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

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement and prospective authorization and coverage for occipital nerve blocks for treatment of the enrollee, who has been diagnosed with occipital neuralgia. Findings:  Two physician reviewers found that this patient currently has chronic neck pain and headache pain. Per the documentation, she has attempted treatment with multiple medications as well as trigger point injections. She has benefitted from occipital nerve blocks. Researchers noted that a local anesthetic agent injection with steroid may be used for therapeutic purposes and usually has a transient effect, but in some cases the pain subsidence may be maintained for several months. In the antoher article, the objective of this study was to determine whether adding triamcinolone to local anesthetic increased the efficacy of greater occipital nerve blocks and trigger point injections for chronic migraine. In both groups, the procedure resulted in significant and rapid relief of headache, neck pain, photophobia and phonophobia. There is sufficient support for the services at issue in this clinical setting. In sum, the services at issue were and are likely to be superior over other treatment options.  Final Result: The reviewers determined that the services at issue were and 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: Reviewers 1, 2 and 3 are board certified in anesthesiology with sub-specialty certification in pain medicine and are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

A 54-year-old male enrollee has requested a musculoskeletal ultrasound, spinal echography, and nerve conduction study for the treatment of his sciatica. Findings:  The physician reviewer found that there is presently insufficient peer reviewed literature to support the diagnostic role of musculoskeletal ultrasound, spinal echography, and lumbar distribution sensory nerve conduction studies for low back pain and sciatica.  These tests are not widely accepted diagnostic modalities nor are they supported for diagnostic use in the spine.  These techniques are generally unproven in the diagnosis of lumbar spinal etiologies and sciatica.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a female enrollee requested D4277, free soft tissue graft procedure for medical treatment of the enrollees gingival recession.  Findings:  The physician reviewer found that the submitted documentation supports the medical necessity of the requested services.  The requested services are medically necessary to prevent continued soft and hard tissue loss of the tooth in question.  If not addressed, the tooth could be compromised and eventually lost.  There is sufficient support for the requested services in this clinical setting.  All told, the requested for D4277, free soft tissue graft procedure is medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Synvisc Syringe injections in the left knee. Current medical literature pertaining to viscosupplementation reveals mixed results. Evidence from eight systematic reviews and six randomized controlled trials indicate that although viscosupplementation may relieve knee pain in some individuals with osteoarthritis, it is not known which individuals will benefit. Different studies have tried mixing hyaluronic acid with corticosteroids, platelet rich plasma, and other agents to make it more effective. The current evidence is limited and guidelines from organizations such as the American Academy of Orthopedic Surgeons indicate that the evidence is not conclusive. As such, the Academy does not currently support viscosupplementation as standard treatment for osteoarthritis of the knees. In light of the foregoing, viscosupplementation can only be recommended in individuals with a history of lasting benefit from prior injections and in carefully selected cases when everything else has been tried and the options are limited. In this case, viscosupplementation has been tried and found to be beneficial for the last five years. Additionally, the patients options are clearly limited. The patient has tried and failed other conservative treatments with the alternative being a total knee arthroplasty. Under these circumstances, Synvisc Syringe injections in the left knee are medically necessary for treatment of the 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 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.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested Sovaldi and Daklinza for treatment of the enrollees chronic hepatitis C virus genotype 2b.  Findings: The physician reviewer found that according to the most recent joint guidelines issued by the American Association for the Study of Liver Diseases (AASLD) and the Infectious Diseases Society of America (IDSA), all patients with chronic hepatitis C should be treated except those with limited life expectancy due to non-liver-related conditions. This applies regardless of fibrosis stage or viral load. The guidelines recommend Sovaldi and Daklinza for 12 weeks in treatment-naive genotype 2 patients (Sulkowski, et al). The guidelines no longer support the use of Sovaldi with ribavirin for treatment-naive genotype 2 patients. The guidelines also cite data showing increased survival with earlier treatment (Jezequel, et al). For these reasons, treatments of hepatitis C with Sovaldi and Daklinza for 12 weeks are supported as medically necessary for the treatment of this patients hepatitis C infection.Final Result: The reviewer determined that the requested medications 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 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: Overturned

