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

A 40-year-old female enrollee has requested for continued outpatient psychoanalysis sessions for treatment of her major depressive disorder. Findings:  The physician reviewer found that stressors have been identified, and there has been a recent medication change.  Recent notes indicate no active suicidal plans.  Molenaar and colleagues published a randomized controlled trial which aimed to evaluate whether 16 sessions of psychotherapy combined with pharmacotherapy is more effective in relieving depression and improving social functioning than eight sessions of psychotherapy combined with pharmacotherapy.  The authors found that there was no clear difference between eight or 16 sessions of psychotherapy, both combined with pharmacotherapy, with regard to severity of depression and social functioning. The medical necessity for continued outpatient psychoanalysis sessions has not been established.
Appeal type: Experimental/Investigational
Decision: Upheld

A 64-year-old female enrollee has requested reimbursement for the sacroiliac joint rhizotomies for treatment of the her low back pain.   Findings:  Three physician reviewers found that the patient has an almost three-year history of low back pain that radiates to the buttock. She describes her pain as throbbing, sore, aching, shooting, tight, stabbing, intense and unbearable. There is occasional weakness and numbness in the right leg.  The patient has tried multiple conservative therapies including acupuncture, chiropractic therapy, massage therapy and lumbar epidural steroid injections. On neurological exam, she has full strength and sensation throughout. Her lumbar MRI shows multilevel degenerative disc disease, worst at L4-5. The patient subsequently underwent a right sacroiliac joint injection that resulted in 90 to 98% pain relief. Sacroiliac joint rhizotomies were then performed. The patient has requested reimbursement for the sacroiliac joint rhizotomies. The Health Plan has denied the treatment at issue, which is the subject of this review. A review of the literature reveals only a single randomized, placebo-controlled study of sacroiliac joint (SIJ) denervation/rhizotomy (radiofrequency ablation) for the treatment of patients with chronic, intractable, injection-diagnosed SIJ pain (Cohen, et al.). Although this study provides preliminary evidence that lateral branch rhizotomy may provide intermediate-term pain relief and functional benefit in selected patients with SIJ, the authors concluded that larger, multicenter studies with long-term follow-up and comprehensive outcome measures are needed to confirm these findings, further establish safety, and determine how best to identify candidates for this treatment (Cohen, et al.).  In the absence of such studies, sacroiliac joint rhizotomy for the treatment of patients with chronic, intractable, injection-diagnosed SIJ pain remains of unproven efficacy.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for autologous chondrocyte implantation of left knee.Findings:  The physician reviewer found that his patient is being treated for chondromalacia of the left patella and deficiency of anterior cruciate ligament. The patient is status post left knee arthroscopy with chondroplasty of the medial femoral condyle and trochlea. The patient autologous chondrocyte implantation of the left knee. Gou and colleagues concluded the pooled analysis found no significant difference in the improvement in International Knee Documentation Committee or Lysholm scores or overall Knee Injury and Osteoarthritis Outcome Score measures between patients in the autologous chondrocyte implantation versus microfracture groups at one to five years of follow-up. However, there is a lack of published, large-scale, long-term peer-reviewed literature demonstrating that autologous chondrocyte implantation is safer and/or more effective in the treatment of this patients pathology than standard therapies. In addition, detailed documentation is not reported regarding ongoing symptoms or clinical examination findings to support an indication for the requested surgical intervention. All told, the requested autologous chondrocyte implantation of left knee is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Findings: Two of the three physician reviewers found the requested autologous chondrocyte implantation of left knee is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the requested services are not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: Physician reviewer 1 is board certified in orthopedic surgery and is actively practicing. Physician reviewer 2 is board certified in orthopedic surgery and is actively practicing. Physician reviewer 3 is board certified in orthopedic surgery and is actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for a Guardant360 comprehensive liquid biopsy. Molecular diagnostic studies in non-small cell lung cancer (NSCLC) are considered within the current standard of care. Numerous gene alterations have been identified that impact therapy selection. Further, the National Comprehensive Cancer Network (NCCN) guidelines strongly advises broader molecular profiling with the goal of identifying rare driver mutations for which effective drugs may already be available, or to appropriately counsel patients regarding the availability of clinical trials. Broad molecular profiling is a key component of the improvement of care of patients with NSCLC. Testing of lung cancer specimens for these alterations is important for identification of potentially efficacious targeted therapies, as well as avoidance of therapies unlikely to provide clinical benefit. For these reasons, the Guardant360 comprehensive liquid biopsy was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.One reviewer found that the Guardant360 comprehensive liquid biopsy was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Final Result: Two of the three reviewers determined that the service at issue was likely to be more beneficial for evaluation 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 internal medicine with sub-specialty certification in medical oncology and is actively practicing. One Reviewer is board certified in internal medicine with sub-specialty certification in medical oncology and is actively practicing.  One Reviewer is board certified in internal medicine with sub-specialty certification in medical oncology 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: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for kyphoplasty surgery performed on 11/23/16.Findings:  Two physician reviewers found that the current medical evidence supports the use of kyphoplasty for acute vertebral body fractures, less than three months from onset of pain to procedure.  In this case, the patient had chronic thoracolumbar back pain with suspected anterior vertebral collapse at the T12 and L1 levels.  The records documented an apparent acute increase in symptoms prior to presentation for orthopedic evaluation on 10/03/16.  He had severe debilitating pain and interference with activities of daily living and quality of life.  There was reported x-ray and MRI evidence consistent with anterior vertebral collapse at the T12 and L1 levels.  Detailed evidence of reasonable and/or comprehensive non-operative treatment protocol trial and failure has been submitted.  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 physician reviewers 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: Medical Necessity
Decision: Overturned

