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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for cardiac ablation. Findings:  Three physician reviewers found this patient has symptomatic, frequent, premature ventricular contractions. Based on the electrocardiogram, these may be of right ventricular outflow tract origin. He has failed a trial of medical therapy with a calcium channel blocker. As it appears his symptoms are more frequent at rest and improve with exercise, it is unlikely that other therapies, such as beta-blockers, would be effective. Catheter ablation is an appropriate treatment in this clinical setting. The procedure has a high success rate, a low incidence of complications, and may provide an improvement in quality of life. Thus, the requested cardiac ablation is likely to be of greater benefit than other treatment options. 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 reviewers 1, 2 and 3 are board certified in internal medicine with sub-specialty certification in cardiovascular disease and are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

The patient is a 43-year-old man who has muscular dystrophy with severe myopathy and is unable to ambulate. The submitted records indicate the patient currently has a power wheelchair, a seat lift mechanism, and a commode chair. The patient indicates that he is unable to access parts of his home due to the width of his chair. The patient has requested authorization and coverage for a standing wheelchair and power-assisted commode chair. The Health Plan has denied this request indicating that the requested equipment is not medically necessary for treatment of the patients medical condition.The patient has requested a standing wheelchair due to problems with access. Review of the occupational therapy evaluation from 4/6/04, indicates the patient can maneuver his current power wheelchair into the bathroom off his bedroom and that his bedroom is accessible. Apparently, the patient cannot reach the kitchen in his current power wheelchair due to a cupboard blocking access. However, a standing wheelchair does not address the issue of access since only the width of the chair is at issue. Thus, a standing wheelchair is not medically necessary to resolve the patients problem of access. The problem with access could perhaps be resolved by use of a portable commode chair and placing a small refrigerator within reach or by use of a narrower chair. Furthermore, a standing wheelchair is not required for purposes of pressure relief as the patient currently has a power wheelchair with recline.The patient has also indicated that he has difficulty urinating on a toilet and requires a power-assisted commode chair. However, the in-home occupational therapy evaluation indicates the requested commode would not allow the patient to be independent with urination since he would still require assistance. Thus, a power-assisted commode chair does not resolve the patients problem with urination and is not medically indicated. Given that the patient would still require assistance with a power-assisted commode chair the alternatives of transfer training with family or a portable commode proposed by the occupational therapist are more clinically appropriate.Based upon the information set forth above, I have determined that the requested equipment is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned

A 54-year-old male enrollee has requested for a CT of the heart for evaluation of his chest pain. Findings:  The physician reviewer found that The presence of coronary calcification is a well-accepted, clinically relevant risk factor for the development of future atheromatous coronary artery disease. In patients with minimal risk factors and high calcification scores, aggressive lipid therapy with interventions to lower LDL cholesterol is recommended. The requested diagnostic procedure has been shown to be a clinically useful, non-experimental application of this technology in this patient subset.
Appeal type: Medical Necessity
Decision: Overturned

A 50-year-old male enrollee has requested authorization and coverage for a 12-week course of Sovaldi and Olysio. The Health Plan has denied this request indicating that the requested medications are not medically necessary for treatment of the enrollees chronic hepatitis C virus (HCV) genotype 1A. Findings:  Three physician reviewers found that given that this patient is co-infected with HIV and has previously failed an interferon based regimen, the request for a 12-week course of Sovaldi and Olysio is medically necessary for treatment of his hepatitis C infection.  The U.S. Food and Drug Administration (FDA) approved combination treatment consisting of Olysio with Sovaldi in this clinical setting. For these reasons, the requested 12-week course of Sovaldi and Olysio is supported as medically necessary for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned

