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

Nature of Statutory Criteria/Case Summary: An enrollee requested authorization and coverage for sacroiliac joint fusion surgery for treatment of the enrollees right sacroiliac joint pain. Findings:  The 3 physician reviewers found that in this case, the patient has mechanical low back pain with evidence of degenerative sacroiliitis and a positive response to sacroiliac (SI) joint injection. SI joint fusion is recommended on a case-by-case basis as a last line of therapy, as treatment for SI joint infection, tumor involving the sacrum, disabling pain due to sacroiliitis due to spondyloarthropathy, SI pain due to severe traumatic injury, and the procedure may be required for multisegmental spinal constructs. SI joint fusion is not recommended for mechanical low back pain, non-specific low back pain, SI joint disruption, degenerative sacroiliitis, SI joint osteoarthritis, or SI joint mediated pain. For these reasons, the requested SI joint fusion surgery is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Final Result: The 3 reviewers determined that the requested surgery 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 reviewer number one is board certified in anesthesiology with sub-specialty certification in pain medicine and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.Physician reviewer number two is board certified in anesthesiology with sub-specialty certification in pain medicine and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.Physician reviewer number three 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: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for tramadol 50 mg, immediate release, 90 tablets for 90 days. The Health Plan has denied this request indicating that the requested medication regimen is not medically necessary for treatment of the enrollees restless leg syndrome.The submitted documentation does not support that the requested medication regimen is medically necessary. Recent practice guidelines on the management of RLS from the International Restless Legs Syndrome Study Group and the American Academy of Neurology do not readily indicate a role for narcotics in the management of RLS. Likewise, earlier guidelines from the American Acdademy of Sleep Medicine only made reference to the use of narcotics with a lower level of recommendation. Current practice guidelinse recommend the preferrential use of other agents as preferred therapies for the management of RLS. These other preferred agents also have more favorable safety profiles and greater bodies of literature to generally support their use. Under these circumstances, where current practice guidelines do not support the frequent use of narcotics in the management of RLS, the requested medication regimen of tramadol 50 mg, immediate release, 90 tablets per 90 days, is not medically necessary for treatment of the enrollees medical condition.Final Result: The reviewer determined that the requested medication is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is board certified in neurology, with subspecialty 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: Medical Necessity
Decision: Overturned

The parent of an 18-month-old male enrollee has requested physical therapy for treatment of the enrollees gross motor delay. Findings:  The physician reviewer found that this patient has significant motor delay due to his hypotonic muscular development. The disorder is congenital, frequently runs in families, and is labeled congenital benign hypotonia. The available medical literature reports a fairly good outcome in this patient population, but states that muscle stretching by physical therapists is essential for these children to attain improved motor function. Given that this patient has an anatomical and pathological diagnosis of congenital hypotonia  a diagnosis for which physical therapy has been shown to be effective  it is medically necessary for him to receive the requested PT.
Appeal type: Medical Necessity
Decision: Overturned

The enrollee is requesting authorization and coverage for transforaminal epidural steroid injections, Norco 10/325, and Flexeril, 10mg. The enrollee has low back and right leg pain. The enrollee received a right lumbar transforaminal block. She has chronic, disabling pain, which has caused psychological, social, and physical impairment. Conservative treatments have been used without relief. These include non-steroidal anti-inflammatory drugs and physical therapy. The record indicated her blood level of Norco was within normal limits and her urine toxicology screen was also normal, with no use of illicit substances. The enrollee indicates with her current pain medications, she was able to feel better, sleep more and be more active. She did not report any side effects related to the pain medication. The prescriber is requesting authorization for dexamethasone, 1mg injections, for nerve block. Limiting epidural steroid injections to four sessions per year is supported by clinical practice guidelines, but there is no limit on the number of years. The procedure is medically reasonable and necessary. This enrollee indicates she is able to sleep more and be more active.  The record shows meaningful improvement in pain and function.  A regulatory body approved Norco for the relief of moderate to moderately severe pain. A professional society indicates persons with over 90 days of opioid therapy should have documentation of urine drug testing for adherence monitoring in order to decrease prescription drug abuse or illicit drug use.  The enrollee was being monitored through the controlled substance utilization review and evaluation reporting system.  The records indicated there was a pain agreement on file and the enrollee had no aberrant behavior. Although there was a lack of documentation indicating the enrollee had been placed into one of three risk categories, the enrollee was being monitored appropriately. There is no indication of any abuse or diversion.  The requested medication is medically reasonable and necessary. Pharmacologic intervention for pain management is the principal treatment modality for pain, even though adverse drug reactions in the elderly are a significant risk. The manufacturer does not recommend the use of Flexeril for periods longer than two or three weeks. Current literature does not support a direct analgesic effect of these drugs. The use of muscle relaxants beyond one month is an off-label use and not supported by clinical evidence.Final Result: The reviewer determined that the requested services are partially medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The physician reviewer is board certified in anesthesiology and pain management 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: Experimental/Investigational
Decision: Upheld

