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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for genetic testing. This patient has a personal history of bilateral upper lobe pulmonary emboli and a family history of breast cancer, blood disorder, and malignant melanoma. The patients provider has recommended genetic testing to determine the presence of mutations in diagnosing and treating the patient. As noted in the medical literature, patients with inherited thrombophilia have a genetic tendency for venous thrombosis. The most common inherited thrombophilias are the factor V Leiden (FVL) mutation and the prothrombin gene mutation (PGM), which together account for up to 60% of cases of an inherited hypercoagulable state. Homozygosity for methylenetetrahydrofolate reductase (MTHFR) polymorphisms is a relatively common cause of mildly elevated plasma homocysteine levels, but these mutations do not appear to increase the risk of venous thromboembolism in women. High quality studies have not found a significant increase in venous thromboembolism risk among patients homozygous for MTHFR polymorphisms. Routine screening for inherited thrombophilias is not recommended due to the low frequency of the condition becoming symptomatic and the lack of a safe long-term method of prophylaxis against thromboembolism. All told, the requested genetic testing is not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Findings:  Two of the three physician reviewers found the genetic testing is not likely to be more beneficial for evaluation of the patient's medical condition than any available standard therapy. Final Result: The reviewers determined that the requested services are not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: Physician reviewer 1 is board certified in pediatrics with subspecialty certifications in neurodevelopmental behavioral pediatrics and genetics and is actively practicing. Physician reviewer 2 is board certified in genetics and is actively practicing. Physician reviewer 3 is board certified in pediatrics with subspecialty certifications in genetics and clinical biochemical genetics 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: Overturned

A female enrollee requested Afirma testing for medical evaluation of her medical condition. Findings:  Two physician reviewers found that while a fine needle aspiration biopsy of a suspicious thyroid nodule is typically an accurate means of assessing whether the nodule is benign or malignant, approximately 15% of fine needle aspiration biopsy results are considered to be indeterminate.  Afirma testing utilizes a gene expression classifier in order to help determine the likelihood of malignancy of nodules with indeterminate cytology on fine needle aspiration biopsy, thereby decreasing the need for unnecessary surgeries.   All told, Afirma testing was likely to have been superior over other modalities for evaluating this patient.
Appeal type: Experimental/Investigational
Decision: Upheld

A 28-year-old female enrollee requested proton beam therapy for medical treatment of her left temporal anaplastic astrocytoma.  Findings:  Two physician reviewers found that Proton beam therapy is not likely to be more effective for this patient than other available options. Proton beam therapy has a role in the treatment of some cancer patients. However there are physical uncertainties about proton depth dose delivery which may render the actual radiation deposition in tissue less conformal than it may appear based upon the treatment plan (Paganetti). In addition, there is a lack of data in the medical literature that demonstrates that proton therapy is superior to photon therapy with respect to outcomes for astrocytomas. The current National Comprehensive Cancer Network (NCCN) guidelines for central nervous system tumors do not address proton therapy for gliomas. Moreover, there is a paucity of published data in support of proton therapy for gliomas and such studies are small. Due to these reasons provided, proton beam therapy is not likely to be more beneficial for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned

A 23-year-old female enrollee has requested access to continuous monitoring and treatment in a pain management department for treatment of her multiple medical conditions.  Findings:  The physician reviewer found that the patient has a history of bipolar disorder, severe chronic back pain, kyphosis and rod placement in her spine. The patient has also been diagnosed with opioid dependence with several reported hospital admissions for overdose. The patient was recommended for a drug rehabilitation program. The patient has been participating in the drug rehabilitation program for several months and has requested pain management treatment, as she has indicated that non-opiate medications have not been effective in treating her condition. Pain management includes multidisciplinary care including psychological assessment and treatment as well as adjuvant medications, non-pharmacologic measures and any interventional procedures that may be applicable to the condition. A patient with chronic non-malignant pain in the setting of an opioid abuse history is appropriate for treatment in the pain management department, with the limitation that the patient is only a candidate for non-opioid treatment. The typical treatment protocol for a patient, such as this, is monthly pain management care with reassessment at twelve months. Thus, a portion of the requested services are medically necessary in this patients case. Therefore, pain management services are medically appropriate at a frequency of one visit per month. However, treatment with opioid medications is not appropriate for the treatment of this patients medical condition, given her history of opiate dependence.