A 42-year-old female enrollee has requested Lidoderm patches for the treatment of her chronic pain. Findings:  The physician reviewer found that while there is no evidence of controlled trials of Lidoderm patches in the treatment of fibromyalgia, a study of pain relief in myofascial pain syndrome (a related chronic pain syndrome) showed significant improvement in pain control and somatic pain thresholds with lidocaine (Lidoderm) patches compared to placebo (see Affaitati and colleagues). This patient was reported to have tried and failed Prozac, Flexeril, Ultram and Motrin. The patients treating rheumatologist documented improvement in the patients pain after the use of Lidoderm patches, which the patient finds preferable to Lyrica since there is no side effect of sedation. This patient has failed multiple treatments for her pain, and is deriving benefit from Lidoderm patches. As such, it is medically appropriate to continue her on Lidoderm patches for pain management.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/ Case Summary:  The enrollee is requesting authorization and coverage for Ketamine HCL Solution nasal spray. The patient has complex regional pain syndrome, migraines, chronic fatigue syndrome, degenerative joint disease, spinal pain, degenerative disc disease, L4-5 disc displacement, lumbago with sciatica, and fibromyalgia.Findings:She had an anterior cervical microdiscectomy and fusions at levels C5-6 and C6-7. Subsequently, she was involved in a motor vehicle accident that exacerbated her back condition.  She has pain in her lower back and both legs. Her back pain wakes her up at night.  She also experiences tingling and numbness in her legs. She has tried epidural injections, Lyrica, Topomax, Celebrex, Amovig, Baclofen, Lidoderm patches, Naproxen, and Tylenol without relief. She has also gone to physical therapy and massage therapy. Review of the medical literature indicates there have been no trials of intra-nasal ketamine for CRPS.  One single study involved a small  number of patients who showed improvement lasting up to 60 minutes.  Intra-nasal esketamine has been approved for the treatment of depression but its use for CRPS is not supported by the literature. Final Result: The reviewer determined that the requested medication is medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The physician reviewer is board certified in 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: Medical Necessity
Decision: Upheld

The patient is a 46-year-old woman who has requested reimbursement for Bi-Est, compounded capsule of estradiol (E2), estriol (E3), and progesterone (P) to treat post-menopausal hot flashes, which she has experienced for four years. She has tried a synthetic combination of conjugated estrogens with medroxyprogesterone acetate and other unnamed remedies. She has been using the compounded capsule because she is concerned about the possibility of cancer and other health problems that might arise from use of the synthetic product. The Health Plan has denied reimbursement for the medication at issue on the basis it was not medically necessary for treatment of the patients medical condition.The only synthetic estrogen on the market are the conjugated estrogens from mares urine such as Premarin and PremPro. FDA approved and regulated preparations of natural E2 and P are readily available in the market and on formularies. Compounded estrogens and P are not regulated and their actual content may vary from 0 to 150% of their stated concentrations. There are no data suggesting any clinical advantage to unconventional estrogens such as Bi-Est or Tri-Est compounded with P compared to FDA approved and regulated E2 and P, either in terms of immediate relief of hot flashes or long-term incidence of cancer or cardiovascular disease. Therefore, I have determined that the medication at issue was not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned

A 48-year-old female enrollee has requested Botox injections for the treatment of her chronic daily headaches. Findings:  The physician reviewer found that this patient has received multiple treatments including analgesics, muscle relaxers and antineuropathic medications, with no pain relief. The patient underwent Botox injections to the cervical paraspinal musculature. This therapy did improve the patients head and neck symptoms. Because standard therapies have failed and Botox therapy has been effective for this patient, the patient should continue with Botox therapy.
Appeal type: Medical Necessity
Decision: Upheld

A 38-year-old female enrollee has requested physical therapy sessions needed for maximum range, at least three times per week for one hour for treatment of her humeral shaft fractures.  Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested therapy in this patients case.  Loss of elbow range of motion following trauma can result in significant functional limitation.  Conservative measures, including physical therapy and splinting, are best applied in the early stages of contracture onset.  In this patients case, she sustained significant trauma to the distal left humerus in a motor vehicle accident.  There is no documentation of therapy or range of motion exercise for more than two months following her open reduction and internal fixation surgery.  She developed reduced range of motion at the left shoulder and elbow.  She underwent physical therapy and started to regain her range of motion.  Shoulder range of motion was ultimately restored to a level that her treating therapists rated as normal.  Elbow range of motion has improved more slowly.  The records do not support the medical necessity of ongoing physical therapy on a regular basis.  No marginally significant improvement in health or functional outcomes is expected with further therapy on a regular basis versus a home exercise and splinting program.  Compliance with a home program would be reasonably expected to be a more significant factor in optimizing outcomes over formal therapy at this point, given that the patient needs to perform her exercises and splinting on a regular basis in order to improve her range of motion and function.  There are no documented exercises that she is performing that could not be performed independently or substituted with independent exercise.  There is no significant, sustained benefit of manual therapy at this stage with respect to health or functional outcomes for this condition.  All told, the requested therapy is not medically indicated for the treatment of this patient.
Appeal type: Experimental/Investigational
Decision: Upheld

