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

A 57-year-old female enrollee has requested for Botox injections for treatment of her migraines.   Findings:  Three physician reviewers found that Botox is not a first-line therapy for treating migraine headache, there is ample literature supporting its use in select patients. An article by Schim notes that the results of a pooled analysis indicated a 57% reduction in acute headache medication use in the 8- to 12-week period following injection of botulinum toxin A. In this patients particular case, she has failed multiple first-line abortive and preventive therapies. In addition, she has benefited from the use of Botox previously with marked worsening while off of Botox therapy.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has been diagnosed with type 2 diabetes. The patient was being treated with Invokana, Janumet, and glimepiride. The patient reported his fasting blood glucose levels were between 130 and 150 mg/dL. The provider noted a hemoglobin A1c level was 7.7%. The provider noted the patient needed an increased frequency of blood glucose checks. The provider prescribed a OneTouch Verio meter; however, the Health Plan denied the request on the basis that the patient has not tried the True Metrix meter. The patient has requested authorization and coverage for a OneTouch Verio meter system. The Health Plan denied the request and reported that the requested equipment is not medically necessary for the treatment of this patient. At issue in this case is whether a OneTouch Verio meter system is medically necessary for the treatment of the patients medical condition. Researchers reported, Self-monitoring of blood glucose (SMBG) is recommended as a core element of self-management of diabetes when used appropriately following suitable training. There are many glucometers currently available for SMBG, and there is a high degree of variability among these meters. The OneTouch Verio is a glucometer (GM) that contains a color range indicator (CRI). Researchers reported, This recent randomized controlled trial confirmed previous studies that showed a reduction of hemoglobin A1c when using CRI-based GMs in both patients with type 1 diabetes mellitus and type 2 diabetes mellitus. The True Metrix glucometer does not have CRI capability. The medical evidence supports the requested equipment in this clinical setting. Therefore, the requested OneTouch Verio meter system is medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested equipment 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 internal medicine with sub-specialty certification in endocrinology, diabetes, and metabolism 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 21-year-old female enrollee has requested for Nuvigil for treatment of her excessive fatigue. Findings:  The physician reviewer found that she does not have a medical condition, specifically a sleep disorder, for which Nuvigil has been approved.  The efficacy of Nuvigil in migraine has not yet been evaluated in clinical trials.  The literature noted above addresses the use of Nuvigil in the setting of sleep disorders (i.e., narcolepsy), for which there is sufficient evidence of efficacy. The medical record includes documentation that the patient feels more alert with Nuvigil and has had some relief of her migraine symptoms with it. However, Nuvigil is often found to result in reports of subjective improvement regardless of whether or not a medical diagnosis exists.
Appeal type: Medical Necessity
Decision: Upheld

A 53-year-old female enrollee has requested endoscopic procedures, including foraminotomy, laminotomy, and percutaneous discectomy for treatment of her neck pain.  Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested services in this patients case.  There is a lack of support in the medical literature for the requested endoscopic procedures, including foraminotomy, laminotomy, and percutaneous discectomy, in this clinical setting.  There is a lack of prospective randomized trials or systematic literature reviews supporting the requested services for the treatment of this patient.  Although the review by Gibson and Waddell focused on lumbar disc prolapse, the authors noted that high-quality, randomized, clinical trials are needed to determine if there is a role for laser discectomy.  In a systematic review by Singh and colleagues, the authors reported that there is a paucity of randomized clinical trials regarding laser discectomy.  In sum, there is an absence of high-quality, randomized, clinical studies demonstrating the safety and efficacy of the requested services.  All told, the requested endoscopic procedures, including foraminotomy, laminotomy, and percutaneous discectomy, are not medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for residential treatment center services for treatment of the enrollees behavioral health condition. Findings:  The physician reviewer found that the submitted documentation does not support the medical necessity of the services at issue. This patient no longer required continued treatment at the residential treatment level of care and could have been treated in a lesser restrictive setting. This patient denied any suicidal or homicidal ideation.  He did not endorse auditory or visual hallucinations. He was not a danger to self or to others.  The patient was not exhibiting symptoms of withdrawal. His mood was noted as stable, calm and cooperative. As such, this patients issues did not require the structured environment of a residential care treatment setting. This patient could have received treatment in a lesser restrictive setting. For, these reasons, the residential treatment center services provided were not medically necessary for treatment of this patient. 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 geriatric 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

