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

The patient is a 42-year-old female with a history of three cesarean sections. The patient reports she was involved in a motor vehicle accident shortly after her most recent cesarean section in November 2003. She subsequent experienced some incision problems that left her with an unwanted incision scar. The patient is seeking coverage for an abdominal scar revision. The Health Plan has determined the requested procedure is cosmetic in nature and therefore, not medically necessary.Review of the submitted clinical records indicates the patient was seen by a board certified plastic surgeon approximately six to seven months after her cesarean section and the motor vehicle accident for evaluation of a leaking saline breast implant and for her abdominal scar. The revision of the abdominal scar was discussed with the patient; however, there is no documentation to support the medical necessity of the requested procedure. There is no conclusive evidence that the scar is causing pain or functional problems. Therefore, I have determined that the requested procedure is not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for surgical repair to the left knee to include subchondroplasty. There is a lack of evidence in the current medical literature to support the safety and efficacy of the requested service in this clinical setting of a young individual without knee arthrosis. Reports in the current medical literature on calcium phosphate injections into symptomatic bone marrow lesions are almost exclusively in the setting of bone marrow edema associated with osteoarthritis of the knee. In this case, the patient is a 28-year-old female with normal x-rays and magnetic resonance imaging (MRI)  that did not suggest articular abnormality, but rather mild medial tibial plateau edema. Given that the patients symptoms are attributed to subchondral insufficiency/stress fracture, which is not an articular problem, there is no role for arthroscopic surgery, partial meniscectomy, or synovectomy. Therefore, surgical repair to the left knee to include subchondroplasty is not likely to be more beneficial for treatment of the patients condition than any available standard therapy.Findings:  Two of the three physician reviewers found the requested surgical repair to the left knee to include subchondroplasty 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 reviewers 1, 2, and 3 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: Experimental/Investigational
Decision: Overturned

A 43-year-old female enrollee has requested reimbursement and prospective authorization and coverage for Botox injections for treatment of the enrollees migraines.  Findings:  Two physician reviewers found that the patient has been diagnosed with migraine, status migrainosus, chronic migraine, medication overuse, and myofascial pain. Her baseline headache frequency is not stated. Her attacks are reported to last four days. She has been treated with triptans and opiates. She has been receiving Botox treatment for approximately two years. The providers clinical notes indicate that Botox has been effective in managing the patients pain. With it, her attacks are infrequent, and headaches are reported to be better responsive to abortive medications. The Health Plan has denied the patients request for coverage for Botox, stating that Botox is experimental and investigational for muscle pain. The medical records document a diagnosis of chronic migraine. The specific terms of numbers of headache days is not documented. Muscle pain is common in patients with migraine, with 60 to 80% of migraine patients reporting neck and shoulder pain. The presence of muscle pain in migraine patients does not indicate a diagnosis of a non-migraine source of pain. Botox has been demonstrated to be effective for the treatment of chronic migraine, with the standard treatment patterns including areas within the neck and shoulder that can be sensitive and sore in migraine patients. The literature documents that Botox is effective for the management of chronic migraine. Neck pain, often diagnosed as cervicogenic headache, is frequently a component of migraine, as documented in the literature. This patients treatments have been consistent with the FDA approved treatment paradigm, and her benefit has been documented in the chart. Thus, it appears she is being treated for chronic migraine for which Botox is likely to be more beneficial than any available standard therapy.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested a Euflexxa injection for treatment of his shoulder pain. Findings:  Three physician reviewers found that evidence based medical guidelines and peer-reviewed literature do not support the use of hyaluronic acid injections, such as Euflexxa, for shoulder osteoarthritis. Kwon and colleagues conducted a randomized controlled trial and concluded that there was no statistically significant difference in outcomes comparing sodium hyaluronate injection with saline injection for glenohumeral osteoarthritis. This patient presents with chronic left shoulder pain and stiffness with functional difficulty in lifting and overhead activities. There is imaging evidence of severe shoulder osteoarthritis with humeral head deformity and large osteophytes. There is documentation that corticosteroid injection has failed to improve symptoms; however, detailed evidence of a recent, reasonable and/or comprehensive non-operative treatment protocol trial and failure have not been submitted. There is no compelling evidence provided to support that this requested service is likely of more benefit than standard therapy. Therefore, in the absence of evidence based peer reviewed support, the requested services are not likely to be more beneficial for the treatment of the patients medical condition than any available standard therapy.  