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

The enrollee is requesting authorization and coverage for intensity modulated radiation treatment delivery. The enrollee has prostate cancer. He had a radical prostatectomy and has been on anti-testosterone therapy. The cancer was staged as stage IV A; no distant metastatic disease, but concern for involved pelvic lymph nodes. Further imaging showed evidence of lymph node involvement.  The enrollees radiation oncologist recommended intensity modulated radiation therapy. The required dosage is higher than normal tissues can tolerate, particularly the bladder and rectum.  Intensity modulation is the accepted way to deliver the dose safely while minimizing the dose to normal surrounding tissues; preventing both short and long-term side effects and complications. For this enrollees situation, the target is the prostate bed, with the surrounding normal structures requiring ways to prevent complications, just as if the prostate was being treated primarily. Because of the required dosage, it is medically necessary and reasonable to use intensity modulated radiation therapy to protect the normal tissues.  This dose will exceed rectal and bladder tolerances. Only intensity modulated radiation therapy can avoid the rectum and bladder and keep those structures within tolerances.Final Result: The reviewer determined that the requested service is 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: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for special cold therapy cryoablation. Findings:  The physician reviewer found that This patients records document that she is being treated for neoplasm of bone. The provider noted that the patient presented with a right talus bone lesion. X-rays of the right ankle showed a bone lesion in her right talus. The patients physical examination revealed right ankle with medial swelling, tenderness to palpation at the medial ankle, and limited range of motion due to stiffness and pain. The patients provider has recommended treatment with cryoablation. In this case, this patient has undergone a thorough evaluation with multiple imaging studies corroborating a non-enhancing sclerotic lesion along the medial aspect of the talus with significant surrounding soft tissue and bone marrow edema, which most likely represents an osteoblastoma. A review of the peer-reviewed medical literature suggests that the requested special cold therapy cryoablation is likely to be more beneficial treatment in this patients clinical scenario than standard alternatives. Cazzato and colleagues concluded that percutaneous image-guided cryoablation represents an effective therapeutic option for patients affected by painful osteoblastomas. Scandiffio and colleagues reported that percutaneous cryotherapy can be considered a safe and effective technique in the treatment of benign and malignant musculoskeletal tumors. El-Hussein and colleagues found that intralesional extended curettage with bone grafting and cryotherapy is a successful and safe treatment for patients with benign tumors of the talus. For these reasons, the requested special cold therapy cryoablation is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Findings: Three of the three physician reviewers found the requested services are 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 likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: Physician 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: Medical Necessity
Decision: Upheld

A 41-year-old female enrollee requested a portable (home) sleep study device for medical evaluation of the enrollees medical condition.  Findings:  The physician reviewer found that based on the medical records submitted for review, the patient has insomnia. However, no snoring or daytime sleepiness is documented on the test order form. Although the sleep study report does document snoring, this is not corroborated by the other documentation provided for review. Moreover, an Epworth Sleepiness Scale score of 10 without supporting information of sleepiness does not necessarily indicate sleep pathology. Based on the documentation submitted for review, the patients presentation is not suggestive of obstructive sleep apnea. Moreover, insomnia is not an indication for sleep testing, and the home sleep study provided was not medically necessary. Given that the portable sleep study device was not medically necessary for treatment of the patients medical condition, it was not medically necessary for the results of the test to be interpreted by a physician.
Appeal type: Experimental/Investigational
Decision: Upheld

