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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Euflexxa injections for both knees.Current medical literature pertaining to viscosupplementation reveals mixed results. Evidence from eight systematic reviews and six randomized controlled trials indicate that although viscosupplementation may relieve knee pain in some individuals with osteoarthritis, it is not known which individuals will benefit. Different studies have tried mixing hyaluronic acid with corticosteroids, platelet rich plasma, and other agents to make it more effective. The current evidence is limited and guidelines from organizations such as the American Academy of Orthopedic Surgeons indicate that the evidence is not conclusive. As such, the Academy does not currently support viscosupplementation as standard treatment for osteoarthritis of the knees. 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 when everything else has been tried and the options are limited. In this case, there is a history of lasting benefit from prior viscosupplementation. The patients options are limited, as the patient does not want surgery, has tried and failed physical therapy, and is currently on addictive opioids. Under these circumstances, Euflexxa injections for both knees are medically necessary to treat the patients medical condition.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

A 64-year-old male enrollee has requested genetic testing for evaluation of his salivary gland cancer.  Findings:  Two physician reviewers found that the testing performed was likely to be more effective for this patient than other available options. Adenoid cystic carcinomas are rare cancers usually arising from the salivary glands presenting as oropharyngeal masses although metastatic presentations have been described (Bhattacharyya, et al). The tumors can be slow growing but have a high propensity for recurrence. Since the tumor is very rare, large randomized clinical trial evidence cannot be expected. Recently, it has become important to identify mutations that may be amenable to targeted therapy. Von Hoffman and colleagues studied 86 patients where the progression-free survival (PFS) on regimen selected by molecular profiling was compared to PFS on the last chemotherapy regimen. The regimen selected by molecular profiling offered a 27% survival advantage (Hoffman, et al). All told, the testing at issue was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.
Appeal type: Medical Necessity
Decision: Upheld

The parent of a 15-year-old male enrollee has requested residential treatment center services for treatment of the enrollees substance abuse and depression.   Findings:  The physician reviewer found that the records from the residential treatment facility do not demonstrate that the patient was and/or is a risk to himself or others. The patient appears to be motivated and is actively participating in treatment. No withdrawal or medical issues were noted. The patient was taking passes and spending time off the unit with no documented adverse consequences. He was expressing appropriate anxiety around his ability to maintain sobriety following discharge. Additionally, the records do not document the use of an evidence based treatment for substance abuse or depression. There is no evidence of physician monitoring or consultation during the patients residential stay. The records provide no indication that the patient was being prescribed any medications for the diagnosis of major depressive disorder. The evidence based practice guidelines indicate that patients with major depression and substance abuse should be treated in the least restrictive setting that is likely to prove safe and effective. The data submitted for review fails to establish that the patient could not have been safely and effectively managed in a less intensive setting such as partial hospitalization. As such, medical necessity for the disputed residential treatment services has not been established.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for a LINX procedure. There is a lack of evidence in current medical literature supporting the safety and efficacy of the LINX procedure. Skubleny and colleagues note that Nissen fundoplication (LNF) is the gold-standard surgical treatment for GERD. The authors further note that while the LINX magnetic sphincter augmentation (MSA) appears to be an effective treatment for GERD, long-term comparative outcome data past one year is needed in order to further understand its efficacy. Sheu and colleagues note that severe dysphagia requiring endoscopic intervention is more common with MSA over LNF. In this clinical setting, given the providers recommendation against a LINX procedure due to associated potential adverse effects and poor outcomes, the requested service is not medically indicated. Therefore, a LINX procedure is not medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested service 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 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: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested stereotactic body radiotherapy (SBRT) for treatment of the enrollees metastatic pancreatic neuroendocrine tumor and breast cancer. Findings: Two physician reviewers found that external beam radiation therapy (EBRT) remains a conventional and efficacious method of palliative radiation therapy for patients with spine metastases. By comparison, SBRT has resulted in comparable rates of pain relief and late treatment related toxicity. SBRT continues to show promise as an emerging modality in selected patients with spine metastases. In the peer-reviewed medical literature, Mahadevan and colleagues concluded that SBRT is feasible and appears to be an effective treatment modality for re-irradiation after conventional palliative radiation fails for spine metastasis patients. This patient has widespread metastatic disease, yet her spine remains untreated. Thus, conventional palliative radiation therapy is considered the standard of care. Given these findings, the requested SBRT is not likely to be more beneficial for treatment of this patients medical condition than any available standard therapy.  Final Result: Two 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: All three physician reviewers are board certified in radiation oncology and are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld

