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

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for radiofrequency ablation for treatment of the enrollees neck pain. Findings:  Two physician reviewers found that current evidence based medical guidelines state that cervical facet joint radiofrequency neurotomy has produced conflicting evidence as to its efficacy. Criteria for the use of cervical facet radiofrequency neurotomy include a diagnosis of facet joint pain using diagnostic blocks, documented improvement in pain scores and function with diagnostic blocks, no more than two joint levels at one time, and evidence of a formal plan of rehabilitation in addition to facet joint therapy. Guidelines limit facet joint therapy to patients with non-radicular pain. This patient presents with reported complaints of neck pain and stiffness. There was documentation of positive medial branch blocks. However, there was no record of a cervical spine and neurologic examinations confirming a diagnosis of facet mediated pain. Given the significant findings consistent with a diagnosis of radiculopathy, proceeding with radiofrequency ablation is not supported by current evidence based medical guidelines and peer-reviewed literature. Final Result: The reviewers determined that the requested service 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. Credentials/Qualifications: Physician reviewer 1 and 3 are board certified in orthopedic surgery and are actively practicing. Physician reviewer 2 is board certified in anesthesiology with sub-specialty certification in pain medicine and is actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

A forty-six year-old female with a history of multiple neck fusions with resultant cervical pain and possible fibromyalgia is requesting authorization for Botox therapy.Reviewers Findings:  The reviewing physician found that no Class I data exists to support the role of Botox injections for the treatment of chronic neck pain. In addition, there is no evidence to support Botox as effective in the treatment of fibromyalgia.  The reviewing physician found that the Health Plan denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld

A 64-year-old male enrollee has requested proton beam therapy for the treatment of his prostate cancer. Findings:  The physician reviewer found that the use of proton beam therapy is an accepted radiation technology that has proven efficacy and tolerability. Certain conditions, such as base of skull chordomas and chondrosarcomas, and pediatric central nervous system malignancies are best treated with proton therapy, due to the sharp dose fall off, allowing high dose delivery to the tumor, while relatively sparing the neighboring normal tissue. Outside of these specific settings, the use of proton beam therapy remains the subject of debate. While proton beam therapy is a safe and effective treatment modality for prostate cancer, the evidence does not demonstrate that it is any more beneficial than intensity modulated radiation therapy (IMRT), which is standard radiation therapy. In fact, with proton therapy for prostate cancer, often only two lateral beams are used, so as to eliminate beams entering through the bladder or rectum. IMRT can be delivered with innumerable beams (often seven to nine), which allows a similarly conformal plan to proton beam therapy. The use of daily ultrasound (image-guided radiation therapy) can improve normal tissue sparing with IMRT. Slater and colleagues in 2004 concluded, `Conformal proton radiation therapy at the reported dose levels yielded disease-free survival rates comparable with other forms of local therapy, and with minimal morbidity. Dose-escalation strategies are being implemented to further improve long-term results.` Furthermore, most reports, including a systemic review (Lodge and colleagues) conclude that patients treated with proton therapy fare comparably to patients treated with photon radiation (i.e. IMRT). There is also the possibility that proton beam therapy is disadvantageous. The depth of proton delivery is more susceptible to changes in tissue density (such as changes of air in the rectum).
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Stelara 45 mg/0.5 mL subcutaneous solution prefilled syringe. The patient has tried and failed other therapies. The patients provider reports that due to her childbearing potential, the use of methotrexate, acitretin and biologics are contraindicated. However, the provider is requesting Stelara, which is a biologic. In addition, Stelara is not preferred in pregnancy category over the preferred agents. As there is no true contraindication or reason provided as why the preferred agents cannot be used in the patient for treatment of chronic plaque psoriasis, the requested Stelara 45 mg/0.5 mL subcutaneous solution prefilled syringe is not supported as medically necessary for treatment of this 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 dermatology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld

A 32-year-old female enrollee requested authorization and coverage of intradiscal electrothermal therapy. The Health Plan denied the request indicating that the requested procedure is considered investigational for treatment of the enrollees back pain.Three physician reviewers performed an experimental/investigational Independent Medical Review. All three physician reviewers concluded that the requested therapy 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 therapy 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: Medical Necessity
Decision: Overturned

