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

A 35-year-old female enrollee has requested transcranial magnetic stimulation (TMS) therapy, CPT codes 90867 (1), 90868 (36), and 90869 (1) for treatment of her major depressive disorder. Findings:  The physician reviewer found that the submitted documentation demonstrates the medical necessity of the requested services in this patients case.  The current medical literature supports TMS therapy in this clinical setting.  TMS therapy has been endorsed by the American Psychiatric Association in its current clinical practice guideline for the treatment of individuals with depression.  In this particular case, the patient is enduring an acute major depressive episode that is causing significant morbidity and functional impairment.  She has pursued other standard therapies and remains symptomatic.  Considering the medical records and the expanding peer-reviewed literature base, TMS therapy is appropriate to treat this patients depressive symptoms.  All told, the requested TMS therapy, CPT codes 90867 (1), 90868 (36), and 90869 (1), is medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Overturned

The patient has requested reimbursement for thoracic epidural steroid injection and prospective authorization and coverage for thoracic epidural steroid injection. Although thoracic spinal pain is not as common as lumbar or cervical pain, researchers found that the degree of disability resulting from thoracic pain seems similar to other painful conditions with associated loss of function. In comparing thoracic epidural injections with injections of local anesthetics, the authors concluded, Based on the results of this trial, it is concluded that chronic thoracic pain of non-facet joint origin may be managed conservatively with thoracic interlaminar epidural injections with or without steroids. In this case, the patient reported 80 percent relief from the injection, indicating that the pain source had been adequately identified and that a repeat epidural steroid injection is likely to be effective. As such, and based on current medical literature, the injection previously rendered and a repeat injection was and is medically indicated to manage the patients chronic thoracic pain. Therefore, reimbursement for thoracic epidural steroid injection and authorization and coverage for future thoracic epidural steroid injection was and is medically necessary for the treatment of this patient.
Appeal type: Urgent Care
Decision: Overturned

A 61-year-old female enrollee has requested emergency services for the treatment of her medical condition. Findings:  The physician reviewer found that the patient presented with acute right lower-quadrant abdominal pain of sufficient severity that a reasonable and prudent layperson would seek immediate medical attention due to fear for jeopardy of her health and/or bodily function.  According to the ER documentation, she appeared ill enough to warrant blood testing as well as a CT scan of the abdomen and pelvis.  The differential diagnosis of her presenting symptoms included several serious disorders including:  Bowel perforation and obstruction, diverticulitis, abdominal abscess and tumor, aortic aneurysm, and other disorders.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a 16-month-old male enrollee has requested speech therapy, occupational therapy and physical therapy services for treatment of the enrollees Down syndrome.  Findings:  The physician reviewer found that this patient with Down syndrome has the anticipated delays in intellectual, motor, and speech development that are typical of the syndrome. Formal testing of his speech level, his motor capacity, and his fine and gross motor control have all demonstrated significant delays. Given this patients delays, the local regional center recommended speech therapy, occupational therapy, and physical therapy for this patient.  The medical community standard for children with Down syndrome is to offer them speech, occupational and physical therapy early in life to maximize the childs developmental potential. A small randomized controlled study reported that with six weeks of physical therapy, children with Down syndrome developed improved lower extremity strength compared to control groups (Gupta, et al.).  Language skills are most often severely affected in children with Down syndrome and speech therapy was found to be effective in improving and developing patients speech (Kroeger and Nelson).  Occupational therapy was noted to effect neurodevelopmental improvement in children with Down syndrome (Uyanik, et al.).  All told, there is significant literature support for the value of speech, occupational, and physical therapy in children with Down syndrome.Therefore, it is medically necessary that this patient receive the requested speech, occupational and physical therapy services.
Appeal type: Experimental/Investigational
Decision: Upheld