A 37-year-old female enrollee has requested coverage for proton beam radiation therapy for treatment of her optic nerve sheath meningioma causing permanent blindness in the right eye.  Findings:  Three physician reviewers found that the patient was pregnant and presented with loss of vision in her right eye. An MRI of the brain demonstrated a right optic nerve mass that is consistent with a meningioma. The patient was evaluated by several providers. Ultimately, this patient was evaluated for radiation treatment that is planned following the delivery of her child. It was recommended that the patient undergo radiation treatment utilizing proton beam radiation therapy.  Proton beam radiation therapy allows the delivery of high doses of radiation to a target utilizing specific volumes and also limits the doses of radiation to nearby sensitive organs. The available peer-reviewed medical literature does not demonstrate that proton beam radiation therapy will provide better clinical outcomes in the treatment of meningiomas than other standard therapies. There are no randomized or large cohort trials comparing proton beam therapy with intensity modulated radiation therapy (IMRT) in patients with this clinical condition. In this case, the Health Plan has offered IMRT as a treatment option. There is an absence of data suggesting that proton beam therapy would be superior to IMRT in terms of clinical outcome.
Appeal type: Experimental/Investigational
Decision: Upheld

A 48-year-old male enrollee has requested authorization and coverage for computed tomography (CT) angiogram of the heart with 3D imaging for evaluation of the enrollees chest pain.  Findings:  Two physician reviewers found that the patient is a 48-year-old male with a history of anxiety/depression, a family history of coronary artery disease and symptoms of typical chest discomfort. He presented to the emergency department with atypical chest discomfort and had a negative cardiac evaluation at that time. An outpatient nuclear stress test revealed no chest discomfort during adequate exercise or ischemic electrocardiographic changes. The stress test also revealed normal ventricular function and normal perfusion imaging. A follow-up visit documents a request for a cardiac computed tomography (CT) scan to assess coronary anatomy. The Health Plan has denied the patients request for authorization and coverage for the coronary CT scan as investigational.  Based on the records provided, this patient presents with mild coronary risk, atypical chest discomfort, and a negative cardiac evaluation, including a recent normal nuclear stress test. In this circumstance, the post-test likelihood of significant obstructive coronary disease is low such that additional cardiac evaluation is not medically necessary and not considered standard accepted practice in the medical community. Should an assessment of coronary anatomy be medically necessary in this setting, then coronary angiography would be preferred given its improved accuracy relative to coronary CT angiography and the ability to intervene with revascularization during the same procedure. Similarly, the current expert consensus guidelines that are endorsed by several national organizations also do not consider coronary CT angiography appropriate in this circumstance of low clinical risk and an unequivocally normal nuclear stress test. For these reasons, the requested diagnostic procedure is not likely to be more beneficial than any available standard alternative.
Appeal type: Medical Necessity
Decision: Overturned

A 43-year-old female enrollee has requested a magnetic resonance imaging of the chest for evaluation of her injuries status post pedestrian versus motor vehicle accident. Findings:  The physician reviewer found that the medical literature suggests an MRI of the chest is oftentimes utilized in the evaluation of patients with a history of chest wall trauma with significant advantages. The MRI can evaluate the sternum, the sternoclavicular joints, the thoracic vertebral bodies and the surrounding soft tissues. Subhas and colleagues stated that, MRI can be a useful technique in the diagnosis of costal cartilage injuries. Further, Aslam and colleagues commented that, MRI is ideal for imaging the sternum because of its multiplanar capability as well as excellent spatial and contrast resolution. The authors also noted that MRI characterizes cartilage and soft tissue better than computed tomography (CT). Moreover, Grosse and colleagues found that, Various factors may be responsible for prolonged sternal pain following thoracic trauma, and these can be viewed with MRI Specifically, the authors concluded that, MRI identified sternal nonunion and other trauma-related abnormalities of the sternum following chest trauma. Thus, the outcome of an MRI of the chest will be helpful in the treatment of this patient and is therefore medically necessary for evaluation of her medical condition.
Appeal type: Medical Necessity
Decision: Overturned

The patient is a 58-year-old female who has had rosacea for many years. Her previous provider indicates she had much greater improvement with Finacea gel than with MetroGel or Doxycycline.  The patients request for authorization of Finacea gel was denied based upon the Health Plans determination that it was not medically necessary to treat her rosacea.The patients rosacea has been effectively treated with Finacea gel for some time after the failure of MetroGel and Doxycycline.  To discontinue an effective treatment in favor of additional trials would not be medically appropriate.  Therefore, I have determined that Finacea gel is medically necessary for treatment of the patients medical condition. The Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Upheld

