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

The patient is a 52-year-old male with a many year history of pain-related problems reported to include fibromyalgia, reflex dystrophy, degenerative disc disease, right hand complex pain, severe recurrent abdominal pain of unclear etiology, irritable bowel syndrome (IBS), chronic fatigue, depression and various surgical procedures. Cymbalta was prescribed by the patients gastroenterologist as treatment for IBS and incidentally for fibromyalgia after several failed trials of other medications over an extended period of time. The patient was evaluated by a rheumatologist in January 2006, and was found to have fibromyalgia with uncontrolled acute and chronic pain. At the time of this evaluation, the patient was taking Cymbalta 60mg daily, Lyrica 50mg three times per day, Oxycontin 10mg twice per day, a Lidoderm patch daily and Ambien and was noted to be very symptomatic, with 18/18 tender trigger points.  Complaints of constantly severe pain above and below the waist, severe fatigue, and disturbed sleep were also noted. The rheumatologist recommended an increase in the dosage of Lyrica, a referral to a multidisciplinary fibromyalgia program and noted the possibility of additional supplements. There was no mention of Cymbalta in the providers progress note.The patients request for authorization of Cymbalta was denied by the Health Plan citing a lack of medical necessity.Treatment of fibromyalgia is difficult and various medications of different classes are often tried based on the knowledge and experience of the treating rheumatologists. The use of antidepressants is standard practice, though tricyclics and trazodone are used more often than the newer selective serotonin reuptake inhibitors (SSRIs) or dual-action agents. This may be because the older drugs are better for direct sleep promotion.Cymbalta is a newer, dual-action agent which has been proven to be useful in the treatment of depression. In addition, the benefit of Cymbalta in the treatment of fibromyalgia, with or without depression, has been reported in the medical literature as cited above. Given the limited number of useful agents for the treatment of this condition, prescribing Cymbalta is now considered standard practice for many rheumatologists.There is limited discussion of the patients response to Cymbalta in the medical records provided. As such, I believe a medically monitored three-month trial of Cymbalta is appropriate to ascertain if the medication provides a benefit to the patient. If it is effective, then its continued use would be considered medically necessary.Based upon the information set forth above, I have determined the requested medication is medically necessary for treatment of the patients medical condition. The Health Plans denial should be overturned.
Appeal type: Experimental/Investigational
Decision: Upheld

A 72-year-old male has requested an X-Stop procedure for treatment of back pain.  Findings:  Two physician reviewers found that there is no class I data demonstrating that X-Stop is more or equally effective as other available treatments. Simple laminectomy decompression is the gold standard in this setting. There is no literature establishing that the X-Stop procedure is superior to laminectomy surgery. To date, the long-term safety and efficacy of X-Stop remains unproven.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for an Inspire upper airway stimulation system. The U.S. Food and Drug Administration (FDA) approves the use of the Inspire device for the treatment of obstructive sleep apnea (OSA). In this case, the patients symptoms and test results are consistent with a diagnosis of OSA. A drug-induced sleep endoscopy (DISE) showed no concentric collapse at velum. The patient has been unable to tolerate continuous positive airway pressure (CPAP) therapy. In this clinical setting, the records support the use of the Inspire device, given the patients intolerance to CPAP, anterior posterior collapse, no central apnea, and body mass index (BMI) and apnea hypopnea index (AHI) within FDA criteria. Therefore, the requested Inspire upper airway stimulation system is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Findings:  Two of the three physician reviewers found the requested Inspire upper airway stimulation system is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the requested device is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: Physician reviewers 1 and 3 are board certified in otolaryngology and are actively practicing. Physician reviewer 2 is board certified in otolaryngology with sub-specialty certification in sleep medicine and is 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: Overturned