A 64-year-old female enrollee has requested authorization and coverage for whole body PET scan. Findings:  Two physician reviewers found that this patient was diagnosed with malignant melanoma. The patient underwent resection of the lesion on her back in addition to a left axillary lymph node biopsy.  The patient had a negative MRI of the brain and PET scan. A CT scan of the lower extremities showed multiple subcutaneous densities. The patient underwent a second biopsy of lesions on her back which showed malignant melanoma in situ. Re-staging PET scans have been requested every four to six months.  The patient has requested authorization for a whole body PET scan.  The National Comprehensive Cancer Network (NCCN) guidelines advocate for the use of PET studies every 6 to 12 months for the first 5 years after treatment for melanoma. Other studies in the peer-reviewed medical literature support the use of PET studies in the surveillance of patients with a history of melanoma.  Xing and colleagues state PET-CT was superior for the detection of distant metastases in both the staging and surveillance of melanoma patients. While Swetter and colleagues concluded that PET is more sensitive and specific than CT for detection of melanoma metastasis and should be considered the primary staging study for recurrent disease.  Kumar, et al. state FDG-PET is a metabolic, noninvasive imaging modality for detecting distant metastatic and recurrent melanoma. Additionally, another study stated [w]hen interpreted with a high threshold approach, PET/CT demonstrates high accuracy for the diagnosis of both regional and distant disease in cutaneous malignant melanoma and frequently changes management in patients with stage II-IV disease referred for a variety of indications (Falk, et al.). As there is adequate support in the peer-reviewed medical literature for the use of PET scans for surveillance of patients with melanoma for five years after treatment, the requested PET scan is likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for ketamine infusions with a five-day inpatient hospital stay. Researchers evaluated the efficacy of a ketamine-containing compound in 13 patients with complex regional pain syndrome (CRPS). The authors found that nine patients experienced pain and symptom reduction, with six patients reporting sustained benefits after two months of treatment, and two patients with complete resolution of symptoms. Authors concluded that intravenous ketamine was safely administered in the hospital setting to patients with refractory chronic migraine. The authors noted that this treatment protocol was associated with short-term improvement in pain severity in six of six patients with refractory chronic migraine. This patient has history of refractory migraine headaches and CRPS. In each of these conditions, where traditional medical therapy has failed, the use of ketamine infusion has demonstrated short-term efficacy. Based on the records provided for review, this patient has undergone adequate treatment with traditional therapeutic regimens without substantial improvement. Given the support in the medical literature, the requested ketamine infusions with a five-day inpatient hospital stay are medically necessary for treatment of 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 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 48-year-old female enrollee has requested laparoscopic gastric band placement (CPT 43770) or laparoscopic sleeve gastrectomy (CPT 43775) for treatment of her obesity.  Findings:  Two physician reviewers found that the records indicate that she has failed self-attempted diets and weight loss programs and was seen in consultation for weight loss surgery. The provider noted the patient was an appropriate candidate for weight reduction surgery and recommended laparoscopic gastric band placement and if not feasible, laparoscopic sleeve gastrectomy. The patient also sought orthopedic consultation for left knee pain and was diagnosed with probable degenerative meniscus tear and non-ideal BMI. Weight reduction surgery is indicated for patients with a BMI greater than 40, or a BMI greater than 35 with significant medical co-morbidities. As defined by the American Society of Metabolic and Bariatric Surgery (ASMBS) guidelines such co-morbid conditions include coronary disease, hypertension, respiratory issues, arthritis, and metabolic diseases including diabetes or hyperlipidemia. The medical literature has demonstrated that patients with one or more of these co-morbidities may experience improvement or resolution of those conditions after weight reduction. This patient presents with knee pain, however she has not been diagnosed with any of the clinically significant co-morbidities discussed by the ASMBS. Additionally, the records do not show that she has undergone any specific therapy for the knee pain such as physical therapy or non-steroidal anti-inflammatory drugs (NSAIDs). Currently, the patient does not meet the criteria for weight reduction surgery set forth by the ASMBS and the requested surgery was appropriately deemed investigational in this clinical setting.
Appeal type: Medical Necessity
Decision: Upheld

A 32-year-old female enrollee has requested acute inpatient treatment for her behavioral health condition. Findings:  The physician reviewer found that the acute inpatient treatment received at a trauma recovery treatment facility provided from the time frame specified was not medically necessary for this patients medical condition. The patients clinical notes showed no evidence that her illness required 24-hour supervision in an inpatient setting and there was no clear evidence that she posed an imminent risk to self or others. Continued hospitalization in the absence of psychosis, acute depression and lethality concerns, is not medically necessary (Shader). With the exception of the more recent sexual trauma, the patients symptoms are chronic, persistent and non-acute and relate to longstanding inter-personal parental conflict. The patients treatment could have been safely provided to her in an outpatient setting, where she could continue to benefit from motivational techniques in the context of her expressed ambivalence about engaging in treatment. According to American Psychiatric Association, the optimal treatment setting and patients likelihood of benefit from a different level of care should be re-evaluated on an ongoing basis through the course of treatment. The psychiatrist should determine the least restrictive setting for treatment that would most likely address the patients safety and promote improvement in the patients condition. Thus, continued acute inpatient treatment received at a trauma recovery treatment facility provided from the time frame specified was not medically necessary. Therefore, based on the documentation provided, coupled with relevant peer-reviewed medical literature and current practice guidelines, the services at issue were not medically necessary.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for confocal microscopy for evaluation of the enrollees atypical nevus syndrome. Findings:  The physician reviewer found that while confocal microscopy may yield a correlation with evaluation of atypical moles and melanoma, it is not standard of care for treatment of patients diagnosed with atypical moles.  The medical studies have not shown that this modality is superior to standard treatment protocols. There is a lack of evidence to indicate that it is more beneficial than standard follow up examinations and biopsies of suspicious lesions. As such, confocal microscopy is not likely to be superior over the available standard techniques of evaluating this patient. Final Result: Two of the three reviewers determined that 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:  All three reviewers are board certified in dermatology 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

