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

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement and prospective authorization and coverage for continued skilled nursing facility (SNF) services. Pelvic fractures, including pubic ramus fractures, are associated with significant complications . Management is generally non-operative, with pain control and ambulation as tolerated. The records provided for review demonstrate that this patient sustained an inferior pubic ramus fracture that was managed non-operatively with weight bearing allowed as tolerated. Treatment in the SNF has included physical therapy. However, the records document that she has plateaued at ambulating with contact guard assistance. There is no report of ongoing progress with self-care. Based on the current medical literature, the patient can continue her rehabilitation in the community. Although she has multiple chronic medical conditions, the patient does not require nursing or medical treatment in an inpatient setting. Therefore, continued SNF services were not and are not medically necessary for treatment of this patient.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 physical medicine and rehabilitation 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 42-year-old male enrollee has requested reimbursement for testing provided (CPT codes 83090, 83698 and 86141) for evaluation of the enrollees hyperlipidemia. Findings:  Two physician reviewers found that the patient has a history of diabetes, hypertension, prior smoking, gastroesophageal reflux disease, Cushings syndrome, hyperlipidemia, hypersomnia, and hypotestosteronism.  An echocardiogram revealed normal ventricular systolic function, and a stress echocardiogram two days later demonstrated no provocable ischemia.  Laboratory testing was performed two days prior.  The Health Plan has denied reimbursement.  This patient had significant coronary risk, but no documented coronary artery disease, no left ventricular dysfunction on echocardiography, and no provocable ischemia on stress testing.  The current guidelines do not recommend routine performance of specialized tests in the context of assessing coronary risk, including high sensitivity C-reactive protein, lipoprotein-associated phospholipase A2, and homocysteine.  Treatment changes based on the results of screening with these specialized tests have not been shown to improve cardiac outcome incremental to that achievable by treatment based on standard risk factor profiling and basic lipid analysis.  Randomized trials evaluating treatment with therapy available to reduce homocysteine levels have not shown significant outcome benefits.  Although elevated lipoprotein-associated phospholipase A2 may be considered an independent or emerging risk marker for coronary disease, there is a lack of controlled trials that demonstrate outcome benefits as a result of treating routinely obtained elevated lipoprotein-associated phospholipase A2 levels.  All told, CPT codes 83090 (homocysteine), 83698 (lipoprotein-associated phospholipase A2), and 86141 (C-reactive protein, high sensitivity) were not likely to have been of greater benefit than other methods of evaluating this patient.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Botox injection.The medical literature does not support that the requested service is medically necessary. The pathophysiology of myofascial pain remains uncertain, and multiple neurologic, myogenous, and psychological theories have been postulated. Although there is strong anecdotal evidence supporting the use of Botox to treat myofascial pain, many clinical trials have fallen short of producing conclusive results and further studies are needed to establish protocols for use. Studies noted that there are conflicting reports in the literature regarding the efficacy, safety, and predictors of therapeutic response to Botulinum toxin type A (BoT-A) therapy for management of refractory masticatory muscle pain. They performed a retrospective chart review involving 116 participants and concluded that BoT-A therapy provides significant relief for approximately one third of patients with refractory masticatory muscle pain. In this case, the patient reports pain, numbness, and a burning sensation on the right side of the face, and she has been given a diagnosis of sprain of the temporomandibular joint (TMJ) on the right side. As noted above, while there is strong anecdotal evidence supporting the use of Botox to treat myofascial pain, many clinical trials have fallen short of producing conclusive results and further studies are needed to establish protocols for use. Under these circumstances, the requested Botox injection is not medically necessary to treat the patients medical condition.Final Result: The reviewer determined that the requested services are not medically necessary to treat the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is board certified in oral and maxillofacial 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: Upheld

A 56-year-old female enrollee has requested the Real-Time Remote Heart Monitor for an evaluation of her palpitations. Findings:  Three physician reviewers found that the relevant scientific literature reveals no benefit to prolonged (30-day) event monitors over conventional Holter monitors in this clinical setting. With presumed normal left ventricle function, the risk of significant arrhythmia would be remote. The patients overall symptoms were non-specific and did not necessitate the use of the equipment at issue. In this clinical circumstance, serial Holter monitoring would have been sufficient for detecting abnormalities. Continuous real-time remote cardiac monitoring is not indicated as an initial strategy in this setting as it does not provide superior benefit over conventional monitoring. The use of a Real-Time Remote Heart Monitor was not likely to be a more efficacious method of evaluation in this patients case.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a four-year-old male enrollee has requested speech therapy for treatment of the enrollees mixed receptive and expressive language disorder. Findings:  The physician reviewer found that speech therapy is indicated with any delay greater than 25% (Law, et al. and Feldman & Messick). An extensive review of the literature including a meta-analysis by Law, et al. noted the positive effect of speech and language therapy interventions for children with expressive phonological and expressive vocabulary difficulty. Feldman, et al. notes that treatment for language disorders is predicated primarily on the childs language profile and level of communication skills. Children who participate in speech-language treatment show better improvement then those children who receive no treatment (Feldman & Messick). This patient continues to display expressive and receptive language impairments with decreased acquisition of language skills. Therefore, speech therapy is medically necessary for this patient.
Appeal type: Medical Necessity
Decision: Overturned