A 59-year-old male enrollee has requested for Xifaxan for treatment of his Crohns disease.  Findings:  The physician reviewer found that although Xifaxan is not FDA approved for the treatment of Crohns disease, a review of the literature indicates it can be useful for patients with this condition. It is thought that bacterial overgrowth contributes to exacerbations of Crohns disease. Like metronidazole, Xifaxan is believed to control bacterial overgrowth and reduce acute symptoms. At this stage of his disease, it appears the more standard treatments are not effective for this patient. Xifaxan has proven to be beneficial and  continued treatment is medically appropriate.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Zepatier 50/100 mg for 12 weeks for treatment of the enrollees hepatitis C. Findings:  The physician reviewer found that there is sufficient support for the requested medication regimen in this clinical setting.  According to the most recent joint guidelines issued by the American Association for the Study of Liver Diseases and the Infectious Diseases Society of America, all patients with chronic hepatitis C should be treated, except those with limited life expectancy due to non-liver-related conditions, regardless of fibrosis stage.  For treatment-naive, genotype 1a patients, the guidelines support Zepatier for 12 weeks when NS5A resistance is not found.  These guideline recommendations are based on clinical trial results showing a 99% cure rate when NS5A resistance is absent.  All told, Zepatier 50/100 mg for 12 weeks is medically indicated for the treatment of this patient.Final Result: The reviewer determined that the requested medication regimen is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The physician 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: Medical Necessity
Decision: Upheld

A 56-year-old female enrollee has requested laminotomy for treatment of her low back pain.  Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested services.  There is a lack of support for the requested laminotomy, as the current medical evidence supports nonoperative management in this clinical setting.  This patient has a history of low back pain and leg pain, and the records note multiple significant comorbidities, including cirrhosis of the liver, pancreatitis and ongoing opiate use.  The patients examinations and anatomical studies suggest a diagnosis of complex regional pain syndrome.  In this patients case, the likelihood of a favorable outcome after a surgical intervention for the lumbosacral spine is limited by her comorbidities and a lack of specificity in diagnosis.  In sum, the requested laminotomy is not medically necessary given her multiple comorbidities and lack of specificity in anatomical diagnosis.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Euflexxa injection series in both knees. Per the medical literature, although viscosupplementation may relieve knee pain in some individuals with osteoarthritis, it is not known as to which individuals will benefit. The current evidence is limited, and guidelines from organizations such as the American Academy of Orthopedic Surgeons indicate that the evidence is not conclusive. 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 where everything else has been tried, and the options are limited. In this case, the patient has a history of significant relief from prior injections. Given the patients limited options and based on the current medical literature, the requested services are medically indicated. Therefore, Euflexxa injection series in both knees are medically necessary for the 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 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: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for breast tomosynthesis. Findings: Three physician reviewers found that the patient had an automated whole breast sonogram exam as well as a targeted left breast sonogram. The targeted sonogram revealed a small benign appearing intra-mammary lymph node in her left breast. There were no masses, areas of suspicious calcifications, or areas of architectural distortion. The patients breast tissues were described as being very dense. 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 (CT) 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 the dense breast.  Tomosynthesis has not been shown to provide significant increased value in patients who do not have dense tissue that could obscure an abnormality, especially when there have been no changes when compared to prior studies.  In this clinical setting, the patient has dense breast tissue. It is specifically those patients who have dense breasts that can benefit most from breast tomosynthesis. The ability to separate out the overlapping structures enables the possibility of demonstrating an otherwise occult tumor. Final Result: The reviewers determined that the services at issue were likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Credentials/Qualifications: Reviewers 1, 2, and 3 are board certified in diagnostic radiology and is actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement and prospective authorization and coverage for residential treatment center (RTC) services. The patients post-acute withdrawal symptoms were described as mild consisting of muscle aches. The patient has not been suicidal, homicidal, aggressive, or violent. The patient has been cognitively intact and not gravely disabled. There have been no emotional, behavioral, cognitive, or impulsive symptoms that would warrant the RTC level of care. The patient has been medically and psychiatrically stable to the extent that they do not require  24-hour a day continuous monitoring. The patient's medication management and Suboxone treatment can be safely provided in an ambulatory setting, which is considered the standard of care in the community. Although described as having impulse control difficulties, there has been no evidence of a high degree of impulsivity, agitation, depression, mania, hallucinations, or any other significant symptom severe enough that would interfere with their care. The patient has been motivated, cooperative, and engaged. The patient is described as participating in all aspects of their treatment plan and treatment modalities. The patient has struggled with emotions, but further treatment to help develop coping skills does not require the structured environment of a RTC setting. The patient could have been stepped down to an ambulatory level of care such as partial hospitalization program (PHP). Given these findings, the RTC services were not and are not medically necessary for treatment of this patients behavioral health condition. Final Result: The reviewer determined that the services at issue were not and 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 addiction 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: Upheld