The enrollee requested authorization and coverage for Platelet-Rich Plasma Injections, any site, including image guidance, harvesting and preparation. The enrollee has a history of right shoulder pain and combination subacromial impingement/acromioclavicular (AC) joint flare up. Progress notes show the enrollees pain was just as bad, if not worse, than before surgery. The physical exam noted breakaway weakness with external rotation and internal positive impingement signs. Over the past months, the enrollee has tried pain medication, anti-inflammatories, steroids, muscle relaxants, and physical therapy. A recent magnetic resonance imaging (MRI) scan shows the tear is worse than before surgery. Literature highlights the methodologic and technical issues that markedly limit any determination of the value of platelet rich plasma. Significant variability exists in the methods used to prepare PRP, resulting in differences in blood component concentrations and biomolecular characteristics. Additionally, the final concentration of platelets, growth factors, and leukocytes has been shown to vary between and within individuals. The varying quality and preparations of PRP make comparison amongst clinical research studies challenging. Attempts to classify and standardize preparations have been made. However, no consensus has been reached regarding the optimal preparation. Studies also show platelet-rich fibrin matrix (PRFM) applied to the tendon-bone interface at the time of rotator cuff repair had no demonstrable effect on tendon healing, tendon vascularity, manual muscle strength, or clinical rating scales. In fact, analysis suggests PRFM may have a negative effect on healing. Final Result: The reviewers determined that the requested services are not likely to be more beneficial than any available standard therapy for treatment of the enrollees medical condition. Credentials/Qualifications: The reviewers are board certified in orthopedic surgery 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 48-year-old woman has had severe pustular psoriasis for at least two years. The information provided indicates the patient has attempted treatment with topical steroids, tacrolimus, urea, Soriatane, and ultraviolet light. According to both the patient and her dermatologist ultraviolet light has been beneficial. The patient states traveling 20 miles three to four times per week is a hardship for her since she works nights. She has requested authorization and coverage for a narrow band ultraviolet B light home unit. The Health Plan has determined the requested equipment is not medically necessary for treatment of the patients medical condition. The submitted information indicates the patient has failed treatment with topical steroids, tacrolimus, urea, and Soriatane. Ultraviolet therapy is the only form of treatment that has been effective for this patient and is medically indicated. However, it has not been established that the patient requires an ultraviolet B home unit. There is no evidence the patient is homebound and unable to receive ultraviolet B therapy as an outpatient. Thus, the requested equipment is a convenience item and therefore, not medically indicated. Therefore, I have determined the requested equipment is not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Experimental/Investigational
Decision: Upheld

A 28-year-old female enrollee has requested the WalkAide system (Code E0770) for treatment of her right-sided lower extremity hemiplegia due to incomplete spinal cord injury.  Findings:  Two physician reviewers found that the peer reviewed medical literature reveals a number of publications with preliminary results supportive of the WalkAide device as promising for patients with foot drop resulting from upper motor neuron disorders. Despite these initial outcomes, the studies are small and not blinded, and require longer follow-up. Wieler and colleagues reported that the results are encouraging in terms of decreased energy expenditure and increased walking speed, but further study is needed to determine the role, if any, of the WalkAide in this patient subset. Further, the benefit of the use of a WalkAide over an AFO in a patient with an incomplete SCI has not been established. Kim and colleagues compared use of an FES against an AFO and found the FES to only be superior in increasing foot-clearance value but not in walking speed or endurance. Per this patients documentation, she presents with right leg weakness including a right foot drop due to an incomplete SCI and uses a right AFO. The records indicate the patient is able to walk with a single point cane. Overall, there is no specific documentation of any specific problem related to the current right AFO. Since there is insufficient objective documentation the patient is unable to use an AFO, and there is inadequate evidence that a WalkAide is superior to an AFO in patients with an incomplete SCI, the WalkAide has not been demonstrated as likely to be more beneficial than any available standard therapy in this clinical setting.
Appeal type: Medical Necessity
Decision: Overturned