A 56-year-old female enrollee has requested left total ankle arthroplasty for the treatment of her end stage post-traumatic arthritis. Findings:  Three physician reviewers found that the medical literature lacks long-term, controlled double-blind studies validating the safety and efficacy of this procedure. While preliminary studies suggest promise for total ankle arthroplasty, without peer-reviewed literature in support of the procedure, its efficacy remains unproven. SooHoo and colleagues state that, This study confirms that, compared with ankle fusion, ankle replacement is associated with a higher risk of complications but also potential advantages in terms of a decreased risk of the patient requiring subtalar joint fusion. Additional controlled trials are needed to clarify the appropriate indications for ankle arthrodesis and ankle replacement. Thus, there is currently insufficient evidence to support the conclusion that total ankle arthroplasty is likely to be more efficacious for this patient than standard therapies.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary:  An enrollee has requested Viekira Pak for treatment of her chronic hepatitis C virus genotype 1b.  Two physician reviewers found that as per the American Association for the Study of Liver Diseases (AASLD) and Infectious Diseases Society of America (IDSA) guidelines, all patients with chronic active hepatitis C are eligible for treatment and should be treated with U.S. Food and Drug Administration (FDA) approved antiviral therapy regardless of fibrosis score. Successful hepatitis C treatment results in sustained virologic response (SVR), which is tantamount to virologic cure, and is expected to benefit nearly all chronically infected patients. In treatment-naive genotype 1b patients, therapy is recommended with Viekira Pak for 12 weeks. Given this recommendation, the requested Viekira Pak is medically necessary for treatment of this patients hepatitis C virus.   Final Result: Two reviewers determined that the requested medication is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.    Credentials/Qualifications: All three reviewers are board certified in internal medicine with sub-specialty certification in gastroenterology and are 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: Medical Necessity
Decision: Upheld

The patient is a 56-year-old woman with a diagnosis of polyneuropathy. She is seeking authorization for a POV to utilize inside her home. It appears that she already has a POV for utilization outside her home. The evidence submitted does not demonstrate that the patient cannot functionally ambulate inside her home or that she cannot utilize a manual wheelchair inside the home.The patient does not meet nationally accepted criteria for authorization of the requested equipment. As set forth above, there is no evidence that the patient cannot functionally ambulate inside her home or that she cannot operate a manual chair within her home. In addition, there is no evidence demonstrating that the patients home cannot accommodate a manual wheelchair. For these reasons, I have determined that the requested equipment is not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for digital breast tomosynthesis for the enrollees breast cancer screening. Findings:  Three physician reviewers found that the patient was asymptomatic with respect to her breasts. She underwent a diagnostic mammogram consisting of a combination two dimensional and three dimensional tomosynthesis examination. There were no masses, areas of suspicious calcifications, or areas of architectural distortion. Her breast tissue was described as heterogeneously dense. The patient requested reimbursement for digital breast tomosynthesis. The Health Plan denied reimbursement for digital breast tomosynthesis indicating that the service at issue was investigational for the evaluation of this patient. Breast tomosynthesis is a technique that was developed several years ago as a problem solving adjunct to routine mammography.  Applying the same basic concept as computed tomography scanning, the logic is that by separating the various layers of breast tissue, one can better detect abnormalities. This has been shown to be most useful in the evaluation of dense breasts.  In this particular patient, her breast tissue was described as heterogeneously dense.  It is specifically those patients who have dense breasts that can benefit most from tomosynthesis. The ability to separate out the overlapping structures enables the possibility of demonstrating an otherwise occult tumor. Therefore, digital breast tomosynthesis performed was likely to have been of greater benefit than other methods of evaluating this patient. Final Result: The 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: All three reviewers are board certified in diagnostic radiology 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: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for proton beam therapy. There is a paucity of medical literature demonstrating that treatment with proton beam radiation offers a clinical benefit compared to conventional radiation therapy techniques for breast cancer (Allen, et al). Further, there is a paucity of data showing that treatment with proton techniques improve sparing of the skin, heart, and/or lungs compared to standard photon techniques. Consensus group guidelines, including those from the National Comprehensive Cancer Network (NCCN), do not support the use of proton therapy in this setting. In the majority of cases, intensity modulated radiation or three-dimensional conformal techniques with photons are able to achieve an acceptable cardiac and lung dosing in left-sided breast cancer. For these reasons, proton beam therapy is not likely to be more beneficial for treatment of the patients medical condition than standard therapy. Findings:  Three physician reviewers found proton beam therapy is not likely to be more beneficial for treatment of the patients medical condition than standard therapy.Final Result: The reviewers determined that proton beam therapy is not likely to be more beneficial for treatment of the patients medical condition than standard therapy.Credentials/Qualifications: Physician reviewers 1, 2 and 3 are board certified in radiation oncology and are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