A 46-year-old male enrollee has requested an increased number of Imitrex kits per month for treatment of migraine headaches.  Findings:  The physician reviewer found that there is no evidence in the submitted medical records that the patients headache pattern has accelerated secondary to medication overuse (rebound) headache. Use of Imitrex at a frequency of 2 doses daily x 2 days weekly x 4 weeks monthly would result in acceptable use of 16 doses monthly. Therefore, 8 Imitrex kits (16 doses) monthly should be authorized for this patient. Consideration should also be given to specialty headache medicine consultation to evaluate novel approaches to prevention such as Botox therapy.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested Cosentyx for treatment of her medical condition.  Findings:  The physician reviewer found that the submitted documentation demonstrates the patient meets medical necessity criteria for the requested medication. Since psoriasis is a chronic lifelong disease the disease modifying drugs are prescribed lifelong.  Studies support the use of biologic medications to control symptoms from chronic disease. The patient is currently on Cosentyx, a biologic medication, with excellent response; so much so, that the symptoms from her medical condition have been greatly reduced; her PASI score is essentially 0.  Cosentyx should be continued at this point and it is not recommended to withdraw the medications when they are working to control chronic diseases (Menter, et al).  The record indicates that the patient has experienced greater than 50% improvement while using Cosentyx. In sum, Cosentyx is 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 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: Upheld