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patients parent has requested authorization and coverage for budesonide EC 3 mg CAPDR-ER, 90 capsules every 30 days. Enteral budesonide is useful for induction of remission in the setting of mild to moderate ileal Crohns disease. Currently, there is limited data on trials comparing budesonide to prednisone. There are guidelines utilizing these pediatric data, published by the European Society of Pediatric Gastroenterology, Hepatology and Nutrition, and the Canadian Association of Gastroenterology, which endorse enteral budesonide as a treatment option for children with mild to moderate ileal Crohns disease. There is a lack of evidence to support using budesonide for maintenance of clinical remission. The Canadian Association of Gastroenterology strongly advises against using budesonide as a maintenance treatment, due to concerns for its ineffectiveness and increased risk of potential side effects such as adrenal suppression and poor linear growth. This patient has been treated with budesonide for chronic right lower quadrant pain, nodularity endoscopic appearance of inflammation on video capsule endoscopy, and hyperenhancement of the terminal ileum. As treatment for ileal Crohns disease, budesonide was appropriate for this patient. However, the medical literature and guidelines do not support ongoing treatment with budesonide. Since budesonide can potentially lead to adrenal suppression, a tapering of the dose would is appropriate prior to cessation. Ruemmele and colleagues noted that, budesonide can be tapered within 10 to 12 weeks. Given this support, budesonide EC 3 mg CAPDR-ER, 90 capsules every 30 days for three months is medically necessary for the patient. Final Result: The reviewer determined that a portion of the requested medication regimen is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be partially overturned. Credentials/Qualifications: The reviewer is board certified in pediatric gastroenterology 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 51-year-old male enrollee has requested one year of aftercare with private counseling for the treatment of his psychiatric condition. Findings:  The physician reviewer found that due to the extent of the patients cocaine dependence, his very meager social support and baseline Paranoid Personality Disorder, any program which would offer him more support and social skill training so as to maximize his chances of sustained sobriety is medically necessary. As well, the patient attended multiple sessions over the weeks.  He attended IOP approximately twice a week. This is not an excessive use of IOP services given the patients pathology. Overall, I find that the requested additional treatment in IOP is medically necessary.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for a continuous glucose monitor (CGM). CGM is a tool to visualize the important role that diet, exercise, stress management, and the appropriate selection of diabetes medications can have in managing type 2 diabetes. Several diabetes organizations have reviewed the literature on the appropriate use of CGM in diabetes management and concluded that CGM may be a useful educational and management tool. Most summaries of CGM studies found that having a standardized glucose pattern report, such as the ambulatory glucose profile report, helps facilitate effective shared decision-making. According to the most recent American Diabetes Association (ADA) guidelines, the chronic care model includes the following elements to optimize the care of patients with chronic disease: delivery system design (moving from a reactive to a proactive care delivery system); self-management support; and decision support. In this case, the CGM system will be a beneficial tool for the patient to optimize his lifestyle and therapy. Moreover, the device meets the elements of the ADA chronic care model for optimization of therapy. Even though this patient has diabetes type 2, his diabetes control has been suboptimal despite treatment with three non-insulin medications. He is motivated to control his diabetes with feedback from the CGM. Given these findings, a CGM is medically necessary for 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 internal medicine with subspecialty certification in diabetes, endocrinology and metabolism 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 20-year-old female enrollee has requested weekly individual therapy for treatment of her behavioral health condition.  Findings:  The physician reviewer found that in this case the documentation submitted for review does not support the medical necessity for weekly individual therapy sessions. The documentation does not include a clinical report of current status. Such a report would provide information such as patient goals, chief complaint, barriers to care, symptom complex, mental status examination, sequential objective rating scales, physical examination, medication list, assessment, interpretative summary and plan. In addition, absent is a comprehensive treatment plan, which develops and organizes interventions. One of the many products of a treatment plan in this case would be the specification of the type, setting and frequency of therapy, in addition to the plan for monitoring progress. Further, the patient has done well with the structure of IOP in the past. With a chronic severe mental illness that impairs multiple domains of functionality, a setting such as IOP or partial hospital, both of which offer the full range of biopsychosocial interventions, might provide the most appropriate comprehensive treatment in a complex case such as this. In sum, although comprehensive, specialty treatment services are indicated there is no medical justification for individual psychotherapy at a frequency of once per week. Moreover, an updated psychiatric evaluation is indicated to determine the patients current clinical status and her subsequent treatment needs. As such, the requested services are not medically necessary for treatment of the patients behavioral health condition.