A 24-year-old female enrollee has requested an off-the-shelf functional anterior cruciate ligament (ACL) knee brace (L1845)for treatment of her post ACL reconstruction and partial lateral meniscectomy on the left knee.  Findings:  The physician reviewer found that  in the article published by McDevitt and colleagues involving 100 volunteers randomized into braced and un-braced group, the authors found  no difference in clinical outcomes. However, patients with chondral injuries or significant meniscal tears were excluded from this study. This specific patient had a complex tear of the lateral meniscus and chondromalacic changes in the lateral compartment of the knee. The study by Sterett and colleagues indicates that functional bracing is likely to be beneficial for this patient.. This study followed 820 skiers who had experienced anterior cruciate ligament injuries and reconstruction. In this study, 257 of the skiers used functional bracing during skiing, and 563 skiers did not. There was a demonstrated statistically significant increase in incidence of subsequent knee injury in non-braced skiers. Sterett and colleagues additionally recommended functional bracing for individuals with anterior ligament reconstruction. Given the presence of complex lateral meniscal tear and chondral changes which are likely to benefit from further protection, the requested off-the-shelf functional anterior cruciate ligament (ACL) knee brace (L1845) is medically indicated for this patient. The presence of a medial collateral ligament tear and 3+ Lachmans test at surgery further contribute to the indications for postoperative functional bracing during rehabilitation.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for   advanced lipoprotein testing (CPT 83704, 82172, and 83695). Based on current American College of Cardiology (ACC) and American Heart Association (AHA) guidelines, the target of lipid lowering is low density lipoprotein (LDL) cholesterol levels (Grundy, et al.). Currently, testing for lipoprotein fractions are not considered to be within the standard of care. Decisions regarding statin therapy are based on LDL levels and atherosclerotic cardiovascular disease risk. In this case, the patients cardiovascular risk factors were minimal, based on the documentation provided for review, and her LDL cholesterol level is not significantly elevated, at 79 mg/dL. Lipoprotein subfraction measurement is not more beneficial than standard lipid measurements in this case. Therefore, the advanced lipoprotein testing (CPT 83704, 82172, and 83695) was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Findings:  Three of the three physician reviewers found the advanced lipoprotein testing (CPT 83704, 82172, and 83695) was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.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: Physician reviewer 1 is board certified in internal medicine with subspecialty certifications in cardiovascular disease and cardiac electrophysiology and is actively practicing. Physician reviewer 2 is board certified in internal medicine with subspecialty certification in cardiovascular disease and is actively practicing. Physician reviewer 3 is board certified in internal medicine with subspecialty certifications in cardiovascular disease and cardiac electrophysiology 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

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for acupuncture services. Findings:  The physician reviewer found that a study opined acupuncture provided highly significant and clinically relevant improvements in treating patients with chronic headaches. In addition, the study noted acupuncture could be a valuable non-pharmacological tool for patients with frequent episodic or chronic tension-type headaches. Regarding this patients chronic pain, another study noted that acupuncture is effective for the treatment of chronic pain. In reviewing the records available, it does not appear that the patient has undergone an acupuncture trial. Given the patients continued symptoms, an acupuncture trial is reasonable and supported by the peer-reviewed medical literature. In order to produce pain relief and functional improvement, six treatment sessions should be provided. Additional care should be based on functional improvements obtained with the acupuncture trial. Given this support, acupuncture services are medically necessary for treatment of this patients chronic headaches. 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 oriental 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: Overturned

Findings:  The physician reviewer found that The patient has requested reimbursement for transthoracic echocardiography. The available documentation supports that this patient presented with symptoms of left-sided chest pain, which worsened with deep inspiration and lying flat, as well as dyspnea. The patients symptoms reportedly started after the patient received COVID-19 vaccines. The patient underwent evaluation with a transthoracic echocardiography. Per the American College of Cardiology (ACC) appropriate use criteria for transthoracic echocardiography, the test is appropriate for patients with symptoms suggestive of  heart disease or dyspnea of uncertain cause (Doherty, et al.). In this case, the patients chest pain may have been due to pericarditis as it was increased with lying flat. The patient also reported associated dyspnea and the provider noted concern for cardiac disease. In this clinical setting, the patient meets the ACC criteria for transthoracic echocardiography. Myocarditis and pericarditis were also considerations, as the patient experienced symptom onset after receiving COVID-19 vaccines (Shay, et al.). Given these findings, the transthoracic echocardiography was medically necessary for evaluation of this patient. Final Result: The reviewer determined that the services at issue were medically necessary for evaluation of the patients medical condition. Therefore, the Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Upheld

A 29-year-old female enrollee has requested chemotherapy (Abraxane) for treatment of her lung cancer.  Findings:  The physician reviewer found that this case of NSCLC is complicated by the presence of pregnancy and the advanced nature of the disease. The patients initial treatment with carboplatin and paclitaxel showed a significant response. The patients imaging studies showed that she had an incomplete response that required more chemotherapy. At that point, she was switched to pemetrexed. This change in therapy is consistent with published medical literature showing an improvement in progression free survival with pemetrexed maintenance (Paz-Ares, et al; Ciuleanu, et al). Subsequently, the patient was switched to Abraxane. The clinic notes document neuropathy, so the continued use of carboplatin or paclitaxel would not have been advisable. A recent phase III study did report a better overall response rate with Abraxane compared with solvent paclitaxel in combination with carboplatin in metastatic NSCLC (Socinski, et al). The study also resulted in less neuropathy in the Abraxane treatment group compared with solvent paclitaxel. However, there is inadequate evidence for Abraxane monotherapy after pemetrexed maintenance for this patient.
Appeal type: Medical Necessity
Decision: Upheld