The patient is a 45-year-old female who was diagnosed with stage III ovarian cancer in June 2004. She was treated with chemotherapy. The patients CA 125 rose from 7 in August 2005 to 65 in September 2006. On serial CT scans, there has been the development of a 1.4cm low-density lesion along the spleen. The patients gynecologist has requested a PET scan for further evaluation. The Health Plan has denied this request.Prior Centers for Medicare and Medicaid Services (CMS) reimbursement standards did not include ovarian cancer as an indication for PET scan. However, the National Oncologic PET Registry (NOPR) was developed in response to the CMS proposal to expand coverage for PET scans to include cancers and indications not previously eligible for Medicare reimbursement. NOPR lists ovarian cancer as an indication for PET scan for the purposes of diagnosis, staging, restaging, and monitoring.Furthermore, review of the scientific literature reveals that PET scans have been shown to be more sensitive than CT scans (87% versus 53%) for suspected recurrent ovarian cancer when there is a rising CA 125. The Gontier, et. al. study found the sensitivity and positive predictive value of PET/CT for lesions larger than 1cm were, respectively, 83% and 93% in a prospective study of 22 patients suspected of having recurrence because of an increasing CA 125 level but who had normal or equivocal findings on CT.  In another study of 56 women, PET/CT resulted in a major change of management plan in 58% of the patients (Simcock, et. al.). These studies demonstrate that PET scan is medically appropriate in this clinical setting and is likely to be superior to other diagnostic modalities.For the reasons set forth above, I have determined the requested PET scan is medically necessary for evaluation of the patients medical condition. The Health Plans denial should be overturned.
Appeal type: Experimental/Investigational
Decision: Upheld

A 53-year-old female enrollee has requested for the addition of Avastin (bevacizumab) to her chemotherapy regimen for treatment of her metastatic breast cancer.  Findings:  Two physician reviewers found that the patient does have chemotherapeutic options (Navelbine and Adriamycin), but she is limited by myelosuppression. Avastin is a reasonable option for her. There has been increasing interest in the role of Avastin in the management of patients with breast cancer. The use of Avastin plus cisplatin has been studied in the neoadjuvant setting. Although in this case the use of Avastin is being proposed in the metastatic setting rather than the neoadjuvant setting, the studies performed to date provide support for the contention that this combination is active in advanced triple negative disease. In addition, there is data indicating that Avastin can be combined with agents other than taxanes.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary:  An enrollee has requested Suboxone for treatment of his behavioral health conditions.   Findings:  The physician reviewer found that as an opioid agonist, buprenorphine can cause euphoria, respiratory depression and other opioid effects.  Thus, an opioid antagonist, naloxone, is added to buprenorphine, creating Suboxone, which minimizes misuse and diversion.  This addition also introduces the possibility of inducing withdrawal if Suboxone is administered in the absence of an opioid-free state. Long-term Suboxone maintenance therapy represents a proven, evidence-based intervention for opioid use disorder. Although the literature supporting the use of Suboxone for the treatment of heroin addiction is less robust, there is adequate evidence to warrant its use in this setting. Given the patients history, treatment with Suboxone is medically reasonable and appropriate at this time. As such, the requested Suboxone treatment is medically necessary for the treatment of this patients 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 psychiatry 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 49-year-old female enrollee has requested continued skilled nursing services and daily physical therapy for treatment of her post right open reduction and intramedullary nailing tibia fracture surgery. Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the services at issue.  This patient sustained right lower extremity fractures and has undergone surgery.  She has ongoing weight-bearing restrictions.  As of the date indicated, she was walking short distances with a walker and had improved functionally to conduct activities of daily living and transfers.  She was propelling a manual wheelchair household distances at supervision.  Further care could have been provided at a less intensive level of care until her weight-bearing restrictions are liberalized.  Significant functional gains would not have been expected given the slow rate of gains achieved up to that point.  All told, continued skilled nursing services for up to three additional weeks including daily physical therapy from the specified date forward were not and are not medically necessary in this patients case.
Appeal type: Medical Necessity
Decision: Overturned

The patients parent has requested authorization and coverage for a wheelchair ramp (suitcase trifold 10-foot ramp by EZ-Access). The patient has been diagnosed with an arteriovenous malformation (AVM) rupture and equinovarus contractures of bilateral feet. The patients parents were noted to carry the patient and his wheelchair up and down three steps to the entry of their home. Researchers noted assistive technology systems can provide opportunities for children with physical limitations to interact with their world, enabling play, communication, and daily living skills. In this case, a portable ramp would enable the patient to safely and effectively enter and exit his home by self-propelling a manual wheelchair or driving a powered chair. Removing a physical obstacle and arranging his home is necessary to promote his health and participation in life. The medical evidence supports the requested equipment in this clinical setting. Therefore, a wheelchair ramp (suitcase trifold 10-foot ramp by EZ-Access) is medically necessary for the treatment of this patient. 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 physical medicine and rehabilitation with sub-specialty certification in pediatric rehabilitation 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: Experimental/Investigational
Decision: Upheld