Final Result: Three 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:  All three reviewers are board certified in orthopedic surgery and are actively practicing. All three reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for a medication regimen of MS Contin and Norco. The Center for Disease Control (CDC) 2016 guidelines recommends that clinicians should evaluate benefits and harms of continued therapy with patients every 3 months or more frequently. If benefits do not outweigh harms of continued opioid therapy, clinicians should optimize other therapies and work with patients to taper opioids to lower dosages or to taper and discontinue opioids. The CDC further recommends that patients should be counseled on the negative effects of opioids, and that tapering should be offered with average reductions of 10% each week. If negative effects including withdrawal are experienced by the patient, slower tapering could be considered including 5% per week or 10% per month. Lastly, the CDC recommends against reversing a taper, and instead suggests that the rate at which tapering occurs may be slowed or paused while monitoring and managing withdrawal symptomsIn this case, the submitted documentation supports that a High Risk Opioid Evaluation was performed. At that time, the significant adverse effects of opioids on the patients health were discussed. The patient was offered a tapering of the opioid dose from the maximum 420 morphine milligram equivalents (MMEs) per day to a lower dose. The patient consented to the recommended taper. Subsequently, the patient was started on a slow taper of ~5% per week with reductions in MMEs from 420 to 290 by end of June. The patient had an opioid use agreement in place since 2016 that included following the recommendations of the provider and regular urine toxicology screening. During the taper, the patient was administered the Screener and Opioid Assessment for Patients with Pain (SOAPP) instrument to assess risk of relapse/success. The patients SOAPP scores were recorded as less than 4, which is low risk. In conclusion, this patient has been tapered from high dose opioids according to established medical standards. The patient was apprised of the risks of maintaining a high dose opioid regimen, and thereafter consented to a taper. Current medical evidence recommends against reversing a taper for long-term opioid users. Therefore, reinstituting the higher 420 MME dose of opioids is not appropriate for this patient.Final Result: The reviewer determined that the requested medication regimen 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 subspecialty certifications in pain medicine, and hospice and palliative 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 54-year-old female enrollee has requested Botox injections for treatment of her myofascial pain and peripheral neuropathy. Findings:  Three physician reviewers found that in this case, the services at issue were not likely to have been of greater benefit than other treatment options.  The submitted records do not support Botox injections in this setting.  There is a lack of information as to whether this patient has had any standard treatment for her neck pain or what diagnostic studies have been done.  Botox is not indicated for treatment of myofascial pain.  Although several studies have assessed the role of intramuscular Botox injections in chronic neck pain, no significant beneficial effect has been demonstrated.  Thus, Botox injections performed on the date indicated were not likely to have been more effective than other treatment alternatives.
Appeal type: Medical Necessity
Decision: Upheld

A 51-year-old female enrollee has requested outpatient psychotherapy for treatment of her behavioral health condition. Findings:  The physician reviewer found the submitted documentation fails to establish the medical necessity of the services at issue. Based on the documentation submitted, the patient has received more than four years of psychotherapy treatment; the patients notes reflect no treatment goals or symptoms at this time. According to the American Psychiatric Association, when initial treatment is not effective or tolerable after 6 to 8 weeks of therapy, treatment guidelines recommend dose titration, augmentation, or switching (Tierney). All told, the medical literature does not support the services at issue in this clinical setting.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: A 54-year-old female enrollee has reimbursement for advanced lipoprotein testing (CPT 83704). Findings:  Three physician reviewers found that the documentation provided does not support the services at issue in this clinical setting. There is no history of known coronary artery disease in this patients case. The records note that she was undergoing preventive screening and underwent advanced lipoprotein profile testing. In this patients case, advanced lipoprotein testing would not add significant information to what is available from a fasting lipid panel.  The patient has only a single risk factor for coronary artery disease, namely well controlled hypertension. The documentation notes that she is asymptomatic and presented to her provider for preventive examination. Her hemoglobin (Hgb) A1C is within normal range with no history of diabetes and she is not a smoker. Final Result: The reviewers determined that the services at issue were 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: Reviewers 1, 2, and 3 are 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: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for laser treatment to destruct cutaneous vascular lesions. Facial erythema is a common chronic disorder characterized by periods of exacerbation, remission and possible progression. Individual subtypes are likely a result of different pathogenic factors and respond best to different therapeutic regimens. The non-pharmacologic approach to therapy is adequate skin care, trigger avoidance and photoprotection. In addition, there are several topical, herbal, systemic and light based therapies available. U.S. Food and Drug Administration (FDA) approved treatments include Metrogel and azelaic acid. Combination of azelaic acid or topical metronidazole with anti-inflammatory doxycycline appears to have a synergistic effect. Light-based therapies with pulsed dye laser and intense pulsed light are also effective in treatment of erythema and telangiectasias in patients with rosacea. Laser treatment can be used in combination with medical and topical treatments. The standard approach is to combine systemic anti-inflammatory effect of tetracycline antibiotics with topical anti-inflammatory and bactericidal treatments. Since this patient has failed treatment with tetracycline, a multifaceted approach to therapy that includes laser treatment is warranted. Accordingly, requested laser treatment to destruct cutaneous vascular lesions is likely to be more beneficial than any other available standard therapy for the patients facial erythema.Final Result: Two of the three reviewers determined that the requested services are 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:  One reviewer is board certified in dermatology and is actively practicing. One Reviewer is board certified in dermatology and is actively practicing. One Reviewer is board certified in dermatology and is actively practicing.  