The parent of a five-year-old male has requested Discrete Trial Model Applied Behavioral Analysis (ABA) for treatment of his autism.  Findings:  Two physician reviewers found that current treatment of autism involves ABA-based intervention. A recent 5-year randomized-controlled study involving 48 children with autism found significant improvements in IQ, adaptive behaviors and overall autism diagnosis using an Early Start Denver Model interaction based on developmental and Applied Behavioral Analysis principles (Rogers, et al.).  Warren, et al. also reviewed 34 studies of early intervention in autism and concluded that studies of Lovaas-based approaches as well as early intensive behavioral intervention variants and the Early Start Denver Model resulted in some improvement in cognitive performance, language skills, and adaptive behavior skills. Although multiple types of behavioral therapy exist, evaluation of efficacy among different therapy modalities is lacking (AHRQ Publication). The Vanderbilt Evidence-Based Practice Center systemically reviewed evidence on therapies for children ages 2 through 12 with autism spectrum disorders (ASD). The focus of the review was on treatment outcomes, modifiers of treatment effectiveness, and evidence for generalization of outcomes to other contexts. The outcomes of therapies for ASD noted that no studies directly compare effects of different treatment approaches (AHRQ Publication). In this case, there is no study comparing the Lovaas-based intervention involving Discrete Trial Training and the Early Start Denver Model. Positive results are noted using both intervention modalities. (AHRQ Publication). In sum, there is no data demonstrating that the Discrete Trial Model of ABA therapy is superior to the Denver Model of ABA therapy.
Appeal type: Medical Necessity
Decision: Upheld

A 27-year-old female enrollee has requested for revision of the right breast lift for symmetry for treatment of her status post breast surgery. Findings:  The physician reviewer found that the documentation fails to establish the medical necessity of the requested right breast lift for symmetry. Photographs show a reconstructed left breast with an indiscrete poorly defined inframammary fold that is lower than the right inframammary fold.  However, the right breast is normal in shape, with the nipple above the level of the inframammary fold, and normally positioned, with visible good quality breast reduction scars.  Per the submitted documentation, this patient does not have any right breast ptosis, and the right breast is normal in shape and size. Therefore, the requested right breast lift for symmetry is not reconstructive in nature and is not medically indicated in this patients case.
Appeal type: Experimental/Investigational
Decision: Upheld

A 53-year-old female requested authorization and coverage of gastric bypass with duodenal switch. The Health Plan denied the request indicating that the requested procedure is considered experimental for treatment of the enrollees morbid obesity.Three physician reviewers performed an experimental/investigational Independent Medical Review. All three physician reviewers concluded that the requested procedure is not likely to be more beneficial for treatment of the enrollee's medical condition than any available standard therapy. Because all three physician reviewers concluded that the requested procedure is not likely to be more beneficial for treatment of the enrollee's medical condition than any available standard therapy, the Health Plans denial has been upheld.
Appeal type: Experimental/Investigational
Decision: Overturned

A 58-year-old male enrollee has requested  for a Morcher iris implant for treatment of her cataract. Findings:  Three physician reviewers found that the Morcher iris implant has a good safety record and success rate in other countries. The compassionate use protocol through UCLA is an appropriate approach in this clinical setting. The patients visual potential with cataract surgery is quite good. However, any improvement will be mitigated by the glare and brightness that will result following cataract extraction if the large iris defect is not addressed. Though still in its early stages, the Morcher iris implant procedure is reasonable and indicated given the patients exceptional circumstance.
Appeal type: Experimental/Investigational
Decision: Overturned