Nature of Statutory Criteria/Case Summary:  An enrollee has requested continued/extended care at a rehabilitation center for treatment of her right femur pathological fracture.  The physician reviewer found that based on the clinical documentation submitted for review, the medical necessity for continued/extended care at a rehabilitation center has not been established. According to the American Association of Physical Medicine and Rehabilitation (AAPMR) standards for determining appropriate of admission of rehabilitation, the patient needs to have significant functional deficits and medical and nursing needs that require close medical supervision with 24-hour availability of skilled rehabilitation nurses. In this case, the patient does not have acute medical issues interfering with rehabilitation. She does not have nursing or medical needs that require SNF or acute rehabilitation facility care. She will benefit from continued skilled physical and occupational therapy which she can pursue as an outpatient. In addition, the patient has been provided home therapies and adaptive equipment. Therefore, continued/extended care at a rehabilitation center is not medically necessary for treatment of the patients medical condition. 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: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for magnetic esophageal sphincter augmentation. The Health Plan has denied this request indicating that the requested services are considered investigational for treatment of the enrollees gastroesophageal reflux disease.Findings There is a lack of randomized controlled trials with long term follow up demonstrating that LINX is safer or more effective than Nissen fundoplication or other surgical anti-reflux procedures. American College of Gastroenterology guidelines for the management of reflux disease also state that more evidence is needed before LINX can be recommended. One best evidence review concluded that long-term comparative outcome data past 1 year are needed in order to further understand the efficacy of magnetic sphincter augmentation. Additionally, LINX (more than surgical fundoplication) is associated with severe dysphagia requiring endoscopic intervention. Another evidence review concluded that the long-term safety and efficacy of LINX - both alone and in comparison to current GERD therapies - remains to be determined. There are 29 reports of LINX erosion through the esophagus in the publicly accessible U.S. Food and Drug Administration Adverse Events database, among other adverse events. The currently available peer reviewed literature does not definitively support the conclusion that LINX is more likely to be beneficial than standard treatment in this clinical setting. For these reasons, LINX Reflux Management System is not likely to be of greater benefit for the treatment of this patients GERD symptoms than any available standard therapy.Final Result: Two of the three reviewers determined the requested services are not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications:  All three reviewers are board certified in internal medicine with sub-specialty certification in gastroenterology 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: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for immunoglobulin therapy with Cuvitru. The records provided for review do not support a diagnosis of specific antibody deficiency. The providers notes indicate that the patients pre-Pneumovax streptococcal pneumonia antibody titers were 13/14 and labeled as low and that his post titers were 7/14. Protective titers of 13 out of 14 demonstrates an adequate level of antibody levels and protection to streptococcal pneumoniae. Although the provider noted the presence of purulent rhinorrhea, there is a lack of evidence of active or chronic infection with computed tomography (CT) sinus scans or positive cultures. Moreover, there is no report of recurrent antibiotic therapy or attempts at treating the patients rhinorrhea and chronic sinusitis with nasal corticosteroids. For these reasons, the requested immunoglobulin therapy with Cuvitru 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 certification in allergy and immunology 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 parent of an enrollee has requested infusions of intravenous immune globulin (IVIG) for treatment of the enrollees medical condition.  Findings:  The physician reviewer found that PANDAS (pediatric autoimmune neuropsychiatric disorders associated with streptococcal infections) is a term used for children that have abrupt onset of tics and/or obsessive compulsive disorder symptoms following group A beta hemolytic streptococcal (GABHS) infection. Operational criteria include the following: presence of obsessive compulsive disorder and/or tic disorder meeting standardized criteria, onset between three years and the onset of puberty, episodic course of symptom severity with abrupt onset of symptoms or significant symptom exacerbations, association with streptococcal infection with positive throat culture or rising anti-streptococcal antibody titers, and association with neurological abnormalities on examination. Despite these criteria and others, there is ongoing debate regarding the diagnosis of PANDAS, including uncertainties with clinical definition and pathophysiology.  There is ongoing debate about the presence of antineuronal antibodies and the means of their formation (molecular mimicry, bystander activation, epitope spreading).  In a recent review of the topic by Tan and colleagues, the following treatment recommendations were made: antibiotics are indicated for treatment of GABHS infection, but the utility of prophylaxis has not been consistently demonstrated, and the use of immunomodulatory therapies (including IVIG) will need further research before it can be recommended. These authors concluded the following: without more knowledge about PANDAS, and definitive evidence linking GABHS infections to neuropsychiatric symptom exacerbations by way of immune-mediated processes, the diagnosis of PANDAS and the use of long-term antibiotic prophylaxis or any immunomodulatory therapies in place of or concomitantly with conventional therapies cannot be recommended. Based on this information, infusions of IVIG are not medically indicated for the treatment of this patient.  Final Result: The reviewer determined that the services at issue 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 pediatrics with sub-specialty certification in pediatric critical care 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 patient is a 49-year-old female who has a history of bipolar disorder, depression and anxiety. She had a manic episode in 2002, which resulted in incarceration and hospitalization. Recently, she lost her job due to her behavioral health problems and has low self-esteem. She had been receiving outpatient psychotherapy from December 2003 to April 2005 and has requested authorization for continuation of her therapy. The Health Plan has denied this request indicating the requested therapy is not medically necessary.Treatment of acute mood disorders requires both pharmacologic and psychotherapeutic methods for optimum treatment and both are standard of care. In this case the patient appears to be undergoing an acute crisis (loss of job). She has a history of state hospitalization for a severe manic episode. Based upon the information provided, it appears she has been relatively stable for four years. The patients psychologist does seem to document a worsening of symptoms as of April 2005. Yet, it appears the patient has not recently been seen by her psychiatrist. Optimal care involves coordination of care between the patients psychiatrist (providing medication management) and her psychologist. Based upon the information set forth above, I have determined the requested therapy is not medically necessary at this time. The Health Plans denial should be upheld at this time. However, the patient should be re-evaluated by her psychiatrist to determine if continued psychotherapy is warranted. If the patients psychiatrist indicates continued psychotherapy is medically indicated, the requested therapy should be authorized.
Appeal type: Experimental/Investigational
Decision: Upheld