All three reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: A 64-year-old male enrollee has requested authorization and coverage for a supervised sleep study. In this case, the patients clinical presentation is suggestive of a sleep related breathing disorder, specifically obstructive sleep apnea (OSA). Testing is indicated to confirm the presence of OSA. However, an attended sleep test is not the most appropriate level of service which can be safely provided to this patient. The utility and validity of home sleep testing for the diagnosis of OSA has been well documented in the peer-reviewed medical literature. In addition, current clinical guidelines, technology assessments, and review articles state that portable or home polysomnogram may be used as an alternative to an attended sleep study for diagnosis of OSA in patients with a high likelihood of moderate to severe OSA and no contraindications, such as comorbid sleep disorders or major comorbid medical disorders. In this case, a home sleep test followed by the use of AutoPAP, if the home study is positive, it is the appropriate testing rather than an attended test. In this setting, the requested attended study would exceed the patients clinical needs for the evaluation of his condition. All told, the requested supervised sleep study is not supported as medically necessary for evaluation of this patients medical condition. Final Result: The reviewer determined that the requested services are not medically necessary for evaluation of the patients medical condition. Therefore, the Health Plans denial should be upheld. 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: Experimental/Investigational
Decision: Upheld

A 40-year-old male enrollee has requested transcranial magnetic stimulation (TMS) therapy for treatment of his tinnitus.  Findings:  Two physician reviewers found that TMS therapy is not likely to be more effective for this patient than other available treatment options. The medical literature lacks adequate evidence on the efficacy of TMS in the treatment of tinnitus. According to Hoekstra and colleagues, Repetitive transcranial magnetic stimulation (rTMS) has been applied as a treatment for chronic tinnitus, but the effect remains controversial. Moreover, Piccirillo and colleagues examined the efficacy and safety of 4 weeks of low-frequency transcranial magnetic stimulation (rTMS) to the left temporoparietal junction in a cohort of patients with bothersome tinnitus. The authors concluded that Daily low-frequency active rTMS to the left temporoparietal junction area for 4 weeks was no more effective than sham for patients with chronic bothersome tinnitus. In sum, the requested therapy is not likely to be more beneficial than other modalities.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The enrollee is a male who has requested authorization and coverage for a WalkAide System, Bioness L300. The Health Plan has denied the requested device as investigational for treatment of the enrollees foot drop.Findings:  Three physician reviewers found that Current data suggest that ankle foot orthoses (AFO) have equally positive combined-orthotic effects as functional electrical stimulation on key walking measures for foot-drop caused by stroke. There is a paucity of peer-reviewed medical literature showing that a functional electrical stimulation device such as the WalkAide System, Bioness L300 is more beneficial for hemiparesis with foot drop than a conventional device such as a standard AFO. In this case, the gait dysfunction and safety concerns are secondary to foot drop, which is equally addressed with the AFO and the WalkAide System, Bioness L300. Therefore, the WalkAide System, Bioness L300 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 device is 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 reviewers 1, 2 and 3 are board certified in physical medicine and rehabilitation 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: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested requested authorization and coverage for Spinraza medication therapy. Findings:  The physician reviewer found that Spinraza is the only U.S. Food and Drug Administration (FDA) approved therapy for the treatment of SMA. In addition, the medication Spinraza has been shown in clinical studies to be effective for SMA of all types. Per FDA approval, Spinraza is indicated for the treatment of SMA in pediatric and adult patients. In addition, there is a lack of available therapies for treatment of SMA. The natural history of the disorder is progressive weakness, progressing to respiratory failure. Spinraza, which has FDA approval, has been shown to alter the disease progression. In sum, Spinraza has been demonstrated as likely to be more effective for treatment of the patients medical condition than any available standard treatment options.Final Result: Two of the three reviewers determined that requested medication 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: All three reviewers are board certified in neurology and are actively practicing. All three reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient is a female with a diagnosis of symptomatic uterine fibroids. She has complaints of heavy periods with clots. A transabdominal ultrasound revealed the uterus is anteverted measuring 14 cm with a large 13 cm calcified fundal uterine fibroid. She was referred to an interventional radiologist for fibroid embolization.The patient has been diagnosed with uterine fibroids by pelvic ultrasound, and has symptoms of fibroids, including heavy menstrual bleeding, menstrual cramping, and pelvic pain. These symptoms can significantly decrease quality of life. Other standard treatment options for symptomatic uterine fibroids include hysterectomy or myomectomy. Hysterectomy often requires hospitalization and a long recovery time. In addition, not all patients are considered candidates for myomectomy. These specific symptoms are the target of treatment by uterine artery embolization. Therefore, the uterine artery embolization is medically necessary for this patient.Final Result: The reviewer determined that the requested services are 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 interventional and diagnostic radiology, and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.