A 51-year-old male enrollee has requested inpatient hospitalization psychiatric care with emphasis on dialectical behavior therapy for the treatment of his bipolar II and borderline personality disorder. Findings:  The physician reviewer found that although dialectical behavior therapy is a valid treatment modality, the most important issue here is the patient's imminent suicidal risk. Dialectical behavior therapy is not very effective in patients who are actively suicidal. In fact, dialectical behavioral therapy is usually discontinued in patients who become suicidal. The patient may be an appropriate candidate for dialectical behavior therapy once it is established that he is no longer actively suicidal and is at low risk of harm to self. However, such therapy can be provided in an intensive outpatient program, partial hospital program or in individual therapy. It is not necessary for dialectical behavioral therapy to be provided at an acute inpatient psychiatric unit.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for acute inpatient psychiatric hospitalization services provided for treatment of the enrollees major depressive disorder with suicidal ideation. Findings:  The physician reviewer found that although presenting to nursing with shoestrings around his neck, the patient was not truly suicidal as per his admission to his provider. He endorsed the fact that the act was attention seeking in nature and without intent. He denied homicidal ideation. Although he showed inappropriate sexual acting out behavior, this type of behavior does not warrant inpatient level of care. He was not psychotic or manic and he was medically stable. He had improved and no new problems had arisen. He tolerated his medications and was compliant with treatment. He had stabilized and no longer required 24-hour supervision at the inpatient level of care. He could have been treated in an ambulatory setting with psychotherapy and medication management in an intensive outpatient program (IOP). Thus, the acute inpatient psychiatric hospitalization services provided were not medically necessary for treatment of this patients medical condition. Final Result: The reviewer determined that the services at issue were 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 with sub-specialty certification in addiction 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: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Dupixent pen 300 mg/2 mL. The U.S. Food and Drug Administration (FDA) approves the use of Dupixent, an interleukin-4 receptor alpha antagonist, for the treatment of adult patients with moderate-to-severe atopic dermatitis whose disease is not adequately controlled with topical prescription therapies. Boguniewicz and colleagues note that moderate-to-severe atopic dermatitis is defined as involving over 10% of body surface area (BSA) and/or involvement of highly visible areas or those that are important for function such as the hands, neck, face, and genitals, and significantly impaired quality of life. Seigels and colleagues note that the data supporting the safety and efficacy of the use of dupilumab (brand name Dupixent) in moderate-to-severe atopic dermatitis is substantial. Systemic cyclosporine is contraindicated in those with hypertension and kidney impairment, is immunosuppressive and associated with increased infection risk, and cannot be used long term due to these toxicities. In this case, the patient has hypertension and thus cyclosporine is not indicated. The use of methotrexate, an immunosuppressive, has been associated with increased hospitalization if a patient is infected with COVID-19, and immunosuppressives such as methotrexate, mycophenolate, azathioprine, and cyclosporine may reduce the response to vaccination. In this case, the patient has moderate-severe atopic dermatitis with 20% BSA involvement and has failed light treatment, Protopic, fluocinonide, ketoconazole, and triamcinolone acetonide. In this clinical setting, the use of the requested medication is medically indicated. Therefore, Dupixent 300 mg/2 mL pen is medically necessary for the treatment of 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 is board certified in dermatology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for cochlear implants. Findings:  Three physician reviewers found that cochlear implantation is a recognized technology to improve patients perception of sound after development of hearing loss or, in the pediatric population, of establishment of hearing perception in children who were born with congenital hearing loss. However, the use of this technology is beneficial in patients with bilateral hearing loss to allow the patient a perception of hearing. While its use in patients with single sided deafness is growing, there are few randomized controlled studies in the literature to establish substantial outcomes of their utilization.  The patient did sustain a clinical impairment of her hearing with severe deafness on the left ear documented with several hearing tests and VNG as well as a normal MRI scan.  Those tests also demonstrated relatively normal hearing in the contralateral right ear, which remained non-affected by the initial sudden event. The patient has relatively normal hearing on the contralateral ear. Currently, although some of the medical literature supports cochlear implantation for patients who have single sided deafness, there is an absence of peer reviewed medical literature supporting data.  For these reasons, the requested cochlear implant is not likely to have a greater benefit over standard modalities for treatment of this patient. Final Result: 2 of 3 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 otolaryngology 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

A 51-year-old female enrollee has requested referral to a pain management specialist for treatment of her pain. Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested service.  There is lack of documentation of the patients response to conservative therapy, which may be appropriately ordered and assessed by the primary care physician.  Specifically, conservative therapy includes physical therapy and nonsteroidal anti-inflammatory medications.  There is also lack of physical examination and diagnostic imaging to corroborate the patients condition and the need for a referral.  The current medical evidence does not support the requested service in this clinical setting.  All told, the requested referral to a pain management specialist is not medically indicated for the treatment of this patient.