A 62-year-old female enrollee has requested physical therapy and biofeedback services for treatment of her musculoskeletal pain.  Findings:  Two physician reviewers found that biofeedback is considered experimental for muscle re-education and is not generally considered a medically necessary component of PT. Although a fixed duration of PT can be useful in the management of knee pain, there is no clinical advantage unless clear progress is documented. In this instance, there was no objective evidence of progress in the PT documentation after the initial re-evaluation except for some change in the patients pain rating.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary:  An enrollee has requested authorization and coverage for an echocardiogram at a tertiary care center.A follow-up echocardiogram done at the same laboratory, using similar technique, image acquisition, equipment and personnel, provides continuity to compare changes from prior examinations. Thus, the requested service is medically reasonable and necessary from a continuity of care standpoint. As the patient has already had subtle reductions in left ventricle function, a repeat scan done at the same echocardiogram laboratory and compared to similarly done prior studies will provide the best assessment of left ventricle function. This would provide the best reliability to the measurements of changes in left ventricle function, especially since her left ventricular ejection fraction was not completely normal on prior studies. According to Wang and Chu, reliable left ventricular ejection fraction results would be critical to her oncologic care, as this could affect further chemotherapy or radiation dosing. Therefore, the requested echocardiogram at a tertiary care center is medically necessary for the evaluation of the patients medical condition.Final Result: The reviewer determined that the requested service is 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 internal medicine with sub-specialty certification in cardiovascular disease and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

A 57-year-old male enrollee has requested Acceptance Commitment Therapy (ACT) by a trained therapist who can provide the therapy out in the field (outside of the office setting) for the treatment of his panic disorder. Findings:  The physician reviewer found that the scientific literature failed to demonstrate that ACT has been found to be a treatment of choice for Panic Disorder with Agoraphobia  or that it is superior to Cognitive Behavioral Therapy (CBT) which is being offered to the patient.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary:   An enrollee has requested a single-site abdominal robotic-assisted hysterectomy, non-vaginal for treatment of her medical condition.  Findings:  The physician reviewer found that this is a patient who has requested a hysterectomy as definitive treatment for her medical condition and due to her history, she has requested a procedure that involves no vaginal instrumentation. However, the medical records include a prior laparoscopy that does not support a diagnosis of endometriosis, which may be an indication for the requested procedure. Further, a robotic laparoscopic approach, just like that of a standard laparoscopic hysterectomy, must use vaginal instrumentation to manipulate the uterus and move it from side-to-side for access, which is particularly necessary with a single-site approach. This helps to protect the bladder and uterus from injury during the dissection, and the device also delineates the connection of the vagina to the cervix, which cannot be easily identified otherwise. The patient indicates that the vaginal cuff would be closed via laparoscopic suturing if done robotically, but this can also be done with standard laparoscopic hysterectomy. In this case, there is a lack of medical or surgical advantage to a robotic procedure if this patient opts for a laparoscopic hysterectomy. All told, the medical records demonstrate that the requested single-site abdominal robotic-assisted hysterectomy, non-vaginal procedure is not medically necessary for treatment of this 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 obstetrics and gynecology 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 60-year-old female has requested a semi-electric hospital bed with a mattress and rails due to her history of prior falls.  Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medically necessity of the requested equipment in this patients case.  Semi-electric or fully electric hospital beds may be necessary if an individual requires head elevation, such as due to respiratory or cardiac impairments.  Additionally, semi-electric or fully electric hospital beds may be indicated if the patient has other frequent positioning needs and is unable to perform these maneuvers independently.  Pressure relieving mattresses may be needed if a person is unable to perform sufficient pressure relief independently.  The records forwarded for review do not establish that the patient has impairments which require a semi-electric hospital bed.  The patient reportedly has fallen out of bed on many occasions, but the impairments that are responsible for this are not clearly documented.  All told, the requested semi-electric hospital bed with a mattress and rails is not medically indicated for the treatment of this patient.
Appeal type: Experimental/Investigational
Decision: Upheld