The enrollee is requesting reimbursement for proton radiation beam therapy.  The enrollee has squamous cell cancer of the left tonsil that has spread to his left neck lymph nodes. He initially presented to his primary care physician with swelling of the left neck. An ultrasound showed two enlarged submandibular lymph nodes suspicious for malignancy. A left neck lymph node biopsy showed keratinizing squamous cell carcinoma. A computed tomography (CT) scan of the neck showed heterogeneous enlarged lymph nodes in the jugulodigastric chain. It was determined his condition was likely occult oropharyngeal primary. The enrollees radiation oncologist notes that proton therapy may be used to reduce the dosage impact to uninvolved salivary glands, oral cavity, and other normal tissues, reducing short and/or long-term toxicity. The enrollee began proton radiation beam therapy. Proton radiation for the patient's condition is the subject of currently ongoing clinical trials. Definitive conclusions cannot be determined regarding the safety/efficacy of this treatment compared to the standard of care, because there are not enough reported high-quality clinical outcomes available. Studies describe proton beam radiation as useful for treating tumors in challenging locations close to non-targeted critical structures. However, aggressive treatment applied close to these critical structures in patients with tumors in the head and neck region may produce debilitating toxic effects. There is interest in evaluating whether this therapy can improve outcomes for patients with head and neck malignancies. An emerging technology committee routinely evaluates new modalities in radiotherapy and assesses the published evidence to determine recommendations for the society as a whole.  The literature indicates the use of proton beam therapy is recommended for a patient who has a diagnosis of advanced, i.e., T4 and/or unresectable head and neck cancers. More robust prospective clinical trials are needed to determine the appropriate clinical setting for proton beam therapy. Additionally, the patient was not noted to have T4 head and neck cancer and/or unresectable disease. Guidelines address the necessity for enrollment in a clinical trial as there is not enough evidence to support the effectiveness of proton radiation beam therapy in this clinical scenario. Final Result: The reviewer determined that the requested service was not medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The physician reviewer is board certified in radiation oncology 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 similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

A 53-year-old female enrollee has requested Botox injections for the treatment of task-specific focal dystonia (writers cramp). Findings:  The physician reviewer found that the safety of Botox has been sufficiently tested in other clinical applications and it was found to be safe. Botox therapy has clearly provided a benefit for this patient and continued treatment is consistent with the standard of care within the neurological community.
Appeal type: Medical Necessity
Decision: Overturned

A 56-year-old female enrollee has requested Procrit for the treatment of her renal insufficiency and/or undiagnosed autoimmune disease. Findings:  The physician reviewer found that Procrit is an approved medication for the stimulation of red blood cell production in patients receiving cancer chemotherapy or those with renal failure. The patients renal failure, despite being mild, is likely instrumental in her anemia. Although it is possible she has some sort of autoimmune process for which Procrit would not be helpful, there is no definitive diagnosis of such and her treating physician notes that she has anemia of renal insufficiency and chronic disease. Thus, there is sufficient clinical evidence to support the use of Procrit in this situation. Furthermore, Procrit appears to have been successful for this patient as her hemoglobin went from under 10.0 to greater than 11.0 during the period of use.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary:  An enrollee has requested authorization and coverage for continued home health nursing services.According to Bhandari and Swiontkowski, acute subtrochanteric fractures are serious injuries that are generally treated with prompt surgery and rehabilitation. Kubiak and colleagues indicate that weight-bearing restrictions are often necessary to optimize healing while mitigating risk of fracture displacement or implant failure. The authors conclude, Most surgeons recommend a period of protected weight-bearing for patients with calcaneal, tibial plafond, tibial plateau, and acetabular fractures. In this case, the patient sustained a traumatic, acute subtrochanteric fracture that was surgically repaired but required weight-bearing restrictions for optimal healing. The patient has been undergoing rehabilitation to compensate for this weight-bearing restriction on his affected leg. The patient has managed to reach stand-by assistance level for his ambulation using a walker, which is the expected level of functioning for the patients baseline functional status as a middle-aged adult without major disabling conditions. The patient had skilled nursing needs initially on community reintegration, but his spouse has been taught and has learned to provide his once-daily enoxaparin injections and to apply a topical dressing over his surgical incision, which is healing well. There are no ongoing skilled nursing needs. Therefore, continued home health nursing services are not medically necessary for treatment of the patients medical condition.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 physical medicine and rehabilitation 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.