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

Nature of Statutory Criteria/Case Summary: This patient relates the development of a severe headache followed by total body pain. This episode has lasted 3 months. There have been hospitalizations and visits to the emergency room to deal with pain. The patient has had trials of opiates, gabapentin, muscle relaxants and Zanaflex without significant improvement. The patient has found relief with intravenous ketorolac and intravenous acetaminophen. The patient requests additional intravenous administration of these medications.These two medications are both available in oral form and the patient has not described any inability to take medications orally. The bioavailability and pharmacokinetics of these medications are not clinically significant when taken in oral form as compared to intravenous form. The requested intravenous administration is not medically reasonable or necessary.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 in anesthesiology, with subspecialty certification 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 a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a 4-year-old male has requested coverage for individual speech therapy once per week for 60 minutes for treatment of his speech delay.  Findings:  The physician reviewer found that based on review of the available records, this patient has a significant delay in speech and language articulation. The patients re-evaluation reveals that one year of speech group therapy was ineffective in improving his articulation errors. In addition, his provider noted that the patients articulation deficiency is secondary to longstanding vocal cord damage due to chronic GERD and without speech therapy his speech production will fatigue over the period of a school day. There is adequate medical literature supporting speech therapy to improve articulation in young children. Sharp and Hillenbrand reported that a comprehensive review of the literature supports the necessity and effectiveness of speech therapy in children over three years of age with articulation dysfunction. Further, Pennington and colleagues discussed the effectiveness of therapy for children with articulation defects. Although the authors concluded that there is limited evidence that speech therapy can alter the natural history of articulation abnormalities in children, it is medically necessary that this patient receive one hour of individual speech therapy per week for one year. Given the patients vocal cord damage secondary to chronic GERD, individualized therapy should be provided with focus on articulation skills. If the patient has not made substantial improvement in his Goldman-Fristoe score by the end of the therapy year, his need for speech therapy should be reassessed.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for the medication Norco.Centers for Disease Control and Prevention (CDC) guidelines for the prescribing of opioids for chronic pain state that clinicians should evaluate benefits and harms with patients within one to four weeks of starting opioid therapy for chronic pain or of dose escalation. The guidelines state that clinicians should evaluate benefits and harms of continued therapy with patients every three months or more frequently. If benefits do not outweigh harms of continued opioid therapy, clinicians should optimize other therapies and work with patients to taper opioids to lower dosages or to taper and discontinue opioids. Federation of State Medical Boards guidelines for the chronic use of opioid analgesics state that continuation, modification or termination of opioid therapy for pain is contingent upon a clinicians evaluation of evidence of the patients progress toward treatment objectives and the absence of substantial risks or adverse events, such as signs of substance use disorder and/or diversion.In this case, the submitted documentation includes Addiction Medicine records that indicate that the patient has a diagnosis of severe opioid use disorder on maintenance therapy and that he has recently acknowledged using illicit opioids. Guidelines recommend discontinuing opioid therapy in patients displaying aberrant substance use behaviors. The risks of combining opioid therapy with a patient who is concurrently demonstrating self-prescribing behaviors outweigh any potential benefit of chronic opioid therapy. Under these circumstances, the medication Norco is not medically necessary to treat 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 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

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for digital breast tomosynthesis for evaluation of the enrollees medical condition.Findings:  Two physician reviewers found that breast tomosynthesis provides advantages to radiologists interpreting mammograms.  This tomographic method often allows the reader to separate dense glandular elements from underlying mass/architectural distortion, resulting in a decrease in biopsies and callbacks and increase in detection of small cancers compared to two-dimensional imaging alone. Final Result: Two reviewers determined that the services at issue were likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: All three physician 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: Overturned