A 52-year-old female enrollee has requested for varicose vein procedures for treatment of her varicose veins. Findings:  The physician reviewer found that this patient reports symptoms including aching, night cramps, and edema. A trial of conservative therapy has failed to improve her symptoms.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested computed tomography microwave ablation for treatment of her medical condition. Findings:  Two physician reviewers found that one of the controversial areas of cancer treatment regards the local treatment of metastatic cancer.  There is data regarding the management of oligometastases, or single or very few metastases.  Solitary liver and/or lung metastases have been the particular focus of this interest.  The most common treatment in this situation has been surgical excision, but there is data using ablative techniques in the liver.  However, most of this data has been in colorectal cancer, and not in breast cancer.  It is believed that the most appropriate use for such techniques would be in patients whose metastatic disease is limited to the liver, which is rarely the case with breast cancer.  It is not clear whether the treatment of such metastases improves survival.  In carefully selected cases, surgical resection of an isolated liver metastasis in breast cancer has been associated with long survival. An alternative to surgical excision has been microwave and other ablation techniques.  However, the overall consensus is that such techniques can be considered if there is a solitary metastasis, no evidence of metastases elsewhere, good performance status, and a long disease-free interval.  Such criteria are not demonstrated in this case, as she has multiple lesions and metastases.  Therefore, the requested computed tomography microwave ablation is not likely to be of greater benefit compared to systemic therapy.Final Result: Two 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: Reviewers 1, 2, and 3 are board certified in internal medicine with sub-specialty certification in medical oncology 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: Overturned

A 41-year-old female enrollee has requested psychiatric acute inpatient services for treatment of her mental health conditions. Findings:  The physician reviewer found that modern psychiatric practice aims to place patients in the least restrictive treatment setting.  However, placement in more restrictive settings is often clinically appropriate.  In this patients case, the hospital course has consisted of active treatment supervised by a physician.  The inpatient services are reasonably expected to improve the patients condition and are for the purpose of diagnosis.  The patient had significant medication changes on the dates indicated.  She has orders pending for neuropsychological testing and brain imaging.  The patient has remained anxious, depressed and suicidal.  On the specified date, she had impaired reality testing.  In sum, the patient remains acutely ill from the psychiatric perspective while a definitive diagnostic assessment has yet to be determined.  To release a patient from the acute setting under such circumstances would be inconsistent with the standards of good medical practice.  All told, the services at issue were and are medically necessary for the treatment of this patient.
Appeal type: Experimental/Investigational
Decision: Overturned

A 35-year-old female enrollee has requested Botox injections for treatment of her intractable migraine.  Findings:  Two physician reviewers found that this patient has continued to have daily headache despite treatment with multiple prophylactics, including lamotrigine, topiramate, amitriptyline, acupuncture, and elimination diets. She uses triptans as acute therapy.  Botox has been recommended.  Phase 3 studies of Botox for treatment of individuals with chronic migraine, not on other preventives, showed definitive statistical and clinical benefit in reduction of headache days in comparison to placebo. A responder rate of nearly 70% was seen in Botox-treated patients. This is a higher responder rate than is seen in management of episodic migraine with standard oral preventives, suggesting that Botox may be more effective than standard preventives, even in individuals who have not tried and failed standard therapies. Therefore, Botox injections are likely to be superior over all other treatment options for this patient.
Appeal type: Medical Necessity
Decision: Overturned

The representative of a 15-year-old female enrollee has requested Xolair for the treatment of the enrollees allergies. Findings:  The physician reviewer found that this patient has been followed for a diagnosis of severe allergic asthma that appears poorly controlled despite optimal medical treatment. The patient has adhered to treatment plans, and her condition has failed to respond adequately. The patients quality of life is severely impaired by her condition. There is concern regarding the episodes of life-threatening anaphylaxis, and it is noted that the patient has been prescribed an Epipen for emergencies. In light of the above, treating this patient with Xolair for her severe allergic asthma condition is appropriate and medically necessary.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for general anesthesia during dental procedure CPT 41899 for treatment of the enrollee, who needs a dental procedure for full crown of tooth #15.  Findings:  The physician reviewer found that the submitted documentation supports the medical necessity for the requested services in this clinical setting. The medical records from multiple sources affirm a degree of handicapping that has historically made routine dental care difficult or dangerous to the providers and the patient. The records show that the patient is not able to comprehend and cooperate to the level necessary to conduct the dental procedure. These sources include dental providers who have documented past attempts to treat the patient in a conventional setting with local anesthesia and oral sedation with a lack of success. The documentation also shows that the patient is not able to follow simple instructions. Moreover, the patient has acute situational anxiety due to immature cognitive functioning, a condition diagnosed by the patients medical providers. The patient is uncooperative due to certain physical or mental compromising conditions, which has been affirmed by the dental providers in past attempts at treatment.  The dental literature demonstrates a deficiency in treatment for the developmentally disabled population. As the patients condition has been well documented to preclude extensive treatment such as the requested crown on tooth #15, the requested general anesthesia during dental procedure CPT 41899 is shown to be medically necessary for treatment of the patients medical condition. 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 dentistry 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.