A 57-year-old male enrollee has requested cold therapy machine and continuous passive motion machine for treatment of his right knee status post arthroplasty.  Findings:  Three physician reviewers found that in a review of the current medical literature, Harvey and colleagues discussed use of CPM devices following total knee replacement surgery. The authors examined a number of end points including active and passive knee flexion, active and passive knee extension, length of hospital stay and the incidence of the need for manipulation under anesthesia. After reviewing 20 randomized controlled trials of 1335 patients, the authors concluded that range of motion (ROM) effects were too small to justify use of CPM status post knee replacement. Further, Bruun-Olsen and colleagues offered similar results when reporting on 63 patients treated with active exercise or CPM and active exercise following total knee replacement. Overall, the authors concluded that the addition of CPM to active exercise did not restore pre-operative ROM and stair climbing capacity had actually decreased in both groups. Moreover, Smith and colleagues evaluated the efficacy of cold therapy compared to compression bandaging after total knee replacement. The study focused on 84 post-operative unilateral knee replacement patients randomized into patients treated with compression bandages versus those undergoing treatment with cryo-pad technology without significant differences between the groups in terms of measured outcomes. In summary, CPM and mechanical cryotherapy remain controversial. Despite use of both modalities following total knee replacement, the objective scientific data does not support the use of either CPM or cryotherapy as opposed to standard applications of ice, early mobilization, and active physical therapy. Based upon the information set forth above, I have determined the equipment at issue was not likely to be 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: An enrollee has requested authorization and coverage for oxycodone. The submitted documentation does not support that the requested medication is medically necessary. Medical literatures have concluded that patients with chronic low back pain who use chronic opiates have much poorer outcomes. In addition, clinical practice guidelines from the Centers for Disease Control (CDC) do not support the use of opiates for this patient. In this case, the patient had an aberrant urine toxicology with hydrocodone detected on one screening, then THC on another screening. The patient had stated that she used another persons oxycodone. These circumstances are red flags. At this time, the patient has an appointment with pain management in the near future. Under these circumstances, the request for oxycodone is not medically necessary for treatment of the patients 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 anesthesiology, with subspecialty certification in pain management. 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 65-year-old male with a PSA of 11.14 in September 2005, which decreased to 8.5 in January 2006. A transrectal ultrasound-guided prostate biopsy performed in November 2005 indicated he was benign on the right side; however, in 10% of the specimen from the left side there was a Gleason score of 4+3 for a total of 7 adenocarcinoma of the prostate. A bone scan showed no evidence of metastatic disease. Digital rectal examination in February 2006 revealed an enlarged but smooth prostate with no nodules. The patient has been found to have a stage T1c prostate adenocarcinoma, with a Gleason score of 7 (4+3).The Health Plan has authorized surgery, a laparoscopic radical prostatectomy, without robotic assistance. The patient wishes to have the procedure performed with robotic assistance. The Health Plans denial should be upheld. To date, there is insufficient peer-reviewed medical literature demonstrating that robotic assisted laparoscopic prostatectomy results in clinically superior outcomes. As such, the requested procedure is not medically warranted. The procedure offered by the Health Plan is within the standard of care for prostate adenocarcinoma, and is medically reasonable and appropriate. Therefore, I have determined that the requested procedure is not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld

