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

A 61-year-old male enrollee has requested lumbar artificial disc replacement surgery for treatment of his low back pain. Findings: Three physician reviewers found that this patient has chronic low back pain. He has not had any localizing features to his pain. His pain generator has not been identified. He has undergone an L4-S1 fusion which is a contraindication to use of ProDisc-L. Moreover, there is a paucity of well designed clinical trials in the peer-reviewed medical literature demonstrating the long-term safety and effectiveness of this procedure. Therefore, the FDA has required a Post Approval Study to determine the long-term safety and effectiveness of ProDisc-L. This study has neither been reported nor concluded. Finally, the American Academy of Orthopedic Surgeons has noted that nuclear replacement and motion sparing technology are too new to have demonstrated long-term data regarding their efficacy (Madigan, et al). Given the lack of scientific data showing the long-term benefits and side effects of artificial disc replacement, the requested surgery is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for RT300 Functional Electrical Stimulation (FES) Therapy System (HCPCS code E1399). The RT300 FES Therapy System provides passive exercise in individuals with neurological weakness by using topical electrical stimulation leads to activate paralyzed limb muscles to drive a stationary cycle. The data from the medical literature, however, has not demonstrated that use of this device improves function or health outcomes in a clinically significant manner for persons with spinal cord pathology. According to Hofer and Schwab, FES does not promote neurological recovery beyond natural recovery and does not improve cardiovascular health, pulmonary health or other health parameters in a clinically significant manner. FES may help to improve or maintain muscle mass in weakened or totally paralyzed limbs, but this provides no significant health or functional benefit in this clinical setting because the muscle tissue that is gained or spared does not provide any clinical or functional benefit. Moreover, Tweedy and colleagues state that health and well-being in this patient population should be promoted with active exercise using volitionally intact muscles and general encouragement of active participation in educational, social, recreational, avocational activities, and vocational activities. In this case, the addition of FES cycle ergometry is not expected to marginally improve health or functional outcomes. Thus, the requested RT300 Functional Electrical Stimulation (FES) Therapy System (HCPCS code E1399) is not medically necessary for the treatment of the patients medical condition. Final Result: The reviewer determined that the requested equipment 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 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: Upheld

A 56-year-old male enrollee has requested authorization and coverage for inpatient rehabilitation for treatment of the enrollee, who is status post left thalamic intracranial hemorrhage. Findings:  The physician reviewer found that in this patients case, the current medical evidence does not support the medical necessity of the requested inpatient rehabilitation.  This patient is five months status post left thalamic intracranial hemorrhage.  The submitted documentation noted partial improvements during inpatient and outpatient therapy.  He has significant neurologic residuals, which may respond to ongoing therapies, per the current medical literature.   However, the medical literature does not show definitively better outcomes with inpatient rehabilitation versus outpatient treatment in this clinical situation.  Although ongoing therapy for his post-stroke residuals is medically indicated, this can be accomplished in an outpatient setting.  This patient may benefit from a day treatment program to facilitate recovery of language, processing, mobility, and self-care.  All told, the requested inpatient rehabilitation is not medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld

A 52-year-old male enrollee requested authorization and coverage of an out-of-plan deep brain stimulator surgery for the treatment of young onset parkinson's disease.  The Health Plan denied the enrollees request indicating that the requested treatment is not medically necessary.One physician reviewer performed a medical necessity Independent Medical Review.  The physician reviewer upheld the health plans denial on the basis that the requested services are not medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld

A 54-year-old male enrollee has requested reimbursement for monitored anesthesia care (MAC) services provided during a colonoscopy. The Health Plan has denied this request indicating that the services at issue were not medically necessary for evaluation of the enrollees risk for colon cancer.  Findings:  The physician reviewer found that the risk of anesthesia is rated according to a grading system developed by the American Society of Anesthesiologists (ASA).  Individuals who have a rating of 3 or greater may require monitored anesthesia care.  There are a number of other conditions or circumstances listed in the policy where a separate provider of anesthesia is considered medically necessary.  This patient did not have any of these conditions or circumstances.  Additionally his physician rated his anesthesia risk level at ASA 2 (low risk.)  Accordingly, the MAC services were not medically necessary.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for a continuous positive airway pressure (CPAP) machine. As noted in the current medical literature, CPAP is recommended as the first-line treatment for patients with OSA. Further, the American College of Physicians (ACP) support CPAP as initial therapy for patients diagnosed with OSA and note that this recommendation is supported by moderate-quality evidence. In this case, the medical records provided for review document the patient was diagnosed with OSA, was subsequently titrated on CPAP, and recommended a CPAP for home use. Although the patient does not present with comorbid conditions, his clinical presentation and history as reported in the consult notes meet the diagnostic criteria for OSA. Considering that CPAP is considered the first-line treatment for patients with OSA, and this patient meets the diagnostic criteria for OSA, the provision of a CPAP unit and related accessories is within the generally accepted standards of clinical practice. Thus, the requested CPAP machine is supported as medically necessary for treatment of this patients medical condition. Final Result: The reviewer determined that the requested equipment 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 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: Medical Necessity
Decision: Overturned