A 40-year-old female enrollee has requested a laparoscopic sleeve gastrectomy for treatment of her obesity. Findings:  Two physician reviewers found that laparoscopic sleeve gastrectomy has now been performed worldwide several thousand times with excellent results. Recently published eight-year follow-up studies show weight loss to be maintained with results as good as or even better than laparoscopic Roux-en-Y gastric bypass. A study by Uglioni and colleagues showed that after five years, there was a 39% failure rate with laparoscopic gastric band. Moreover, in this particular case, the standard alternatives of laparoscopic Roux-en-Y gastric bypass and laparoscopic gastric band are not recommended due to the patients lack of success with these procedures in the past. In sum, laparoscopic sleeve gastrectomy is the most appropriate weight loss procedure available in this specific setting.
Appeal type: Experimental/Investigational
Decision: Upheld

Physician 1: The patient is a 44-year-old female with degenerative disc disease. She has had a positive discogram at L5-S1. Her provider is recommending a disc replacement at this level. The Health Plan considers this procedure experimental. The Health Plan is correct that the proposed procedure is considered experimental. There is no evidence to support disc replacement as the best available treatment for this patient. Artificial discs are currently being investigated for single level disc replacement in the treatment of degenerative disc disease in the lumbar spine. Current data for single level disc replacement demonstrates a 63% short-term success rate; however, long-term outcomes are unknown and complications may be severe. Because there is no evidence supporting the safety and efficacy of a two level disc replacement, I have determined the requested procedure 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.Physician 2: The patient is a 44-year-old female with degenerative disc disease. She is seeking authorization for artificial disc replacement utilizing the Charite III disc. The Health Plan has denied this request because it considers the artificial disc replacement experimental. The current clinical evidence regarding the Charite III disc has allowed for Food and Drug Administration (FDA) approval that it is not inferior compared to fusion. Similarly, current studies appear to indicate it is not worse than fusion. Additional claims of efficacy are based upon a small number of short-term, non-randomized studies. A 300 patient FDA regulated investigational device exemption trial with long-term follow up is underway. Without the results of this trial the Charite III disc replacement remains experimental. Furthermore, it is not established as superior to fusion. Therefore, I have determined 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 3: The patient is a 44-year-old female with degenerative disc disease at L5-S1. Artificial disc replacement has been recommended. The patient is status post laminotomy in 2000 and has persistent pain. The Health Plan has denied authorization for the requested procedure.The proposed procedure is experimental without established long-term safety and efficacy. Available data does not demonstrate an advantage to disc replacement over fusion. The long-term safety profile is unknown. There is no clinical indication demonstrating the proposed procedure is the best treatment option for this patient. There are other treatments available. For these reasons, I have determined the requested procedure 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.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested real time heart monitor (heart monitor, connected to a lab by cellular phone) (CPT code 93229) for evaluation of the her palpitations. Findings:  Two physician reviewers found that based on the records provided, the patient presented with intermittent near weekly palpitations. In this circumstance, if additional evaluation for a dysrhythmia was indicated, then prolonged serial 48-hour Holter monitoring or offline self-activated or auto-triggered cardiac event monitoring would be sufficient in recording cardiac rhythm during symptoms. In this patients case, there is no documentation that these devices have already been tried and failed for evaluation of her current symptoms. Current expert consensus guidelines endorsed by several national organizations also consider Holter monitoring and/or patient-activated or auto-triggered event recorders appropriate initial tests and standard of care for evaluation of dysrhythmias. Continuous real time monitoring by telemetry services was not appropriate in this case since off-line analysis of a patient-activated or auto-triggered event recorder would have been sufficient in the identification of dysrhythmias during symptoms without jeopardizing patient safety. Immediate recognition and reporting of dysrhythmias through a call center provided by real time mobile telemetry services has not been shown to improve health outcome compared to standard monitoring techniques. Final Result: The reviewers determined that the services at issue were not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: Reviewer 1, 2, and 3 are board certified in internal medicine with sub-specialty certification in cardiovascular disease 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.