A male enrollee requested sumatriptan (Imitrex) 100 mg twice per day for treatment of his cluster headaches. Findings:  The physician reviewer found that there is a lack of documentation on the medications that have been previously used and the duration. Given the lack of evidence for the daily use of oral triptans in cluster headache, the potential for harm caused by daily high dose triptan usage, and the presence of medication overuse headache in cluster patients who use frequent triptans, the request for sumatriptan (Imitrex) 100 mg twice per day is not medically necessary for treatment of this patients medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for additional ceftriaxone sodium injection (HCPCS-J0696) with accompanying supplies and home infusion nursing visits (CPT 99601). The Health Plan has denied this request indicating that the requested services are considered investigational for treatment of the enrollee who has a history of neurologic disorder. Findings:  The documentation provided does not support the superior efficacy of the requested services. While there is documentation that this patient has been diagnosed with Lyme disease, the available records do not substantiate conclusively the presence of Lyme disease or any other infection in this patient.  However, even if the records support the diagnosis of Lyme disease in this patient, peer reviewed literature supports treatment for no more than four weeks with any antibiotics. This patients request is for intravenous ceftriaxone for a period in excess of four weeks. Based on the documentation provided as well as the medical literature, additional ceftriaxone sodium injection (HCPCS-J0696) with accompanying supplies and home infusion nursing visits (CPT 99601) is not likely to be of greater benefit when compared to the available standard duration for treatment of this patients medical condition. Final Result: All three reviewers determined that the services at issue were 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:  Two reviewers are board certified in internal medicine with sub-specialty certification in infectious disease and is actively practicing. One reviewer is board certified in internal medicine with expertise in Lyme disease. 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

A 31-year-old male enrollee has requested inpatient psychiatric hospitalization services for treatment of his schizophrenia.  Findings:  The physician reviewer found during the course of the hospitalization from the specified time period, the patient is described as having improved quite a bit while becoming stabilized on Abilify. Further, the patient indicated that he liked the way Abilify made him feel. The patient was cooperative with his care and taking his medications. The progress notes indicate that while he remains gravely disabled, the patient is not a danger to self or others. Thus, the patient did not require the intensity and 24-hour supervision provided at the inpatient psychiatric hospital setting. Consistent with American Psychiatric Association (APA) treatment guidelines, the patient could have been discharged to a structured living environment where he could have received assistance with his activities of daily living, and any further changes to his medications could have been provided on an outpatient basis. Thus, the inpatient psychiatric hospitalization services were not medically necessary for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld

A 62-year-old female enrollee has requested Lyrica for treatment of her pain. Findings:  The physician reviewer found that there is a lack of clinical trial evidence supporting the use of antiepileptic medications such as Lyrica for chronic low back pain (Chang, et al.). Per Eisenberg, et al., there is a need for large-scale randomized controlled trials on the efficacy of antiepileptic drugs in neuropathic pain. The authors note that trials with long-term follow-up are required to establish the sustained efficacy of antiepileptic drugs for this indication. Recent systematic reviews recommend a treatment algorithm for any neuropathic pain syndrome, regardless of etiology, with the drugs of first choice being tricyclic antidepressants, gabapentin or pregabalin (Lyrica), and opioids (Dworkin, et al. and Finnerup, et al.). However, these papers acknowledge the limitation that most of their conclusions are drawn from randomized trials in patients with diabetic neuropathy and postherpetic neuralgia. Extrapolation to neuropathic pain of other etiologies is unproven. As such, further studies are warranted to establish the medical necessity of Lyrica in this clinical situation.
Appeal type: Medical Necessity
Decision: Upheld