A 56-year-old male enrollee has requested coverage for X-Stop interspinous process decompression for treatment of his low back pain. Findings:  Three physician reviewers found that the patient has a history of low back pain with numbness and tingling going down into both feet.  He denies bowel or bladder problems.  On neurological testing, he has full strength and normal sensation in all four extremities, with normal gait.  An MRI of the lumbar spine showed severe spinal stenosis at L4-5 with near complete block of the canal.  The MRI report noted circumferential disc protrusion at L5-S1.  The patient has requested coverage for X-Stop interspinous process decompression.  The requested services are not likely to be superior over other treatment alternatives in this patients case.  In 2004, Zucherman and colleagues reported the results from a prospective, randomized trial of the X-Stop conducted at nine centers.  Two hundred patients were enrolled in the study, and 191 were treated.  In this study, 100 patients received the X-Stop, and 91 patients received non-operative therapy as a control.  The success rate at one year was 59% for the X-Stop group and 12% for the control group.  In a follow-up study, Zucherman and concluded that the X-Stop offers a significant improvement over non-operative therapies at one and two years.  However, Weiner cited FDA criticisms of these data.  Weiners letter to the editor noted that the outcomes in both groups were significantly worse than expected, results from one particular center were clearly superior to results from other centers, and overall effectiveness of the device was not shown in the majority of the clinical study population.  Additionally, concerns with long-term effectiveness were noted.  At this time, there is a lack of studies comparing the X-Stop to decompressive laminectomy.  While non-operative care may have been an appropriate control therapy for these trials, these trials have not demonstrated the superiority of the X-Stop over decompressive laminectomy.  As such, X-Stop interspinous process decompression has not been proven to be more effective than available standard therapy (decompressive laminectomy).
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage of Vytorin 10-40mg. The Health Plan has denied this request indicating that the requested medication is not medically necessary for treatment of the enrollees hyperlipidemia. A review of the records indicates the enrollee has been prescribed Vytorin at least since 8/15/13. The enrollee has a medical history of hypertension, high cholesterol, cardiac catheterization with stenting (1/3/91), and gout. The enrollee was seen for yearly examinations on 8/15/13, and 11/2/17. Vytorin has combination of statin and ezetimibe. This medication was tested in research study that measured Carotid Intimal Medial thickness (IMT). This study did not show an outcome benefit for Vytorin despite lower lipid levels when on the combination. Since then Vytorin has been used much less often. Guideline updates from 2017, reviewed more recent studies show that despite evidence for benefit in lowering cholesterol levels, the benefit of ezetimibe over intense statin treatment is not yet established. For these reasons it has not been proven that Vytorin is better than other standard lipid treatments. Therefore, the requested Vytorin 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 internal medicine, with subspecialty 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 58-year-old male enrollee requested acute inpatient mental health services for treatment of his behavioral health condition.  Findings:  The physician reviewer found that acute psychiatric hospitalization was initially indicated and consistent with good medical practice. However, based on the medical records, the acute level of care was necessary only until the patients antipsychotic medication had been increased, the patient had an improved appearance and was doing better. The trend continued as the patients thought processing was notably improved, his affect was appropriate and, although he disagreed for the need for a conservator, the patient was stable.  His thoughts were more organized and his behavior was cooperative. He was not suicidal or homicidal. He was adherent with his medications which were both well tolerated and efficacious. In sum, this patient has severe mental illness. His illness responds well to pharmacotherapy.   However, the patient has history of discontinuing his psychotropic medications and subsequently decompensating. Thus, a portion of the services were medically necessary for treatment of the patients medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld

A 52-year-old female enrollee requested human epididymis protein 4 (HE4) screening for medical evaluation of her medical condition.  Findings:  Two physician reviewers found that this patients records document a long history of close observation, with no evidence of malignant disease, and without any progression of the abnormal tumor marker.  In this setting, the elevated CA-125 was not likely to have been of clinical significance, and did not require additional investigation.  Furthermore, the patient was not considered at higher risk of ovarian malignancy on the basis of her prior diagnosis of ductal carcinoma in situ, as she had been screened for BRCA mutations and tested negative.  The medical evidence does not support the services at issue in this patients case.  Thus, HE4 screening was not likely to have been more effective than other alternatives for evaluating this patient.