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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for computer-assisted navigation during right knee replacement, such as the Mako Robotic Knee System. Medical literature concluded that when total knee arthroplasty was performed by an experienced provider, no significant difference was identified at five-year follow-up between patients who underwent computer-assisted versus manual total knee arthroplasty. Medical literature found that patient specific instrumentation for total knee arthroplasty has not reliably demonstrated improvement of postoperative limb or component alignment when compared with standard instrumentation. Researchers reported that patient specific instrumentation has not been shown to result in clinically meaningful improvement in alignment, better early patient-reported outcome measures, or reduction of operation time. This patient is being treated for right knee pain with a diagnosis of osteoarthritis. The patient has significant joint space narrowing medially and changes of the patellofemoral joint on x-rays. The patients provider has recommended total knee replacement with computer-assisted navigation, such as with the Mako Robotic System. However, there is a paucity of large volume, high quality clinical trials demonstrating that the clinical benefits of computer-assisted surgery over standard surgical approaches in total knee arthroplasty. Therefore, the requested computer-assisted navigation during right knee replacement, such as the Mako Robotic Knee System is not 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 computer-assisted navigation during right knee replacement, such as the Mako Robotic Knee System is not 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 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: 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

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for weekly in-person mental health therapy services. There is a lack of evidence of disparity in effectiveness of telehealth versus in-person therapy. Per Shore and colleagues, Telemental health in the form of interactive videoconferencing has become a critical tool in the delivery of mental health care. It has demonstrated its ability to increase access and quality of care, and in some settings to do so more effectively than treatment delivered in-person. Moreover, the authors noted that there are no absolute contraindications to patients being assessed or treated using telemental health. In this case, the Health Plan has provided the patient with adequate time to transition to an in-network provider with telehealth services. Based on the current medical literature, use of telehealth mental services is appropriate for this patient to address her symptoms of depression. Therefore, the requested weekly in-person mental health therapy services are not medically necessary for treatment of this patient.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 psychiatry and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested coverage for OvaGene gene expression testing for evaluation of the enrollees recurrent ovarian cancer.  Findings: Three physician reviewers found that the current medical evidence has not established the superior effectiveness of the services at issue.  With regards to OvaGene testing, there is insufficient evidence to supplant standard of care chemotherapy.  There is a lack of support for chemotherapy sensitivity and resistance assays in this clinical setting.  The use of these assays has not been shown to improve survival in women with ovarian cancer.  There is a lack of evidence indicating that OvaGene gene expression testing is more beneficial than standard chemotherapy choices.  Therefore, OvaGene gene expression testing was not likely to have been of greater benefit than other methods of evaluating this patient.Final Result: Three 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: All three physician reviewers are board certified in internal medicine with sub-specialty certification in medical 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

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the AmniSure test for evaluation of the enrollees pregnancy. Findings:  2/3 of the physician reviewers found that as noted by the American College of Obstetricians and Gynecologists (ACOG), the diagnosis of ROM is traditionally made based on patient history and clinical examination including a speculum evaluation of the vagina and cervix. Typically, the patient history, with its description of leakage of fluid, can be of help to rule in or rule out the diagnosis. This coupled with a sterile speculum examination to provided direct visualization to help better evaluate vaginal/cervical secretions, to evaluate the pH of any secretions, and to perform a microscopic examination for cervical ferning complete the examination. From a review of the medical records, there is little documentation of the evaluation for this patient other than some nursing notations and laboratory results. Several tests were performed including a non-stress test which demonstrated intrauterine fetal wellbeing and a swab. AmniSure testing was performed to evaluate the complaint of leakage of fluid. The nursing documentation stated that orders were to discharge home if this testing was negative. However, there is no documentation that a sterile speculum examination was performed. There is no documentation in the chart of fluid consistent with rupture of membranes. In addition, pH testing was negative and consistent with no ROM. Given these findings, the AmniSure test performed was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Final Result: 2/3 of the reviewers determined that the testing at issue was 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: Physician reviewer number one is board certified in obstetrics and gynecology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.Physician reviewer number two is board certified in obstetrics and gynecology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.Physician reviewer number three is board certified in obstetrics and gynecology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