This case involves a 55-year-old woman with a diagnosis of major depressive disorder, post-traumatic stress disorder (PTSD) and generalized anxiety disorder (GAD). She is in psychotherapy and receives psychotropic medication from her primary care physician. She has been in therapy with the psychotherapist for an extended period of time. The patient has requested reimbursement for the outpatient therapy she received from January 2004 onward and is seeking authorization for continued outpatient psychotherapy.There are several issues that are presented by this case. The first is that there is no end point to the proposed psychotherapy; it seems there is an expectation that therapy will go on in perpetuity. Secondly, it appears the patient is receiving a sub-optimal dose of antidepressant medication. She should be evaluated by a psychiatrist skilled in psychopharmacology so that an effective medication regimen can be devised and implemented. The psychotherapy the patient received beyond January 2004 was not medically necessary. The patients condition is chronic and does not appear to have improved during the period at issue. Furthermore, she has a better chance for improvement with psychotropic medications than with continued, ongoing psychotherapy. Therefore, I have determined the therapy at issue was/is not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested reimbursement and prospective authorization and coverage for 40 hours per week of direct applied behavioral analysis (ABA) therapy (CPT code H2019) for treatment of the autism spectrum disorder. Findings:  The physician reviewer found that the request for 40 hours per week of direct ABA therapy (CPT code H2019) was and is medically necessary for treatment of the patients medical condition. Based on the documentation submitted for review, the patient demonstrates significant maladaptive behaviors that include taking clothes off in public, tantrums, self-harm, elopement, motor stereotypy, visual stereotypy, self-touch and poor self-awareness. The patient continues to require a high level of support to transition appropriately. Failure to master these skills places the patient at an increased risk for injury. In addition, the Behavior Analyst Certification Board indicates that typical comprehensive ABA programs range from 30 to 40 hours of treatment per week. Final Result: The reviewer determined that the services at issue were and 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 pediatrics with sub-specialty certification in developmental-behavioral pediatrics 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 57-year-old female has requested a positron emission tomography (PET) scan for evaluation of her small cell lung cancer.  Findings:  Two physician reviewers found that five years ago the patient was diagnosed with endometrial cancer and was treated with total abdominal hysterectomy.  At that time, she was found to also have a lung mass diagnosed as small cell lung cancer and was treated with radiation therapy and chemotherapy. At this time, she has no change in symptoms. She has diabetes mellitus and is taking Metformin. A positron emission tomography (PET) has been requested for three-month surveillance because her provider states that Metformin use requires 96 hours of withholding the drug to avoid contrast enhanced nephropathy with routine contrast enhanced computed tomography (CT) scanning.   The National Comprehensive Cancer Network (NCCN) guidelines for surveillance of small cell lung cancer specifically state that PET scans are not recommended. Similarly, the Centers for Medicare and Medicaid Services (CMS) does not advocate in favor of PET scanning as a surveillance modality for patients with small cell lung cancer. In addition, the argument that Metformin therapy needs to be withheld for 96 hours after iodinated contrast administration is not supported by the American College of Radiology (ACR) position paper on contrast usage in this clinical setting. The ACR recommends halting Metformin therapy the day of the contrast study and followed by 48 hours without the drug. Moreover, there have been no documented adverse effects on patients with diabetes with this regimen. For these reasons, the requested diagnostic procedure is not likely to be more beneficial for evaluation of this patients medical condition than any available standard therapy.
Appeal type: Medical Necessity
Decision: Upheld

The parents of a ten year-old female with delayed reading skills and learning disabilities and a diagnosis of a central auditory processing disorder (CAPD) are requesting for authorization and coverage of the recommended speech/auditory therapy.Reviewers Findings:  The reviewing physician found that the current literature suggests that CAPD is an ill-defined diagnosis and that the efficacy of the various treatments available for the disorder has not been established.  The reviewing physician found that the Health Plan denial should be upheld.