Appeal type: Medical Necessity
Decision: Overturned

The patient is a 40-year-old woman with a history of sudden onset of vertigo occurring 5/24/2003. She also had a history of migraine headaches, which do not appear to always coincide with the episodes of vertigo. The patient also has had complaints of neck and back pain, stress, and vision problems. There is a significant diagnosis of benign paroxysmal positional vertigo and also a later possible diagnosis of Menieres disease.At the time the patient sought treatment from an acupuncturist her symptoms were vertigo, dizziness, unbalanced headaches, poor concentration, fatigue, weakness, and ear ringing. In his letter/report of 11/20/03, the patients acupuncturist reports a favorable response to clinical treatment, as do his chart notes for the treatment dates. The only exception is on 11/10/03 when there was an increase in symptoms due to the onset of menses. Currently, it appears that the patients chief complaint is vertigo, which is greatly affecting her quality of life, both personal and professional. She cannot drive for periods over 10-15 minutes, must walk with her head down so she can watch her feet to maintain balance, and must slowly and cautiously move her head. The patient has requested authorization for continued acupuncture treatments. The Health Plan indicates that acupuncture is not medically indicated for treatment of the patients vertigo.Upon review of the submitted medical records, it appears the patient has had a number of examinations/tests to determine the cause of her vertigo symptoms without much success. These include neurological consultations (two), otolaryngology consultation, MRIs (two), a color flow Doppler, and an outpatient consultation. The results of these examinations/tests were essentially normal. She has been prescribed medication and physical therapy, which she states have been of no help. Dizziness is one of the conditions that is commonly treated with acupuncture. In addition, acupuncture is used to treat depression, stress, and headache/migraine, all of which the patient has experienced. The patient reported no benefit from traditional treatments; in fact, she indicated some of the medications caused her symptoms to increase. She has reported a good response to non-traditional medicine (acupuncture/herbs) in that her symptoms have decreased and are not as severe and she is sleeping better. In light of the failure of standard therapies and the patients favorable response to acupuncture, continued acupuncture treatments are medically appropriate and indicated.Based upon the information set forth above, I have determined that the requested therapy is medically necessary for treatment of the patients medical condition. The Health Plans denial should be overturned. The patient should receive eight acupuncture treatments followed by re-evaluation by her acupuncturist and primary care physician.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for genicular nerve radiofrequency ablation of the bilateral knees. Findings:  The physician reviewer found that the patient presents with bilateral knee pain associated with osteoarthritis. The patients provider has recommended genicular nerve radiofrequency ablation of the bilateral knees. Radiofrequency ablation of genicular nerves is a potential therapeutic alternative for chronic pain associated with osteoarthritis of the knee, particularly for some patients with comorbidities who are not considered ideal surgical candidates. Bhatia and colleagues found that, Radiofrequency treatments on the knee joint (major or periarticular nerve supply or intra-articular branches) have the potential to reduce pain from osteoarthritis or persistent postarthroplasty pain. However, the authors cautioned that, Ongoing concerns regarding the quality, procedural aspects, and monitoring of outcomes in publications on this topic remain. The authors concluded that additional studies are needed to determine whether genicular nerve radiofrequency ablation is a safe and effective modality at long-term follow-up. For these reasons, the requested genicular nerve radiofrequency ablation of the bilateral knees is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Findings: Three of the three physician reviewers found the requested genicular nerve radiofrequency ablation of the bilateral knees 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 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: Physician reviewer 1 is board certified in orthopedic surgery and is actively practicing. Physician reviewer 2 is board certified in orthopedic surgery and is actively practicing. Physician reviewer 3 is board certified in physical medicine and rehabilitation with subspecialty certification in pain management 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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage of Vemlidy 25 mg daily for eight weeks for treatment of her chronic hepatitis B virus. Findings:  The physician reviewer found that guidelines for the treatment of hepatitis B from the American Association for the Study of Liver Disease (AASLD) recommend entecavir and tenofovir compared with alternatives for the treatment of chronic hepatitis B. The records note that Entecavir has failed in treatment of this patient due to suspected resistance. In comparison with tenofovir disoproxil fumarate (Viread), which the patient takes, the Vemlidy formulation of tenofovir is effective for hepatitis B, but is associated with fewer side effects, including osteopenia and renal disease. 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 gastroenterology 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 54-year-old male enrollee has requested cryosurgical ablation for treatment of his external renal tumor.  Findings:  Three physician reviewers found that partial nephrectomy is the preferred treatment option according to the recent American Urological Association (AUA) guidelines for management of small renal masses. Ablative techniques such as cryoablation have a greater risk of tumor recurrence and salvage surgery is more difficult. Based on the current peer-reviewed medical literature, the requested cryosurgical ablation 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 hip arthroplasty for treatment of the enrollees medical condition. The Health Plan has denied this request indicating that the requested procedure is not medically necessary for treatment of the enrollees medical condition. Findings: The physician reviewer found that the standard practice and the medical literature recommend total hip arthroplasty when all reasonable conservative measures have been exhausted and other reasonable surgical options have been seriously considered or implemented. These criteria include exercise therapy, supervised physical therapy and/or home rehabilitation exercises, and medications (unless contraindicated non-steroidal anti-inflammatory drugs or steroid injection). Subjective findings should include limited range of motion, or night-time joint pain, or no pain relief with conservative care. The American College of Rheumatology 2012 recommended total joint arthroplasty for patients with hip osteoarthritis following failed medical therapy. Medical therapy recommendations included exercise, weight loss for overweight patients, medication management, walking aids, and psychosocial interventions (Hochberg et al). Hofstede and colleagues stated that study results showed that pre-operative function and the severity of radiological osteoarthritis may be strong indicators of effectiveness of total hip arthroplasty. In this patients case, the left hip x-ray documented a normal study and the signals from the visualized osseous structures were unremarkable. Moreover, there is mild loss of left hip range of motion with groin pain in internal and external rotation. While current treatment includes opioid medications, activity modification, and corticosteroid injections, detailed evidence of exercise and physical therapy are lacking. There is also a lack of imaging evidence of hip osteoarthritis or any other hip pathology to support the medical necessity of a total hip replacement. Therefore, evidence based medical guidelines and peer-reviewed literature criteria have not been met, in this patients case. As such, the requested hip arthroplasty is not medically necessary for treatment of this patients medical condition.  Final Result: The reviewer determined that the requested procedure is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.  Credentials/Qualifications: The physician reviewer is board certified in orthopedic surgery 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.