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

A 60-year-old male enrollee has requested radiofrequency ablation treatment (L5-S1) for treatment of his low back pain. Findings:  Three physician reviewers found that requested services are not likely to be of greater benefit than other treatment options in this patients case.  Facet joint lumbar spine pain has been treated with a number of methods, including intra-articular injections, medial branch blocks and radiofrequency neurolysis.  This patient has chronic low back pain and is status post multiple surgical interventions.  There is a lack of support for the requested services for the treatment of this patient.  There is no documentation of previous lumbar medial branch blocks or facet injections to confirm location of the patients pain.  Given the absence of documentation of lumbar medial branch blocks, the superior efficacy of the requested radiofrequency ablation treatment (L5-S1) has not been established.
Appeal type: Medical Necessity
Decision: Upheld

A 62-year-old female enrollee has requested Orthovisc injections for treatment of her osteoarthritis.  Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested services in this patients case.  The current medical evidence does not support the requested services in this clinical setting.  Rutjes and colleagues performed a systematic review and meta-analysis to assess the benefits and risks of viscosupplementation for adults with symptomatic knee osteoarthritis.  The authors reviewed 89 trials involving 12,667 adults.  The authors concluded that viscosupplementation is associated with an increased risk of adverse events and a clinically irrelevant benefit.  There is a documented incidence of aseptic inflammatory reactions due to allergic response.  Additionally, there is a risk of iatrogenic infection within the joint.  All told, a third series of Orthovisc injections is not medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a 15-year-old female enrollee has requested eating disorder residential treatment services for treatment of her anorexia nervosa and major depressive disorder, recurrent.  Findings:  The physician reviewer found that the submitted medical records support the medical necessity of the services at issue in this patients case.  Per the clinical documentation, residential treatment services continue to be indicated.  The patient is not ready to decrease the intensity of service to a lower level of care.  She demonstrates poor motivation to recover and is preoccupied with intrusive thoughts.  The patient continues to require supervision during meals.  The current medical evidence supports the services at issue in this clinical setting.  All told, eating disorder residential treatment services provided from the date indicated forward were and are medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Overturned

The patient is a three-year-old female with a history of prematurity at age 36 weeks complicated by oligohydramnios and fetal bradycardia. She has persistent hypotonia and gross motor delays. She has been receiving physical and occupational therapy to address these issues and her parent has requested authorization for continued physical and occupational therapy. At issue is whether these therapies were/are medically necessary for treatment of the patients condition.With regard to physical therapy services, it appears that although treatment goals have not been well established or outlined, there have been documented functional gains. The physical therapist continues to document difficulty with ascending and descending stairs while alternating legs; the patient also has difficulty with hopping and standing on a single extremity, which is required for higher level dressing skills. While the patient has received benefit from physical therapy services she received in the past, she still has functional difficulties and therefore requires continued physical therapy. The patients physical therapist should outline functional goals using a more formal standardized method and her physician should monitor her progress. Regarding coverage for occupational therapy, the treatment goals set forth by the patients provider primarily outline gross motor skills and appear to overlap the physical therapy goals. Although the provider outlines fine motor deficiencies in holding a pencil and scissors as well as difficulties with coloring, cutting and use of a Lite-Brite and Play Doh, these are educational issues and should be addressed with early intervention through an IEP. Overall, goals are poorly outlined and no measures are used to document improvement in these goals. Given this, as well as the fact that the therapy overlaps with the physical therapy services the patient has been receiving, occupational therapy was/is not medically necessary for treatment of the patients condition. Based upon the information set forth above, I have determined that physical therapy was/is medically necessary for treatment of the patients medical condition; however, occupational therapy was/is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be partially overturned.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for residential treatment for treatment of the enrollees behavioral health conditions. Findings: The physician reviewer found that this patient was struggling with interpersonal issues along with mood and anxiety issues. The medical records do not support active suicidal ideation or psychosis at the time the patient was admitted to the residential treatment center or during the disputed period. The records indicate the patient was open to receiving therapy to aid with his behavioral health issues. He had minimal prior behavioral health treatment. The records do not indicate that he had any intensive outpatient services of any type.  There were no significant or severe behavioral problems noted. Based on the records, the patient did not need the restrictiveness of a residential psychiatric treatment facility in order to receive his care. The records indicate the treatment objectives could have safely and effectively been addressed in a less restrictive setting. Residential treatment is used for acute stabilization of psychiatric conditions and is not evidenced-based for long-term type treatment. Outpatient treatment and least restrictive options are considered first lines of care. There are benefits to in-home therapy due to the involvement with family as well as generalization of learned skills in a natural setting. Final Result: The reviewer determined that the services at issue were 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 with sub-specialty certification in child and adolescent 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: Experimental/Investigational
Decision: Upheld