A 37-year-old female enrollee has requested for a laparoscopic adjustable gastric band (lap-band) procedure for treatment of her obesity and chronic low back pain.  Findings:  The physician reviewer found that according to the National Institutes of Health (NIH) Consensus Guidelines, bariatric surgery is indicated for individuals who have morbid or clinically severe obesity with a BMI of 40 or a BMI of 35 with serious co-morbid conditions. Based upon the documentation, this patient has a BMI of less than 35 without documentation of any serious co-morbid conditions such as diabetes, hypertension or sleep apnea. In the absence of documentation that the patient meets NIH weight loss surgery guidelines, the medical necessity of lap-band surgery is not established. There is potential that further attempts at conservative weight loss will be successful for individuals such as this patient. Furthermore, as the patient has the potential for further weight loss through conservative means, the risks of weight loss surgery outweigh the potential benefits of the procedure.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: A enrollee has requested authorization and coverage for methadone. The stepwise ladder for pain relief is considered the reasonable approach to pain control in the palliative setting. Not all non-opioid and narcotic treatment options have been utilized in this patients case. There is no documentation of the completion of behavior therapy despite much research to support its use. Furthermore, no objective treatment goals for pain and function are noted for the requested medications. When opioids are started, providers should prescribe the lowest effective dosage. For these reasons, the requested methadone 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 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.
Appeal type: Experimental/Investigational
Decision: Overturned

A 31-year-old male enrollee has requested for intrastromal corneal ring segments implantation (INTACS) procedure for treatment of his keratoconus.  Findings:  Three physician reviewers found that the indication for INTACS implantation were entirely within the FDA guidelines for INTACS therapy based on the age of the patient, progressive keratoconus with reduced corrected visual acuity and contact lens intolerance, a clear central cornea, and a cornea thickness of greater than 450 microns. This patient tried conservative therapies of glasses and contact lenses but the glasses could not correct his vision enough to function and the contact lenses were irritating and caused the patient dryness and headaches. When indicated, INTACS implantation should be tried prior to undergoing cornea transplantation in patients with visually significant keratoconus that cannot be corrected with spectacles and who are contact lens intolerant.
Appeal type: Medical Necessity
Decision: Upheld

A 50-year-old female enrollee requested a bone growth stimulator for medical treatment of her low back pain.  Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested device.  The current medical evidence does not support a bone growth stimulator in this clinical setting.  The reasons for ongoing pain and numbness stated to be present in this patient are not sufficiently specified to support the use of an external bone stimulator.  All told, the requested bone growth stimulator is not medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: A 34-year-old female enrollee has requested authorization and coverage for Cosentyx for treatment of the enrollees psoriasis. Findings:  The physician reviewer found that systemic therapies for psoriasis, including methotrexate and cyclosporine, have a well-documented array of toxicities, particularly end-organ toxicities. Over the past several years, the use of anti-tumor necrosis factor (anti-TNF) biologic therapies for the treatment of moderate to severe psoriasis has been a major clinical and research focus. Despite difficulties with documenting risks, some systemic treatments for psoriasis have been linked with an increased risk of selected cancers. In addition, patients treated with anti-TNF drugs may develop adverse events such as infections, acute infusion and injection reactions, autoimmunity and cardiovascular effects.The U.S. Food and Drug Administration (FDA) has approved secukinumab (Cosentyx) to treat adults with moderate-to-severe plaque psoriasis. Cosentyx was more effective than placebo in studies specifically investigating efficacy in the difficult-to-treat palmoplantar and nail psoriasis populations. Studies investigating drug efficacy in these populations are rare, and treatment options for these patients are limited. Cosentyx  has also shown promising results for the treatment of psoriatic arthritis. The medical records indicate increased disease progression and symptoms despite multiple treatment attempts with topical, methotrexate, and biologic therapies. The records documented a prior trial with the requested medication had beneficial results. Therefore, Cosentyx is 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 dermatology 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.