A 64-year-old female enrollee has requested radiofrequency ablation to a tumor in the lung for treatment of her colorectal cancer with lung metastases.  Findings:  The physician reviewer found that the submitted documentation fails to establish the medical necessity for radiofrequency ablation to a tumor in the lung. Based upon the documentation provided, the patient has no contraindication to undergoing surgical resection or additional systemic chemotherapy. According to the National Comprehensive Cancer Network (NCCN) Clinical Practice Guidelines, radiofrequency ablation is not recommended as a standard treatment option for metastatic pulmonary lesions from colon cancer. Although there is some literature that suggests radiofrequency is a treatment method for a metastatic pulmonary nodule, these are preliminary results from clinical trials in which the patient is not a candidate for surgical resection of the pulmonary lesion. In this patients case, there is no evidence demonstrating that she is not an appropriate surgical candidate. Given the documentation provided and current peer-reviewed literature, there is a lack of evidence supporting the use of radiofrequency ablation in this clinical setting. As such, the medical necessity of the requested procedure has not been established.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested Rituxan infusions for treatment of her medical condition.  Findings:  The physician reviewer found that review of the submitted documentation fails to establish the medical necessity of the medication at issue. In this case, the patient has a reported history of rheumatoid arthritis. Her treating provider indicates that that the patient has tried several medications with inadequate response, however there is a lack of clinical documentation to support this. In addition, the patient reports that rituximab helped her in the past. However, there are no records to support this as well. Moreover, there is no documentation the patient has tried and failed anti-tumor necrosis factor (TNF) agents.  Based on the clinical documentation provided, Rituxan infusions were not and are not medically necessary for treatment of the patients medical condition. Final Result: The reviewer determined that the medication at issue was not and 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 and allergy and immunology with sub-certification 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: Overturned

Nature of Statutory Criteria/Case Summary:  An enrollee has requested a patent foramen ovale closure for treatment of his medical condition.  Findings:  Two physician reviewers found that the current medical evidence supports the requested services in this clinical setting.  The meta-analysis by Khan and colleagues compared patent foramen ovale closure with medical therapy trials and demonstrated a beneficial effect in the prevention of recurrent neurologic events with percutaneous patent foramen ovale closure.  Additionally, there is potentially significant long-term benefit for avoiding lifelong anticoagulation.  Therefore, the requested patent foramen ovale closure is likely to be more efficacious than other treatment options. Final Result: Two 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:  All three reviewers are board certified in internal medicine with sub-specialty certification in cardiovascular disease 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

Nature of Statutory Criteria/Case Summary: an enrollee has requested reimbursement and prospective authorization and coverage for intensive outpatient program (IOP) services.  Findings:  The physician reviewer found that the patient had participated successfully in the groups which he had attended, demonstrated useful insight, had established therapeutic alliances and was not demonstrating evidence of significant depression, suicidality, or others serious indications of deteriorating function. Treatment of addictive disorders, especially in the setting of long periods of abstinence, can be successfully accomplished in the outpatient setting. Social anxiety disorder as well as mild eating disorder are also typically treated in the outpatient setting. Final Result: The reviewer determined that the services at issue were not and 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 psychiatry and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