A female enrollee requested the cooling device (water circulating cold pad with pump) for medical treatment of her status post right foot bunionectomy.  Findings:  Three physician reviewers found that in this clinical scenario the standard of care is the use of elevation and ice packs to the surgical area to achieve reduction in swelling as well as reduction in pain. Pain medication may also be used to alleviate surgical pain. The medical literature does not demonstrate that cryotherapy pumps and pads are more efficacious than the use of elevation and ice pack applications. Furthermore, there are some risks and complications associated with cryotherapy units (Wilke and Weiner). Therefore, based on the peer-reviewed literature and medical evidence submitted the device at issue was not likely to be more beneficial than standard medical therapy.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary:   An enrollee has requested magnetic resonance imaging (MRI) of the lumbar for evaluation of her back pain.  The physician reviewer found that the American College of Radiology (ACR) has established criteria for the evaluation of low back pain and defined several variants such as acute low back pain, post-traumatic low back pain, low back pain in cancer patients, low back pain with radiculopathy, low back pain in patients who have had prior lumbar surgery. The ACR reports that MRI is not warranted in the acute setting. However, the ACR criteria support the utility of MRI in the setting of low back pain with radiculopathy in which the patient is a candidate for surgery or other intervention. In the medical literature, Roudsari and Jarvik noted that the available guidelines emphasize the importance of a focused history and thorough physical examination before any imaging is ordered. In addition, all agree that for patients with acute low back pain and without any risk factor for serious spine abnormalities, imaging within the initial four to eight weeks should not be performed. Chou and colleagues noted that providers should evaluate patients with persistent low back pain and signs or symptoms of radiculopathy or spinal stenosis with magnetic resonance imaging (preferred) or computed tomography only if they are potential candidates for surgery or epidural steroid injection (for suspected radiculopathy) (strong recommendation, moderate-quality evidence). In this case, the patients back pain, sciatica, and symptoms were chronic and there were no immediate precipitating factors. All told, an MRI was medically necessary and directed this patients medical treatment.  Final Result: The reviewer determined that the services at issue were 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 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: Upheld

A 32-year-old female enrollee has requested a consultation for bariatric surgery (gastric sleeve) for treatment of her diabetes.  Findings:  The physician reviewer found that the patient is a 32-year-old female with long standing type 1 diabetes and several diabetic complications including retinopathy and nephropathy. She also has class I obesity with a body mass index (BMI) of 34. The patient has requested a consultation to undergo a sleeve gastrectomy. The requested service fails to meet criteria for medical necessity based on the National Institutes of Health (NIH) criteria for bariatric surgical candidates. In addition, there is limited published data on the impact of bariatric surgery on blood glucose control in type 1 diabetes. The largest series consists of six patients, only one of whom had a sleeve gastrectomy (Raab, et al). There is not sufficient evidence to suggest that a sleeve gastrectomy will improve this patients long-term blood glucose control. For these reasons, the requested consultation for a bariatric surgery consultation is not supported as medically necessary for treatment of this patients medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld

A 52-year-old female enrollee has requested radiofrequency neurolysis for treatment of her back pain with sciatica and lumbar radiculitis.  Findings:  Three physician reviewers found that pulsed radiofrequency, a modification of the conventional radiofrequency ablation treatment, has been utilized in managing chronic pain. Generally radiofrequency neurotomy is applied for facet joint pain. Epidural steroid injections are commonly performed for managing lumbar radiculitis. Although pulse radiofrequency of the dorsal root ganglion may be a potential alternative to epidural injections in treating chronic lumbar radicular pain, there is a paucity of peer-reviewed medical literature demonstrating the efficacy of pulsed radiofrequency for dorsal root ganglia. Shanthanna and colleagues published a report showing no difference in pain ratings at four weeks or three months following pre-operative assessment. Simopoulos and colleagues retrospective report included 76 patients. The authors reported improvement in 75% of the patients in the short-term, but all of them lost any benefit at eight months. All told, there is a lack of scientific data supporting the use of radiofrequency neurolysis in this clinical setting.
Appeal type: Medical Necessity
Decision: Upheld

A 22-year-old male enrollee has requested for surgery for treatment of his Moyamoya disease. Findings:  The physician reviewer found that the physician specializes in neurovascular procedures including the surgical treatment of aneurysms and AVS, as well as extracranial to intracranial bypass surgery and microvascular decompression. No evidence has been provided that the physician recommended by the Health Plan is not qualified to evaluate and treat patients with Moyamoya disease.