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

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for lidocaine 5% patch (Lidoderm) medication. Findings:  The physician reviewer found that The U.S. Food and Drug Administration approves the use of Lidoderm for relief of pain associated with post-herpetic neuralgia. McColgan and colleagues found that topical lidocaine patches have not been proven effective for the treatment of musculoskeletal pain. They further found that a large proportion of inpatients were inappropriately prescribed topical lidocaine patches predominantly for musculoskeletal pain. In a systematic review evaluating the efficacy, effectiveness and safety of using of lidocaine patches for chronic low back pain, Santana and colleagues concluded, We found no randomized controlled trials with substantial evidence to support the use of 5%  transdermal lidocaine patch in chronic low back pain. In this case, the patient has chronic low back pain due to lumbar radiculopathy and knee pain. The documentation does not reflect any history of post-herpetic neuralgia. The patient has declined conservative management of his lumbar radiculopathy with epidural steroid injections. Given that current medical literature does not support the efficacy of lidocaine patches for the treatment of lumbar radiculopathy and knee pain, the requested medication is not medically indicated. Therefore, lidocaine 5% patch (Lidoderm) medication is not medically necessary for the 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 anesthesiology with sub-specialty certification in pain 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

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement and prospective authorization and coverage for transcranial magnetic stimulation (TMS) treatments for treatment of the enrollees behavioral health condition. Findings:  The physician reviewer found that while there is support in the medical literature endorsing the efficacy of TMS for the acute phase treatment of major depressive disorder, there is a lack of evidence based literature for its use as maintenance therapy. An open label prospective study recommended that further studies with larger cohorts would be helpful in determining the long term efficacy of TMS maintenance therapy. In another cited literature, they found that the evidence available on the use of TMS as maintenance therapy remain underdeveloped. In this patients case, she showed a positive response to the initial TMS treatments. The patient reported depression and indicated that the week prior was one of the best she had had in years. By the end of the year, the patient had received 70 TMS sessions. The patients provider had noted that the TMS treatments would eventually be tapered off and discontinued. The records are unclear as to why TMS treatments after the initial 35 sessions were continued. As such, the submitted records do not demonstrate a clear rationale or benefit of the TMS sessions for treatment this patient.  Moreover, there is a lack of support in the literature to indicate the efficacy of TMS as maintenance. Final Result: The reviewer determined that the services at issue were not and 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 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