Nature of Statutory Criteria/Case Summary:  A female patient has requested reimbursement for the porcine xenograft wound treatment that was utilized during surgery. The Health Plan has denied this request and reported that the services at issue were investigational for the treatment of the enrollee, who was status post excision of malignant melanoma. A review of the record indicates that the enrollee was diagnosed with malignant melanoma of the right foot. Per the records, excision was performed. The provider noted that the graft was required due to the size of the surgical defect and tightness of the closure on this anatomical location. Per the provider, the surgical defect was partially closed, with the remainder of the defect filled with a porcine xenograft to facilitate secondary healing. The Health Plan indicates that the services at issue were investigational for the treatment of the enrollees medical condition. Therefore, the Health Plan has denied reimbursement for the services at issue. At issue is whether porcine xenograft wound treatment utilized during surgery was likely to have been more beneficial for the treatment of the patients condition than any available standard therapy.Three physician reviewers found that there is sufficient support for the services at issue in this clinical setting. This patient had a malignant melanoma on the dorum of the foot, Breslow level 0.3, which required wide excision with a 1 cm margin. The skin over the dorsum of the foot is thin and subject to radial stresses with motion.  There is not a lot of redundancy that would allow a flap to be rotated in.  The defect was closed in layers, leaving an open area that would need to granulate in and would cause contraction.  Porcine xenograft was used to cover the defect, allow healing without tension, and provide a suitable lattice for epidermal ingrowth. The other alternative would have been a skin graft, which involves a higher morbidity. Therefore, porcine xenograft wound treatment that was utilized during surgery was likely to have been more beneficial for the treatment of the patients condition than any available standard therapy.Final Result: The reviewers determined that the requested treatment is 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: Physician reviewers 1, 2 and 3 are board certified in general surgery and are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary:  An enrollee has requested Harvoni for treatment of her hepatitis C virus (HCV). Three physician reviewers found that per the American Association for the Study of Liver Diseases (AASLD) and Infectious Disease Society of America (IDSA), Successful hepatitis C treatment results in sustained virologic response (SVR), which is tantamount to virologic cure, and as such, is expected to benefit nearly all chronically infected persons. Evidence clearly supports treatment in all HCV-infected persons, except those with limited life expectancy (less than 12 months) due to non-liver-related comorbid conditions. AASLD/IDSA further state, The goal of treatment of HCV-infected persons is to reduce all-cause mortality and liver-related health adverse consequences, including end-stage liver disease and hepatocellular carcinoma, by the achievement of virologic cure as evidenced by an SVR. Therefore, based on the guidelines cited above the patient should be approved for Harvoni for the treatment of HCV. Thus, Harvoni is medically necessary for this patient.  Final Result: Three reviewers determined that the requested medication is medically necessary for treatment.  Credentials/Qualifications: One reviewer is board certified in gastroenterology and is actively practicing.  Two reviewers are board certified in internal medicine with sub-specialty certification 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 15-year-old male who has been diagnosed with septo-optic dysplasia resulting in pituitary growth hormone deficiency. He has been receiving growth hormone for more than 12 years. The patient has responded well to treatment. In September 2004, it was noted the patient was receiving Nutropin at 2.2 mg once a day and had a height of 177.2 cm. On 5/17/04, the patients IGF-1 level was 571 and IGFBP-3 was 4.4 (both high normal values). The patients parents indicate the patients mid-parental height was 69.5 inches, though there is some indication in the submitted documentation the mid-parental height may be 72 inches. At this time, the patient, by whatever criteria is used for attainment of mid-parental height, should have achieved this mark, albeit his epiphysis may not have completely closed as yet. Therefore, continued therapy for his growth is not necessary or indicated. However, the patient has been apparently documented to have a structural or developmental problem of his brain that will likely cause him to be growth hormone deficient for life. Thus, there should be consideration to providing the patient with smaller, adult maintenance amounts of rhGH hereafter to sustain his IGF-1 level within a normal adult range, for all of the other indicated reasons excluding that for his growth. Repeat stimulation testing for his growth hormone reserve would be problematic since he likely has high levels of GH antibodies that would interfere with routine laboratory measurements of the hormone in serum samples. In any event, continued growth hormone therapy is no longer medically necessary for the patients growth. Because growth hormone therapy has been requested for continued growth, I have determined that the requested therapy is not medically necessary. The Health Plans denial should be upheld. However, the Health Plan should consider providing adult maintenance doses of growth hormone because of the patients developmental brain problem.
Appeal type: Medical Necessity
Decision: Upheld

A 32-year-old male has requested a laminectomy (63012) with removal of abnormal facets and/or para interarticularis with decompression for treatment of his low back and left leg pain.  Findings:  The physician reviewer found that the patient has grade I spondylolisthesis and spondylolysis L5 status post recent L5-S1 instrumented fusion after an anterior lumbar interbody fusion (ALIF). Despite previous treatment, he continues to experience back and left lower extremity pain, which was present before the fusion. He had a recent electromyography that showed an L5 radiculopathy. A computed tomography (CT)  and MRI showed his solid fusion, without evidence of canal or foramen stenosis, and no loosening of screws. Despite both an anterior and posterior solid fusion, the provider has recommended a laminectomy for micromotion (Gill Procedure).  Based on review of the available records, this patient has a history of back pain and lumbar radiculopathy due to spondylolysis/spondylolisthesis, for which he has undergone an ALIF and more recently, a posterior instrumented fusion. The records indicate that he continues with the same symptoms. However, his most recent CT and MRI scans do not show any new or compressive findings. In addition, there is no evidence of infection, fracture, disc herniation, or canal or foramen stenosis, as required by InterQual and Milliman criteria for laminectomy.
Appeal type: Experimental/Investigational
Decision: Overturned

A 59-year-old female enrollee requested Orthovisc injections (hyaluronic acid viscosupplementation) to the right knee and Orthovisc bilateral knee injections for medical treatment of her knee pain.  Findings:  Two physician reviewers found that in this patients case, the services at issue were and are likely to be of greater benefit than other treatment options.  She has failed conservative treatment and benefitted from two prior sets of injections one year apart.  The degree of benefit reported is not consistent with a placebo effect.  Three sets of injections serve to provide comfort by virtue of cushioning and lubrication of the knees and delay the need for total knee arthroplasties.  Thus, the superior effectiveness of the series of Orthovisc injections to the right knee and future Orthovisc bilateral knee injections has been established.
Appeal type: Medical Necessity
Decision: Overturned