The patient is a 61-year-old male with a history of night sweats and fever. The patient has undergone extensive workup, which included a physical exam, chemistries, blood counts, chest x-ray and colonoscopy. All of the results were normal. The patient wishes to undergo a PET scan to rule out a tumor. The Health Plan has denied the patients request on the basis that a PET scan is not medically necessary. The Health Plans denial should be upheld. There is no established role for PET scanning in this setting. There is no medical indication or justification for PET scanning in the treatment of this patient. In addition, there is no evidence to suggest that PET scanning is indicated for this patient. Therefore, I have determined that the requested PET scan is not medically necessary for evaluation of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary:  An enrollee has requested chiropractic services for treatment of her neck, hip, and back problems.  The physician reviewer found that the records indicate that this patient had an eight visit trial of chiropractic treatment. However, the submitted records for treatments in dispute do not document any type of subjective or functional improvement as a result of treatment. Chiropractic care may be appropriate after a trial of treatments based on documented improvement. Further, the provider has submitted diagnoses that are mild and should not require extensive treatment. Thus, the patient could have been well managed with the eight authorized visits over two months and should not require additional treatment. The provider has not documented any flare-ups or comorbidities that would justify continued treatment. For these reasons, the requested chiropractic services were not and are not medically necessary for treatment of this patients medical condition.  Final Result: The reviewer determined that the services at issue were not and 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 chiropractic and oriental 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 61-year-old male enrollee has requested Nuvigil for treatment of his traumatic brain injury.  Findings:  Three physician reviewers found that as supported by the clinical studies and approved by the FDA, Nuvigil is indicated to improve wakefulness in adult patients with excessive sleepiness associated with obstructive sleep apnea, narcolepsy and shift work disorder. Currently there is a paucity of reliable scientific data demonstrating an improvement in quality of life in terms of concentration and memory problems due to head trauma in patients treated with Nuvigil. As such, large, prospective, randomized controlled clinical trials evaluating the potential benefits and side effects are required to define the clinical role of Nuvigil and to establish patient selection criteria. Accordingly, its use in the management of this patients condition is not likely to be more beneficial than standard therapies.
Appeal type: Medical Necessity
Decision: Upheld

A 45-year-old female enrollee has requested brand name CellCept for treatment of her history of kidney transplant.  Findings:  The physician reviewer found that Almeida and colleagues reported on a bioequivalency study that has been performed for one generic formulation of mycophenolate mofetil (CellCept). Studies have also been performed to show equal efficacy in kidney transplantation (Rutkowski, et al; Abdallah, et al). Videla and Godoy conducted a study that evaluated the outcomes following conversion from brand name CellCept to a generic, which demonstrated equivalence. In summary, there is adequate data that generic medications approved by the FDA are considered bioequivalent to name brand. In this case, the records document that the patient tolerated the generic version of CellCept without new side effects and has maintained stable graft function. Thus, name brand CellCept is not considered medically necessary for her kidney transplant care.