Nature of Statutory Criteria/Case Summary:  An enrollee has requested Morphine for the treatment of her medical condition.   Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested medication.  The current standard of care for chronic pain is treatment in a multidisciplinary pain management practice to include physical therapy, massage therapy, cognitive behavioral therapy, and injections to help reduce pain.  Researchers reported that high-dose opiates might contribute to pain sensitization via opioid-induced hyperalgesia, decreasing patient pain threshold and potentially masking resolution of a preexisting pain condition.  In this retrospective study, the majority of patients undergoing detoxification of high-dose opiates for chronic pain reported a significant decrease in pain at the end of the study, further supporting the theory of opioid-induced hyperalgesia.  Long-term, short-acting opiates may also cause adverse outcomes.  Researchers also reported that prolonged use of opiates might induce tolerance, abnormal pain sensitivity, and hormonal effects. The aim of current guidelines is to protect patients from the adverse effects of opioid therapy.  All told, the requested Morphine is not medically indicated for the 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 anesthesiology with sub-specialty certification pain 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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Tramadol 50mg for the requested quantity of 120 tablets for a 30-day supply. Findings:  The physician reviewer found that Centers for Disease Control and Prevention (CDC) guidelines for the prescribing of opioids for chronic pain state that nonpharmacologic therapy and nonopioid pharmacologic therapy are preferred for chronic pain. The guidelines state that clinicians should consider opioid therapy only if the expected benefits for both pain and function are anticipated to outweigh the risks to the patient. If opioids are used, they should be combined with nonpharmacologic therapy and nonopioid pharmacologic therapy, as appropriate. Federation of State Medical Boards guidelines for the chronic use of opioid analgesics recommend opioid therapy for chronic pain that is not cancer-related, or part of palliative care or end-of-life care, only when non-opioid and non-pharmacological options have not been effective. The guidelines state that opioid dosage should be maintained as low as possible and continued only if clear and objective outcomes are being met. American Society of Interventional Pain Physicians (ASIPP) opioid prescribing guidelines state that the prescription of opioids at a dosage of less than 40 morphine equivalents a day is considered low dose therapy.In this case, the patient has chronic knee pain that has been managed with tramadol 50 mg every 6 hours as needed, 120 tablets, for the past year. The requested quantity of medication is considered low dose opioid therapy according to ASIPP guidelines, and the providers notes state that the patient has not shown any aberrant or drug seeking behavior and that the patients medications are managing his pain and allowing him to perform his activities of daily living. There is no documentation showing that there have been any irregularities in the patients CURES report, and there have not been any inconsistent urine drug screens documented. Under these circumstances, Tramadol 50mg for the requested quantity of 120 tablets for a 30-day supply is medically necessary to treat the patients medical condition.Final Result: The reviewer determined that the requested medication is medically necessary to treat the patient's medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in anesthesiology, with subspecialty certification in pain 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: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for deep brain stimulation (DBS) surgical procedure. Naesstrom and colleagues note that the U.S. Food and Drug Administration (FDA) has approved the use of DBS for the treatment of obsessive compulsive disorder (OCD). The authors further note that DBS has shown promising results for the treatment of therapy-refractory OCD. In a long-term follow-up study of 24 patients with severe, treatment-resistant OCD, Luyten and colleagues reported that electrical stimulation in the bed nucleus of the stria terminalis was a promising therapeutic option. In this case, the patient has a history of severe, medically refractory OCD and has tried and failed maximum standard medical therapy. Therefore, a DBS surgical procedure is 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 deep brain stimulation (DBS) surgical procedure 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 service 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, 2, and 3 are board certified in neurological 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: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for genetic tests: Bloom syndrome, dihydrolipoamide dehydrogenase deficiency, familial hyperinsulinism, Fanconi anemia C, Gaucher disease, glycogen storage disease type 1A, Joubert syndrome, maple syrup urine disease, mucolipidosis type IV, nemaline myopathy, Niemann-Pick disease, spinal muscular atrophy, Usher syndrome type IF, Usher syndrome type III and Walker-Warburg syndrome for evaluation of the enrollee who underwent prenatal genetic testing. Findings:  The physician reviewer found that the submitted documentation supports the medical necessity for a portion of the services at issue in this clinical setting. The American Congress of Obstetricians and Gynecologists (ACOG), notes that certain disease conditions are more prevalent in individuals of Eastern European Jewish descent. In this patients case, both she and her husband are of Ashkenazi Jewish descent. The ACOG Committee Opinion recommends the following, Carrier screening for Tay-Sachs disease (TSD), Canavan disease, cystic fibrosis, and familial dysautonomia should be offered to Ashkenazi Jewish individuals before conception or during early pregnancy. ACOG also specifies that Preconception and prenatal screening for spinal muscular atrophy (SMA) is not recommended in the general population at this time. The services at issue involved screening for Bloom syndrome, dihydrolipoamide dehydrogenase deficiency, familial hyperinsulinism, Fanconi anemia C, Gaucher disease, glycogen storage disease type 1A, Joubert syndrome, maple syrup urine disease, mucolipidosis type IV, nemaline myopathy, Niemann-Pick disease, spinal muscular atrophy, Usher syndrome type IF, Usher syndrome type III and Walker-Warburg syndrome. In this patients case, only spinal muscular atrophy and Walker-Warburg syndrome were not medically indicated. As such, the genetic tests performed for Bloom syndrome, dihydrolipoamide dehydrogenase deficiency, familial hyperinsulinism, Fanconi anemia C, Gaucher disease, glycogen storage disease type 1A, Joubert syndrome, maple syrup urine disease, mucolipidosis type IV, nemaline myopathy, Niemann-Pick disease, Usher syndrome type IF, and Usher syndrome type III were medically necessary. However, the genetic tests for spinal muscular atrophy and Walker-Warburg syndrome were not medically necessary for evaluation of this patient. Final Result: The reviewer determined that a portion of the services at issue was medically necessary for evaluation of the patients medical condition. Therefore, the Health Plans denial should be partially overturned.  Credentials/Qualifications: The reviewer is board certified in obstetrics and gynecology with sub-specialty certification in maternal and fetal 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

A 44-year-old female enrollee has requested bariatric surgery including duodenal switch and laparoscopic cholecystectomy for treatment of her morbid obesity.  Findings:  The physician  reviewer found that this patient clearly meets the criteria set by the National Institutes of Health for surgical treatment of obesity. The question raised relates to what would be the best surgical approach. Serious consideration should be given to the medications the patient is likely to take the rest of her life for her SLE and associated joint pain. Specifically, NSAIDs, Methotrexate, Plaquenil, and potential high-dose steroids with exacerbation of SLE symptoms. These medications can predispose the patient to ulcer formation and other gastrointestinal complaints. In comparing the duodenal switch procedure to the standard Roux-en-y gastric bypass, the literature indicates that the duodenal switch has proven to be superior with regard to gastritis, marginal ulcer formation, dumping syndrome, nutritional abnormalities and the stability of the weight loss.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for transcranial magnetic stimulation. The submitted documentation supports the medical necessity of the services at issue. The records document severe depression. The patient does not appear to have any comorbid substance abuse or personality disorders. The evidence base for transcranial magnetic resonance has grown over the past several years. There is supporting evidence in the literature that numerous medication trials do not often yield higher levels of success. This patient has failed multiple medication trials in the past. Due to the patients level of depression and lack of response to antidepressant treatment, transcranial magnetic stimulation was medically appropriate. Therefore, transcranial magnetic stimulation was medically necessary for the treatment of this patient.Final Result: The reviewer determined that the services at issue were 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: Overturned