The patient is a 46-year-old female with a prior history of major depression. She presented to the emergency room of a hospital due to substantial increase in depression and anxiety to the point of not having slept in three nights, and feeling hopeless and helpless.  When evaluated in the emergency room, her psychiatrist noted the patient as obviously quite agitated, with jumbled up thoughts in her mind and feeling seeming inadequate. The psychiatrist stated that her negativity was almost of delusional proportion. The patient stated that she was not willing to go on with life. She had been helped significantly five years earlier when she was hospitalized after several attempts with outpatient psychiatrists. Prior to her most recent hospitalization, she had a two-month history of feeling depressed with gastric irritation and diarrhea. She began limiting her activities at work and made frequent visits to the family physician, though the symptoms continued unabated.  Interview in the emergency room revealed blunted affect and she was very concerned about medications, not wanting to try any new medication without being observed. She was diagnosed with major depression, recurrent, severe.  After admission to the inpatient unit, the nurses noted the patient as very tearful and labile, becoming very irritable and demanding at times though quickly apologetic. The patient cited worrying about many things in her life, inclusive of not getting the right medical and psychiatric care from the health care team. Due to noted past sensitivity to a variety of antidepressants, the patient was started on very low dose Celexa during her three-day hospital stay, in addition to Seroquel 50 mg per night. Fairly quickly, her sleep and anxiety improved and she was discharged within three days of admission. At issue is whether the patients acute inpatient hospitalization in August 206 was medically necessary. Review of the submitted clinical records indicates the patient was quite depressed and anxious by the point of her presentation to the emergency room and given her negative rumination (noted as nearly to the degree of delusion), admission for inpatient treatment was indicated. Given the tenor of the patients anxiety and depressive rumination, it is extremely unlikely that outpatient treatment would have fared nearly as well as the immediacy of brief, inpatient stabilization. Three days worth of inpatient treatment also does not seem a disproportionately long period in which to stabilize a patient.  All told, I find that the services at issue were medically necessary for treatment of the patients medical condition. The Health Plans denial should be overturned.
Appeal type: Experimental/Investigational
Decision: Overturned

A 27-year-old female enrollee has requested Botox injections for treatment of her piriformis syndrome.  Findings:  Two physician reviewers found that this patient has tried almost all modalities of treatments available, including conservative management with multidisciplinary pain management. Further, a diagnostic block provided relief.  The results of the study by Fishman and colleagues showed that as measured on the visual analog scale, patients injected with botulinum toxin A experienced more relief from pain than patients receiving lidocaine with steroid, and more relief than patients receiving placebo. They concluded that injection with botulinum toxin A is an effective adjunct to physical therapy in the treatment of piriformis syndrome.  Childers and colleagues concluded that visual analog pain scales data suggest that intramuscular piriformis injection with botulinum toxin type A can reduce pain to a greater extent than similar injections with saline alone. An additional study by Bennett and colleagues reported that, with imaging guidance, interventional Botox was effective for the treatment of piriformis syndrome.  All told, Botox injections are likely to be more beneficial for the treatment of this patient than standard therapies.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for methotrexate subcutaneous autoinjector. This patient presents with seropositive non-erosive rheumatoid arthritis. The patients provider has recommended a change in therapy from oral methotrexate to subcutaneous autoinjector methotrexate due to gastrointestinal side effects and a continued low level of rheumatoid disease with the oral formulation. In the medical literature, researchers reported that patients with an inadequate clinical response to oral methotrexate may benefit from switching to subcutaneous methotrexate. Bianchi and colleagues noted that subcutaneous methotrexate is more effective than oral methotrexate in both in methotrexate-naive patients with early rheumatoid arthritis and in patients who switch from oral methotrexate to subcutaneous methotrexate due to previous treatment failure, lack of efficacy, or adverse events. In this case, the patient indicated she has a fear of utilizing an open exposed needle to self-inject. Due to this fear of needles, the patient is unable to tolerate administration of intramuscular methotrexate. Per the submitted documentation, she is able to tolerate subcutaneous needle injections via autoinjector pen. She is tolerating subcutaneous injection with Enbrel. Methotrexate can be administered subcutaneously via autoinjector pens.  Due to fear and anxiety reported by the patient caused by viewing open exposed needles, her ability to administer methotrexate intramuscularly is impaired. Therefore, the requested methotrexate subcutaneous autoinjector is medically necessary for this patient. Final Result: The reviewer 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: The reviewer board certified in rheumatology 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 31-year-old female enrollee has requested acupuncture for the treatment of her temporomandibular joint (TMJ) disorder. Findings:  Three physician reviewers found that the literature does not support the notion that acupuncture was likely to be more beneficial than available standard therapies for this patients condition. There have been several randomized trials that have demonstrated a short-term beneficial effect from acupuncture for this indication. However, the size of the studies was small, and none of the studies employed a placebo arm to investigate the possible placebo effect. None of the studies looked for longer term benefits, and none of the studies compared the effectiveness of acupuncture with standard treatments for TMJ. Ernst and White concluded that the treatment may be beneficial, but that further studies are needed to demonstrate if there is in fact a beneficial effect compared with a placebo group. The Health Plans denial was medically appropriate.