidence supporting the efficacy of techniques such as ultrasound, trigger point pressure release, compression, deep massage, spray and stretch and laser therapy. Therefore, the requested direct manipulation techniques (such as compression, trigger point pressure release, deep massage, spray and stretch, ultrasound transverse friction massage and laser therapy) are not medically necessary for 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 with subspecialty certification in neuromuscular 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 son of a deceased 85-year-old female, who was admitted to a skilled nursing facility (SNF) after a prolonged hospitalization, has requested authorization for skilled nursing facility services.Physician's Findings:The reviewing physician found that the patient was appropriately discharged from skilled services as she had no skilled nursing or rehabilitation needs  no injections, no wounds, and no complexity requiring daily skilled observation.
Appeal type: Experimental/Investigational
Decision: Upheld

A 44-year-old male enrollee has requested a DelRoyal T600 Digital hot/cold therapy system with blanket for treatment of his vertebral fractures. Findings:  Three physician reviewers found that the patient was prescribed the DeRoyal T600 Digital hot/cold therapy system with blanket for treatment of his low back pain. A literature search revealed no studies demonstrating or even assessing the efficacy of a heating/cooling system for the treatment of low back pain. As such, this therapy should be considered experimental at this time absent additional clinical trials demonstrating the equivalence or superiority of the device when compared to standard alternatives.
Appeal type: Medical Necessity
Decision: Overturned

Findings:  The physician reviewer found that The patient has requested authorization and coverage for Synvisc One injection to the right knee. Evidence from systematic reviews and randomized controlled trials indicate that although viscosupplementation may relieve knee pain in some patients with osteoarthritis, data has not established which patients will benefit. Guidelines from the American Academy of Orthopedic Surgeons (AAOS) indicate that the data on safety and efficacy of viscosupplementation remain inconclusive. As such, the AAOS does not currently recommend viscosupplementation as routine treatment for osteoarthritis of the knees. Viscosupplementation is reserved for patients with a history of lasting benefit from prior injections and in cases where the remaining options are limited. In this case, the patients available treatment options are limited. The patients right knee pain has not responded treatment with corticosteroid injections, NSAIDs, or arthroscopic surgery. The provider has recommended treatment with a Synvisc One injection for the right knee, which is consistent with the current AAOS guidelines and medical literature. For these reasons, the requested Synvisc One injection to the right knee is medically necessary for 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.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Botox injections for treatment of the enrollees chronic migraine. Findings:  The physician reviewer found that as per the International Headache Society Classification of Headache Disorders, chronic migraine is defined as greater than 15 days per month for greater than three months, headache not attributable to another disorder, at least two characteristics of unilateral, pulsatile, moderate to severe in intensity, or aggravation by or causing avoidance of routine physical activity. Additionally, there must be one characteristic of nausea and/or vomiting, photophobia and phonophobia. Botox is a tool in the management of chronic migraine which has shown effectiveness in the PREEMPT trials. However, there were significant criticisms of the trails outcomes including absolute gain of headache-free days, primary efficacy end point of PREEMPT 2, which was only 2.3 days on average over a 28 week period, high placebo effect, and the trials enrolled a majority of subjects with concomitant medication overuse headache possibly confounding the results. In a study by colleagues, they compared Topamax, Botox, and placebo in a double blind study. The authors concluded OnabotulinumtoxinA and topiramate demonstrated similar efficacy in the prophylactic treatment of chronic migraine. In this patients case, there is a lack of support for the requested Botox therapy for treatment of her headaches. The clinical evidence and the limitations in the PREEMPT trials suggest that Botox is not superior to alternative oral therapies. Moreover, there is insufficient documentation to support the patient has failed other drug classes which are potentially equally as effective.  The patient has a history of kidney stones.  However, this is not a contraindication for future use of topiramate in the appropriate setting and/or with adequate monitoring.  As such, Botox injections for treatment of her medical condition is not medically necessary. 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 neurology with expertise in episodic and chronic migraine 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.