A female enrollee requested unicompartmental/total knee replacement of the left knee for medical treatment of her knee pain.  Findings:  The physician reviewer found thatthis patient has failed conservative measures, including nonsteroidal anti-inflammatory medications and steroid injections.  Prior interventions have not significantly influenced the patients bilateral knee pain.  The current medical evidence supports either unicompartmental arthroplasty or total knee arthroplasty in this clinical setting.  All told, the requested services are medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Overturned

 A male enrollee requested Sovaldi for medical treatment of his hepatitis C.  Findings:  Three physician reviewers found that the recommended treatment regimen of Sovaldi with ribavirin has been demonstrated to be effective for patients with hepatitis C, genotype 2.  As noted by the American Association for the Study of Liver Diseases and Infectious Diseases Society of America, the medical evidence supports treatment of all patients with hepatitis C, except those with limited life expectancy due to non-liver-related comorbid conditions.  Early treatment may allow patients to avoid complications from advanced disease, including liver failure and extrahepatic complications from hepatitis C.  All told, the requested Sovaldi is medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Overturned

The patient is a 25-year-old female who has a history of recurrent depression. She failed a trial of Lexapro and a stimulant but responded well to a six-week trial of Cymbalta. Her prescribing physician then gave her samples for another six weeks. The progress notes document that the patient responded to Cymbalta and is stable on this medication.  The patients request for authorization of Cymbalta was denied by the Health Plan based upon a determination that the medication is not medically necessary.Authorization of Cymbalta by the Health Plan requires a trial and failure of Effexor XR.  The patient has not tried Effexor XR, but has tried other medications that were not successful in treating her depression. Although Cymbalta and Effexor XR are similar in pharmacology, when individual patient variability is considered there is no guarantee the patient would have the same positive clinical response to Effexor XR.  At this point in time, it would not be medically appropriate to discontinue a medication that is successfully treating the patients depression.  Therefore, 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: Medical Necessity
Decision: Upheld

The patient is a 57-year-old woman who has a stage T3,N0,M0 carcinoma of the rectum. This is an invasive carcinoma. The tumor measures 3.5 cm x 1.6 cm and is located on the anterior wall of the rectum extending from 2 cm above the dentate line to 5 cm superiorly. Transrectal ultrasound reveals the tumor extends to the perirectal fat. The recommended treatment plan includes pre-operative chemoradiation to try to shrink the tumor for a more complete tumor resection. It has been proposed that the patient receive intensity modulated radiation therapy (IMRT) as opposed to external radiation therapy. The Health Plan has denied coverage for IMRT on the basis it is not medically necessary for treatment of the patients condition.In this clinical setting, all publications currently support 512 weeks of external beam irradiation or 5000 cGy in 512 weeks in combination with chemotherapy, preoperatively. Though IMRT is superior to external radiation because of its ability to deliver a higher dose without increased side effects, in this case the dose is fixed at 5000 cGy in 512 weeks. Additionally, the toxicity of conventional 5000 cGy to the pelvis has been well studied for all pelvic tumors and is well tolerated by most patients. As the side effects of radiation of pelvic tumors are similar to those experienced in patients with rectal tumors, it is likely that external radiation therapy will be well tolerated in this patient. In summary, IMRT has no significant role as a preoperative modality. Therefore, I have determined the requested therapy is not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld

A 39-year-old male enrollee has requested for Xyrem for treatment of his obstructive sleep apnea and idiopathic hypersomnia. Findings:  The physician reviewer found that Xyrem is known to increase the amount of N3 stage of sleep, but based on the patients sleep study results, it is not necessary here. The sleep study also showed some reduction of REM sleep which can be associated with untreated sleep apnea, as well as the effect of medications.Based on diagnostic criteria, this patients pathologic sleepiness cannot be categorized as a separate disorder such as idiopathic hypersomnolence (i.e., this patient has untreated sleep apnea, which is the primary cause of his sleepiness). The disorder of sleepiness or narcolepsy can only be diagnosed when other sleep disorders are being treated. In a test interpretation, the patients provider did not make a diagnosis of narcolepsy.