The patient is a 52-year-old female who is status post removal of a left-sided acoustic sarcoma in 1989 resulting in total hearing loss in the left ear. Her physician has recommended an implanted bone-anchored hearing attachment (BAHA). The Health Plan has denied this request indicating the patient does not meet criteria for authorization of the requested device. The patient has residual total loss of hearing in the left ear and normal hearing in the right ear. Optimal hearing rehabilitation would involve being able to hear from the left side. The BAHA device is designed to accomplish this. Though as the Health Plan indicates the patient has an anacoustic ear and no functional neurologic or bone conduction mechanism for hearing on the left, the neurologic and bone conductive mechanism for hearing in the right ear is normal. The BAHA device works by stimulating the entire skull, i.e., both inner ears at the same time. The purpose of the BAHA device is to rehabilitate the anacoustic left ear by transmitting sound across the skull to the hearing right ear. Based upon the information provided, the patient is an appropriate candidate for the BAHA device and is likely to benefit from implantation of the device. Therefore, I have determined that the requested device is medically necessary for treatment of the patients medical condition. The Health Plans denial should be overturned.
Appeal type: Experimental/Investigational
Decision: Overturned

A 32-year-old female enrollee has requested breast magnetic resonance imaging (MRI) for evaluation of her diagnosis with breast cancer. Findings:  Two physician reviewers found that the requested diagnostic procedure is likely to be superior over other available treatment options.  Per the medical records, this patient has a particularly aggressive form of breast cancer.  MRI is the most sensitive means with which to detect breast cancer.  Given this patients multifocal disease, MRI is appropriate after chemotherapy to determine which site or sites should be excised.  The MRI will be valuable as a surgical and prognostic test and is superior to all other available techniques.  Therefore, the requested MRI is likely to be of greater benefit than other options for evaluating this patient.
Appeal type: Medical Necessity
Decision: Upheld

A 53-year-old male has requested a 12-week course of Sovaldi 400mg and Olysio 150mg for treatment of his hepatitis C. Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested medication combination.  There is a lack of support for the requested medication regimen in this clinical setting.  The patient has hepatitis C, genotype 1b and he is treatment-naive.  It appears that he has minimal or no hepatic fibrosis based on laboratory testing and imaging.  Per the current medical evidence, the benefit of therapy is of unclear value in patients with minimal disease.  In this patients case, further stratification of disease burden with liver biopsy or fibrosis panel is needed.  All told, the requested 12-week course of Sovaldi 400mg and Olysio 150mg is not medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a three-year-old male has requested speech therapy (ST) and occupational therapy (OT) services for treatment of his autistic spectrum disorder (ASD). Findings:  The physician reviewer found that review of the available peer reviewed medical literature indicates that ST and OT are medically necessary interventions for the treatment of patients diagnosed with autism. Laryngeal/oropharyngeal or anatomical abnormalities are not necessary for abnormal language development, as is often seen in children with developmental delay of speech and language.  At issue is the notion that plasticity in the developing brain still exists, and ST and OT can be utilized to improve overall neurologic health. Thus, specific treatment, including speech and occupational therapies, can be used to help induce brain plasticity, with the ultimate goal of retraining neural circuitry not compromised by the underlying pathogenetic processes that give rise to developmental delay of speech as well as deficits in communication, play skills, and self-help skills, with the clear message that language skills and to a lesser degree, non-verbal skills improve with long-term application of speech and occupational therapy during critical developmental periods in childhood.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for radiofrequency ablation of genicular nerve of the left knee. Arden and colleagues note that in the management of knee osteoarthritis, clinical practice guidelines recommend education, structured exercise, and weight loss as core treatments, topical nonsteroidal anti-inflammatory drugs (NSAIDs) as first-line treatments and oral NSAIDs and intra-articular injections for persistent pain. The American College of Rheumatology (ACR) and the Arthritis Foundation recommendations for the management of hand, hip, and knee osteoarthritis include strong recommendations for exercise, weight loss in patients who are overweight or obese, self-efficacy and self-management programs, cane use, tibiofemoral bracing for tibiofemoral knee osteoarthritis, topical NSAIDs, oral NSAIDs, and intraarticular glucocorticoid injections. The guidelines noted that while there were some studies demonstrating potential analgesic benefits with various ablation techniques, due to the heterogeneity of techniques and controls used, as well as the lack of long-term safety data, a recommendation on its use was conditional. Overall, there are insufficient published high-grade data at this time to establish that a genicular nerve block or a genicular nerve ablation is a clinically effective procedure that provides benefits beyond a placebo effect in the setting of knee osteoarthropathy. Therefore, radiofrequency ablation of genicular nerve of the left knee is not likely to be more beneficial for treatment of the patients condition than any available standard therapy.Findings:  Three of the three physician reviewers found the requested radiofrequency ablation of genicular nerve of the left knee is not 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 service 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: Physician reviewer 1 is board certified in physical medicine and rehabilitation and is actively practicing. Physician reviewer 2 is board certified in physical medicine and rehabilitation with sub-specialty certification in neuromuscular medicine and is actively practicing. Physician reviewer 3 is board certified in physical medicine and rehabilitation with sub-specialty certification in pain 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: Experimental/Investigational
Decision: Upheld