A 47-year-old male has requested coverage for Oramorph/MC Contin 200mg, 2 tabs, every six hours and oxycodone 5mg, 4 tabs, every four hours for treatment of the enrollees migraine headaches. Findings:  The physician reviewer found that based on review of the available records, authorization of Oramorph/MC Contin 200mg, 2 tabs, every six hours and oxycodone 5mg, 4 tabs, every four hours is not medically necessary in this patients care. Such narcotics and at the doses taken by the patient is presently indicated for severe cancer pain in patients who are opioid tolerant and with a limited life expectancy. The patient has non-malignant chronic daily headaches which will often worsen or incite as a result of opioid rebound. The current standard of care for chronic pain is treatment in a multidisciplinary practice to include physical therapy, massage therapy, cognitive behavioral therapy, and injections to help reduce pain. Opiates are considered adjunctive to this therapy under close monitoring by a certified physician (Fishman). In the medical literature, Baron and McDonald reported that high dose opiates might contribute to pain sensitization via opioid-induced hyperalgesia, decreasing patient pain threshold and potentially masking resolution of a preexisting pain condition. In this retrospective study, the majority of patients undergoing detoxification of high dose opiates for chronic pain reported a significant decrease in pain at the end of the study, further supporting the theory of opioid-induced hyperalgesia. It is in the patients best interest to wean off opioids and participate in adjunctive therapy including non-narcotic medications, physical therapy, massage therapy, with cognitive behavioral therapy, in order to address his chronic pain issues. Therefore the patients requested authorization and coverage for Morphine 800mg per day with Oxycodone 120mg per day is not indicated. Ballantyne and Mao reported that prolonged use of high dose opiates might induce tolerance, abnormal pain sensitivity, and hormonal effects. The aim of current guidelines is to protect patients from the adverse effects of opioid therapy. All told, the requested medications are not medically necessary for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for morphine 15 mg, four times per day for treatment of his chronic pain. Findings:  The physician reviewer found that the Centers for Disease and Control and Prevention (CDC) guidelines suggest that chronic opiate maintenance is associated with elevated risks. The CDC also indicate that a consultation with pain management is necessary before tapering the patient. The general approach is to taper 10% per week while replacing the opiate with another non-narcotic pain therapy. The patient was treated with morphine 15 mg with a total dose of 60 mg. His morphine prescription has been cut in half. A 50% reduction is not a gradual taper. He is currently on a sub therapeutic dose of gabapentin. The clinical documentation does not include a plan for changing the dose of gabapentin or adding any other analgesics. There is also no treatment plan documented for adjunctive medications to deal with withdrawal symptoms. In addition, there is no treatment plan documented for psychosocial support as recommended by the CDC. The patient should be tapered off of morphine but this needs to be done slowly and carefully. A 50% reduction is not the standard of care. Final Result: The reviewers determined that a portion of the requested medication is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be partially overturned. 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: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Zepatier 50-100 mg, one per day for 12 weeks for treatment of the enrollees hepatitis C. Findings:  The physician reviewer found that according to the most recent joint guidelines issued by the American Association for the Study of Liver Diseases and the Infectious Diseases Society of America, all patients with chronic hepatitis C should be treated (except those with limited life expectancy due to non-liver-related conditions), regardless of fibrosis stage.  The guidelines recommend that treatment-naive, genotype 1a patients should be treated with regimens including Zepatier for 12 weeks when NS5A resistance is not found. These guideline recommendations are based on clinical trial results showing a 99% cure rate when NS5A resistance is absent. However, Zepatier is significantly less effective when NS5A resistance is present, and a different regimen is needed (Zepatier and ribavirin for 16 weeks).  In this patients case, NS5A resistance testing results were not provided.  For these reasons, although hepatitis C treatment is needed, Zepatier 50-100 mg, one per day for 12 weeks is not medically indicated for the treatment of this patient. Final Result: The reviewer determined that the requested medication regimen 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: Medical Necessity
Decision: Overturned

The parent of a 10-year-old male enrollee has requested applied behavioral analysis (ABA) therapy (40 hours per week of ABA therapy and up to 20 hours per month of program supervision, progress monitoring and data analysis) for treatment of the enrollees autism.  Findings:  The physician reviewer found that the medical literature strongly supports the treatment of autism with ABA therapy. Applied behavior analysis has been shown to be effective in treating behaviors associated with autism spectrum disorder (Granpeesheh, et al.). Treatments based on operant principles of learning are more effective for reducing maladaptive behaviors than alternative treatments. Additional studies have shown that ABA methods continue to result in positive outcomes in individuals with autism and intellectual disability (Grey, et al.). Evidence-based studies also note improvement of function in older children with autism spectrum disorders using intense ABA interventions (Grey, et al). The goals for older children often are to identify and remediate particular deficits. Older individuals with autism may need intensive and comprehensive treatment particularly if they present with dangerous behaviors (BACB 2012). The evidence suggests treatment intensity can play an important role and ABA therapy must be implemented at a sufficient intensity in order to provide optimal outcomes. Granpeesheh and colleagues studied 379 children with autism who were receiving behavioral intervention services and found that increases in treatment intensity led to continued increases in treatment gain. They noted the rate of learning was much higher for those children receiving relatively high intensity treatment of at least 40 hours per week (Granpeesheh, et al.). For individuals over 3 years of age, 30-40 hours per week of ABA behavioral therapy is recommended (BACB 2012). Furthermore, a specific tiered services delivery of ABA therapy with carefully trained and well-supervised behavioral techniques is common practice in ABA treatments (BACB 2012). This patient presents with significant maladaptive behaviors including self-injurious and aggressive behaviors, poor adaptive skills, and stereotypic and perserverative behaviors and therefore ABA therapy is medically necessary. In conclusion, it is medically necessary that this patient receive 40 hours per week of ABA therapy and up to 20 hours per month of program supervision, progress monitoring and data analysis.