Physician 1The patient is a 28-year-old man with a history of degenerative disc disease. The patient has low back pain and lower extremity pain. The patient has attempted conservative treatment including NSAIDs, muscle relaxants, physical therapy, and epidural steroids. The patient has requested authorization and coverage for nucleoplasty. The Health Plan has denied the patients request on the basis that it is considered investigational.Nucleoplasty is considered an investigational procedure and lacks established efficacy. Blinded-controlled studies have not established the clinical efficacy of this procedure. Nucleoplasty is not likely to be of greater benefit to this patient than other clinically available therapy. Therefore, I have determined that the requested procedure is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Plans denial should be upheld.Physician 2The patient is a 28-year-old man with a history of multi-level lumbar degenerative disc disease. The patient has experienced chronic back pain for 11 years. He has tried multiple treatment modalities without success. The patient wishes to undergo nucleoplasty. The Health Plan has denied the patients request on the basis that nucleoplasty is considered investigational.Nucleoplasty is not standard care for treatment of multi-level degenerative disc disease. There are no randomized, controlled trials demonstrating long-term efficacy of nucleoplasty. Furthermore, there is no peer-reviewed class I data to suggest that nucleoplasty is a more effective treatment option for this patients condition than standard therapies. Therefore, I have determined that the requested procedure is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Plans denial should be upheld.Physician 3The patient is a 28-year-old male with a history of chronic back pain with positive discogram at L3-4 and L4-5. The patient would like to avoid spinal fusion and has requested authorization and coverage for nucleoplasty. The Health Plan has denied authorization for the requested procedure on the basis that it is experimental in nature.There is no role for nucleoplasty in the treatment of this patient. There are no randomized, controlled trials demonstrating the long-term success of nucleoplasty in the treatment of discogenic chronic back pain. Nucleoplasty is without proven benefit in the treatment of this patients condition. There are no prospective controlled trials establishing the safety and efficacy of nucleoplasty for this category of patient. Therefore, I have determined that the requested procedure is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned

A 43-year-old female enrollee has requested panniculectomy and abdominoplasty for treatment of her symptomatic abdominal pannus.  Findings:  The physician reviewer found that based on review of the available records, there is adequate documentation describing a functional impairment likely related to the lower abdominal overhang. A panniculectomy may correct this lower abdominal overhang. The American Society of Plastic Surgeons (ASPS) stated that, a panniculectomy to eliminate a large hanging abdominal panniculus and its associated symptoms would be considered reconstructive. Manahan and colleagues noted that, the abdominal panniculus may cause disabling rashes, pain, physical limitation, back strain, and cosmetic deformity, and symptoms are more marked the heavier the panniculus. Panniculectomy can treat these symptoms. This patient reports typical symptoms including skin rashes and periodic open sores associated with redundant skin overlap. She is documented to have treated these problems with multiple topical medications, which have failed. Her examination and photographs are consistent with this clinical picture of a functional impairment related to the significant lower abdominal overlap. Consistent with these findings, the requested panniculectomy is supported as medically necessary for treatment of this patients medical condition. However, it is not likely that a functional impairment is related to this the patients diastasis rectus. There is conflicting data whether correction of rectus diastasis may serve a functional purpose. Coriddi and colleagues evaluated patients functional status following abdominoplasty and reported that, rectus plication did not significantly improve functional outcomes. Overall, a functional purpose for correction of diastasis is not reported with sufficient detail to support surgical correction. Thus, the requested abdominoplasty, which treats the upper abdomen and corrects diastasis recti, is not a medically necessary procedure for treatment of this patients medical condition. The patients functional impairment is likely related to the lower abdomen and not the upper abdomen. In summary, the requested panniculectomy has been shown to be medically necessary while the requested abdominoplasty is not medically necessary for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned

A 58-year-old female enrollee has requested Xyrem for the treatment of her fibromyalgia. Findings:  The physician reviewer found that although Xyrem is not a first-line therapy for fibromyalgia, there is medical evidence to suggest that it can be useful in patients with this disorder. In Swicks paper, there was a substantial benefit noted in many modalities for fibromyalgia patients as compared to placebo patients. This was true for pain, fatigue and sleep. Similarly, Scharf et. al. demonstrated that Xryem can reduce symptoms of pain, fatigue and sleep abnormalities in patients with fibromyalgia.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for hyperthermic intraperitoneal chemotherapy. Findings:  Three physician reviewers found that hyperthermic intraoperative chemotherapy involves instillation of heated chemotherapy at the time of surgery. Major concerns about this approach include its inherent potential morbidity, the lack of randomized trials confirming the theoretical advantage of hyperthermia, and that longer postoperative recovery time may result in delay, decreased dose intensity, or even withdrawal from subsequent systemic chemotherapy, thereby worsening prognosis. The National Comprehensive Cancer Network guidelines do not mention the use of hyperthermic intraperitoneal chemotherapy as a treatment option. Therefore, the requested hyperthermic intraperitoneal chemotherapy is not likely to be superior over other treatment options.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 reviewers 1, 2 and 3 are board certified in internal medicine with sub-specialty certification in medical oncology and are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

 Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for the medication Tecfidera.Findings:  The physician reviewer found that the submitted documentation supports that the requested medication Tecfidera is medically necessary. The submitted documentation indicates that the patient has Multiple Sclerosis (MS) and has been under treatment with Tecfidera for more than two years. The patient is reported to have tolerated Tecfidera well and has had a good response in terms of any progression. The patient would be put at risk of having a relapse, progression, and/or further neurologic decline if his medication were changed now, when the medication is being well tolerated and with good effect on condition. While evidence may show benefit to a population as a whole, any new agent may not be as well tolerated or have the same treatment effect for the patient. Under these circumstances, the requested medication Tecfidera is medically necessary to treat the patients medical condition.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 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: Medical Necessity
Decision: Overturned

The patient is a 34-year-old woman who has a prior history of migraine type headaches. She is requesting authorization for Botox therapy. The submitted records indicate the patient has been on nortriptyline, Topamax, Atenolol and Depakote. She has used Imitrex for breakthrough headache activity. The records provided do not demonstrate any evidence that the patient has analgesic dependent headache. Her headache diary indicates headache activity of at least 30% in any given month. She has tried Botox with a reduction in frequency and severity of headache activity. At issue is whether Botox is medically necessary for treatment of the patients medical condition.Review of the submitted records indicates the patient has been treated with a number of different prophylactic agents without adequate relief. She meets the clinical criteria for migraine type headache and tension type headache. There is sufficient medical literature demonstrating the efficacy of Botox in double-blind, placebo-controlled studies. The use of Botox in this clinical setting is medically appropriate and indicated. Therefore, I have determined the requested therapy is medically necessary for treatment of the patients medical condition. The Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: A female enrollee has requested reimbursement for digital breast tomosynthesis for evaluation of the enrollee, who presented for a breast examination.  Findings:  The physician reviewer found that Breast tomosynthesis is a technique that was developed several years ago as a problem solving adjunct to routine mammography.  Applying the same basic concept as computed tomography scanning, the logic is that by separating the various layers of breast tissue, one can better detect abnormalities. This has been shown to be most useful in the evaluation of dense breasts. In this particular patient, there are multiple indications for tomosynthesis.  First, her breast tissue is extremely dense.  It is specifically those patients who have dense breasts that can benefit most from tomosynthesis.  The ability to separate out the overlapping structures enables the possibility of demonstrating an otherwise occult tumor.  Similarly, areas of asymmetry can often be resolved by tomosynthesis.  Lastly, patients who are BRCA1 positive are at a very high risk for developing breast cancer. She is currently undergoing a very intensive program of magnetic resonance imaging (MRI)/mammography/ultrasound as well as physical examinations. The American College of Radiology, in its Appropriateness Guidelines, indicates that mammography and MRI are complementary examinations and that one should not replace the other.  Further, they give tomosynthesis their highest appropriateness rating for patients who are BRCA positive.  One of the disadvantages of MRI is that magnetic resonance scanning can be exceedingly sensitive, but it is not as specific as tomosynthesis. Tomosynthesis offers one advantage of better delineating a focal abnormality. The ability to separate out the overlapping structures enables the possibility of demonstrating an otherwise occult tumor. Therefore, digital breast tomosynthesis used was medically necessary for the evaluation of this patient. Final Result: The reviewer determined that the service at issue was medically necessary for evaluation of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in 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.
Appeal type: Medical Necessity
Decision: Overturned

A 28-year-old female enrollee has requested coverage for past skilled nursing services provided for treatment of her closed fractures of the sacrum/coccyx and sternum.  Findings:  The physician reviewer found that skilled inpatient rehabilitation is medically indicated when daily skilled therapy (five days per week) is necessary, there are appropriate goals that will likely be achieved in a reasonable and predictable period of time, the patient is participating and progressing with the treatment program, and the patient requires inpatient care to achieve the stated goals. Optimal recovery following hospitalization for a debilitating illness is best achieved in a skilled inpatient setting when a high intensity of therapy services is provided (Jette, et al). In this case, the patient had not achieved the stated long-term goals of the therapy program as of the date at issue. She was actively participating in regularly scheduled therapy sessions and it was likely, given her age and pre-morbid functional status that she would achieve additional functional gains. Since the patient needed to function at a modified independent level in order to safely return to the home setting, and she appeared to be tolerating daily therapies, the inpatient services provided were medically necessary.