A 60-year-old female, who presented to her physician for evaluation of pain and numbness of both feet, has requested authorization for pulsed radiofrequency.Reviewers Findings:All three reviewing physicians found that there is insufficient evidence supporting the long-term efficacy of pulsed radiofrequency in good quality, scientific peer-reviewed literature. In addition, there is insufficient current peer-reviewed literature demonstrating the safety of pulsed radiofrequency to recommend it for use at this time. There is no data to suggest that pulsed radiofrequency has greater efficacy than standard treatment such as orthotics, medications and injections.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary:  An enrollee has requested methadone and Tylenol with codeine #4 for treatment of her migraine headaches.  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested medications.  This patient has chronic migraine.  She has been receiving chronic opiate treatment for headache.  Per the medical records, she has had treatment with numerous preventives, and with current regimen reports improvement from Botox.  The medical literature indicates that opiates are generally not advised for migraine, as they can contribute to transformation to chronic migraine, and can provoke opiate-induced hyperalgesia.  The medical evidence does not support the requested medications in this clinical setting.  All told, the requested methadone and Tylenol with codeine #4 are not medically indicated for the treatment of this patient.  Final Result: The reviewer determined that 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 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: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Repatha SureClick pen injector. Proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitor therapy may be used for LDL cholesterol lowering in the management of patients at risk for cardiovascular disease. In this case, the patient had hyperlipidemia, type 2 diabetes, and a strong family history of early cardiovascular disease. She was on a moderate dose statin, atorvastatin 40 mg, with side effects, but could not tolerate ezetimibe. Due to her family history and intolerance of high dose cholesterol lowering agents, the patient was at elevated risk for development of cardiovascular disease. She had undertaken successful lifestyle changes, including weight loss, diet and exercise, but these did not have a marked effect on her lipids, and her LDL and non-HDL cholesterol levels were elevated. Based on current medical literature and this patients elevated risk for cardiovascular disease, Repatha SureClick pen injector is medically indicated for the treatment of this patients persistent and refractory hyperlipidemia. Therefore, the requested Repatha SureClick pen injector 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 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: Overturned

A 55-year-old male enrollee has requested coverage for CT scan of the abdomen for treament of his abdominal pain. Findings:  The physician reviewer found that review of the submitted clinical evidence demonstrates a CT scan was medically reasonable and appropriate in this clinical setting. The patient had abdominal pain and required further workup. In light of his weight issues, a CT scan was likely to be of greater clinical value than an ultrasound or other diagnostic test.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary:  An enrollee has requested reimbursement for laboratory testing (CPT- 82523) provided. Findings:  The physician reviewer found that DEXA measures bone mineral density, which helps in estimating fracture risk and in identifying patients who may benefit from treatment. Greenblatt and colleagues indicate that because of limitations of the DEXA scan, including radiation exposure and limited ability to predict fracture risk, BTMs, such as C-telopeptide can act as an adjunct in management of osteoporosis and are indicative of the rate of bone turnover. Szulc and colleagues state, The International osteoporosis foundation and the International Federation of Clinical Chemistry (IFCC) Bone Marker Standards Working Group have identified N-terminal propeptide of type I procollagen (PINP) and C-terminal telopeptide of type I collagen (CTX-I) in blood to be the reference markers of bone turnover for the fracture risk prediction and monitoring of osteoporosis treatment. Further, Williams and colleagues state, Unlike DEXA measurements, bone turnover markers, such as CTX, show appreciable, rapid response to changes in turnover rate, making them of great use clinically for monitoring treatment response and adherence in osteoporotic patients from the onset of treatment initiation. Therefore, laboratory testing (CPT- 82523) provided  was likely to have been more beneficial for evaluation of the patients condition than any available standard therapy.Findings: Two out of three physician reviewers found that laboratory testing (CPT- 82523) provided was likely to have been more beneficial for the enrollee than any available standard therapy.Final Result: The reviewers determined that the service at issue was likely to have been more beneficial than any available standard treatment for the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer 1, reviewer 2, and reviewer 3 are board certified in board certified in internal medicine with sub-specialty certification in endocrinology, diabetes, and metabolism. 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.