The parent of a 14-year-old female enrollee has requested acupuncture for treatment of the enrollees fibromyalgia and depression. Findings:  Three physician reviewers found that the published clinical studies offer little evidence to support the use of acupuncture in patients with fibromyalgia. As noted by Langhorst and colleagues, A small analgesic effect of acupuncture was present, which, however, was not clearly distinguishable from bias. Thus, acupuncture cannot be recommended for the management of fibromyalgia. This recommendation is consistent with Kellys report that, Acupuncture has not been proven as there is not enough evidence to draw conclusions. There is also little proof that acupuncture is effective in management of depression, as reported by Smith and colleagues. This patient has been receiving acupuncture for several months however the documentation is vague with regard to the actual effects the treatments have had on her various conditions. While she appeared to have some pain resolution on Elavil, it is unclear whether the acupuncture has been directly responsible for any of her symptom resolution. Her provider has documented on numerous occasions the importance of her obtaining psychiatric care and counseling services and has also stressed the importance of this as it relates to her achieving adequate pain control as well. These services are likely to offer substantial benefit to this patient. In general, patients with chronic pain and fibromyalgia often have mood symptoms, and this appears to be the case with this patient as well. The stressors that the patient has at home are having an obvious effect on her mood and likely her pain as well. The records indicate the patient was prescribed Cymbalta, which is a standard medical therapy for patients with fibromyalgia, and is more likely to provide her relief from her pain associated with this condition than acupuncture.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the blood test for evaluation of the enrollees ankylosing spondylitis. Findings: All three physician reviewers found that measurement of serum concentrations of tumor necrosis factor (TNF) antagonist drugs and antibodies to TNF antagonist drugs is not supported for routine use in the current peer-reviewed medical literature. This patient is currently being treated with Remicade and is described as generally stable. It is not considered standard of care per current peer-reviewed guidelines given the paucity of peer-reviewed medical literature to support this type of testing for the management of ankylosing spondylitis. Final Result: The reviewers determined that the testing at issue was 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 rheumatology 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 bilateral balloon frontal sinuplasty for the treatment of his medical condition.   Findings:  Two physician reviewers found that the current medical evidence supports the services at issue in this clinical setting.  Endoscopic sinus surgery has been widely used since the early 1980s.  Since that time, instrumentation has evolved, including the use of microdebriders and computerized localization.  The use of balloon instrumentation is the addition of another mode of carrying out standard functional endoscopic sinus surgery in a less invasive fashion.  Per the medical literature, the use of balloon instrumentation shows positive outcomes in symptomatology and sinus ostia patency.  In addition, balloon sinuplasty has been shown to require less postoperative debridement than standard endoscopic sinus surgery.  All told, bilateral balloon frontal sinuplasty was likely to have been superior over other treatment options.   Final Result: Two reviewers determined that the services at issue were 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 otolaryngology 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: Experimental/Investigational
Decision: Upheld

A 60-year-old female enrollee has requested a positron emission tomography (PET) scan for an evaluation of her left lung cyst. Findings:  Two physician reviewers found that this patient has a history of a cyst within the left lung. A chest x-ray showed the cyst measured 2.5 cm. On the most recent chest x-ray, the cyst measured 4.0 cm. Prior computed tomography (CT) scan showed that the cyst has a thin wall with no other associated findings within the cyst.  A PET scan has been requested for further evaluation of the lung cyst. A cyst within the lung can be a pneumatocele or bulla. Pneumatoceles usually are secondary to a prior episode of infection. Bullae can be seen in patients with lung disease such as fibrosis or emphysema or can be secondary to collagen vascular disease such as Marfans syndrome. Both pneumatoceles and bullae can enlarge over time. They are usually asymptomatic, although very large bullae can cause dyspnea. PET scans are appropriate to evaluate solitary pulmonary nodules. These nodules are solid in nature. This patient has a lung cyst, which is not a solitary pulmonary nodule. Review of the scientific literature revealed no peer-reviewed studies to support the use of PET scan in the evaluation of a lung cyst. Although the cyst should continue to be monitored, a PET scan is not likely to be of clinical value in this setting.
Appeal type: Experimental/Investigational
Decision: Overturned

An enrollee has requested reimbursement for the Optune device. Tumor treating fields are a non-invasive antimitotic therapy that delivers alternating electric fields via the Optune device. Although data on its use is limited, the Optune device has been demonstrated to be effective in a large number of patients with glioblastoma. One trial in newly diagnosed glioblastoma showed significantly improved progression-free, overall and long-term survival when Optune was combined with maintenance temozolomide compared with temozolomide alone. The records provided for review document that resection, radiation, and chemotherapy have not been adequate to control this patients disease. Given the support in the medical literature, the Optune device was likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Final Result: The reviewers determined that the device at issue was 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

A 48-year-old male enrollee has requested for Clomid for treatment of his hypogonadism. Findings:  The physician reviewer found that clomiphene citrate may, in selected men, improve LH and testosterone concentrations. It will not cause lower sperm counts, which can be seen with long-term testosterone treatment.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for breast augmentation and gender reassignment surgeries performed at the same time for treatment of the enrollees gender dysphoria. Findings:  The physician reviewer found that there is support for the requested services in this clinical setting. This patient is documented to have gender dysphoria. The patient has made a request for a combined augmentation mammaplasty and vaginoplasty. Based on the photographs provided, the patients chest contour is consistent with a male chest. The patients breasts and genital/external anatomy should be consistent with the female gender. According to her diagnosis and history, her external anatomy should be more consistent with a male gender than a female. Combining the procedures would decrease the operative time as compared to doing them at separate time, as the augmentation mammaplasty would be a relatively short procedure. Additionally, performing the procedures in this manner would prevent a second surgery and anesthesia, which may reduce the overall risk for this patient. The requested procedures are consistent with services that will assist in providing this patient to achieve a female anatomy. All told, the requested bilateral augmentation mammaplasty and gender reassignment surgery, to be performed at the same time, are medically necessary for the treatment of this patients medical condition. 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 plastic 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.
Appeal type: Experimental/Investigational
Decision: Overturned

A 24-year-old female enrollee has requested cardioverter defibrillator device for treatment of her longed QT syndrome.  Findings:  Three physician reviewers found that this patient had a class II indication for the implanted ICD to prevent sudden cardiac death based on the American College of Cardiology (ACC) guidelines (Rubens, et al). An ICD was indicated for primary prevention of sudden cardiac death in long QT syndrome. The records provided for review document that this patient was found to have the same genetic mutation as family members, which placed her as at risk of sudden cardiac death. All told, the cardioverter defibrillator device was likely to have been 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:  The parent of an enrollee has requested eye movement desensitization and reprocessing (EMDR) for treatment of the enrollees behavioral health condition. Findings:  The physician reviewer found that the submitted documentation fails to establish the medical necessity of the requested services. Based on the current peer-reviewed literature, EMDR is a therapeutic technique that is indicated for treating individuals who are diagnosed with PTSD. There is a lack of literature supporting EMDR for the treatment of individuals diagnosed with autism spectrum disorder who do not carry a diagnosis of PTSD. Moreover, the medical literature practice parameter for children with autism strongly recommends behavioral interventions and specifically ABA therapy, which this patient is currently receiving, as being empirically supported by research. In sum, the medical necessity for EMDR in this clinical setting has not been established.  Final Result: The reviewer determined that the requested services 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 with sub-specialty certification in child and adolescent 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

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement and prospective authorization and coverage for Nuedexta 20/10 mg capsules. Pseudobulbar affect (PBA) is characterized by uncontrollable emotional episodes that are disconnected from or disproportionate to mood, and often occurs in adults with neurologic conditions. Hammond and colleagues noted that dextromethorphan/quinidine was shown to be an effective and well-tolerated treatment for PBA secondary to dementia, stroke, or traumatic brain injury. The U.S. Food and Drug Administration has approved the use of Nuedexta for the treatment of PBA. In this case, the patient presented with PBA and was prescribed Nuedexta. Given that treatment with Nuedexta is the standard of care for the patients diagnosis, the medication at issue was and is medically indicated. Therefore, Nuedexta 20/10 mg capsules were and are medically necessary for the treatment of this patient.Final Result: The reviewer determined that the medication at issue was and is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in neurology 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 female enrollee has requested coverage for Xolair injections for treatment of the enrollees severe asthma, chronic pulmonary fibrosis, and respiratory insufficiency.  Findings:  Two physician reviewers found that the patient has a history of asthma, pulmonary fibrosis, hypertension, hyperlipidemia, and chronic obstructive pulmonary disease (COPD) with exacerbations. The patients provider has requested Xolair to treat asthma in this patient. The providers documentation for a routine office visit notes that the patient is complaining of persistent cough with white, thick mucus and wheezing with some shortness of breath. The shortness of breath has reportedly been better on prednisone. At the time of the visit, the patient was taking Xolair 225 mg every two weeks, prednisone 20 mg per day, Ventolin, Daliresp, Spiriva, Advair, and Singulair. The patient has an IgE level of 307 and her forced expiratory volume in one second (FEV1) on spirometry was 90% of the predicted. A respiratory profile panel revealed allergies to alder tree, birch white tree, cedar mountain juniper, dog hair, elm tree, oak tree, olive Tree, and Ragweed Pollen. A letter from the provider states that her FEV1 is 90% of predicted. The patient has requested authorization and coverage for Xolair injections, which the Health Plan has denied as investigational.  Xolair is FDA approved for patients who have moderate to severe persistent asthma, a skin test or in vivo reactivity to perennial aeroallergens, symptoms that are not controlled on inhaled long acting corticosteroids and long acting beta agonists, FEV1 of less than 80% predicted, and serum IgE level greater than 30 IU/ml. Based on the providers office note and his letter, the patient does not have moderate or severe persistent asthma or an FEV1 of less than 80% of predicted. Therefore, use of Xolair in this patient is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.