A 30-year-old female enrollee has requested nose surgery (rhinoplasty) for treatment of her nasal septal perforation.  Findings:  The physician reviewer found that based on review of the available records, this patients abnormal structure of the body is the perforated septum that was caused by trauma, specifically steroid nasal sprays. The provider has recommended surgical intervention consisting of open rhinoplasty. This approach is frequently utilized to expose the nasal septum and allow insertion of the graft to close the perforation. It is used as a reconstructive technique and not to alter the appearance of the nose (Watson, et al). The use of alloderm as a grafting material is a standard material for flap reinforcement and perforation closure (Ayshford, et al). All told, the requested surgery is medically necessary as planned by the treating provider and should provide this patient with relief from her symptomatic condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Euflexxa injections. The Health Plan has denied this request indicating that the requested treatment is not medically necessary for treatment of the enrollees osteoarthritis. A review of the records indicates that the enrollee has been diagnosed with bilateral knee osteoarthritis with associated catching, locking, and effusion. The physical examination revealed mild knee effusion, lateral joint line tenderness, and range of motion 0-130 degrees bilaterally. Radiographic imaging was documented to reveal significant findings. The diagnoses included bilateral primary osteoarthritis of the knees. Prior conservative treatment had been tried for more than 6 months, including corticosteroid injections, non-steroidal anti-inflammatory drugs (NSAIDs), and Tylenol with no relief. The treatment plan documented a discussion of conservative treatment and recommended bilateral Euflexxa injections. Evidence based medical peer-reviewed literature supports the use of viscosupplementation injections for the treatment of pain in patients with osteoarthritis of the knee. Viscosupplementation has been found to be safe and effective and allow for delay of total knee replacement, and more effective than corticosteroid injections. In this case, the patient has been diagnosed with bilateral knee osteoarthritis. The patients subjective complaints included persistent bilateral knee pain with intermittent catching. The clinical examination findings are documented and consistent with radiographic and imaging evidence of tricompartmental bilateral knee osteoarthritis. The patient has reportedly failed to respond to other conservative treatment, including NSAIDs, analgesics and corticosteroid injections. Therefore, the requested Euflexxa injections for both knees would be considered medically necessary. 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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Inspire upper airway stimulation system (hypoglossal nerve stimulation). The records provided for review document that this patient has obstructive sleep apnea (OSA) without evidence of nasal obstruction. The patients drug induced sleep endoscopy (DISE) showed no concentric collapse at velum and primarily anterior posterior collapse. The provider noted that the patient has an apnea/hypopnea index (AHI) of 36 events per hour. The patient has not been able to tolerate treatment with a continuous positive airway pressure (CPAP) device. The Inspire Upper Airway Stimulation System is U.S. Food and Drug Administration (FDA) approved for the treatment of OSA. Based on these findings, the patient is a candidate for Inspire device given intolerance to CPAP, no concentric collapse at velum, no central apnea, and BMI and AHI within FDA criteria. Therefore, the requested Inspire Upper Airway Stimulation System (hypoglossal nerve stimulation) is 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 upper airway stimulation system (hypoglossal nerve stimulation) is 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 likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: Physician reviewer 1 is board certified in otolaryngology and is actively practicing. Physician reviewer 2 is board certified in internal medicine with subspecialty certification in sleep medicine and is actively practicing. Physician reviewer 3 is board certified in otolaryngology with subspecialty certification in sleep 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: Overturned

The enrollee is requesting reimbursement for fertility preservation. The enrollee has breast cancer. Her treatment plan includes 12 weeks of chemotherapy followed by a double mastectomy. Her physician recommended that she freeze her eggs or embryos to protect her future fertility. She underwent fertility preservation. Literature indicates a professional society recommends that, as part of the education and consent process prior to cancer therapy, health care providers address the possibility of infertility with individuals treated during their reproductive years, or with parents or guardians of children, and be prepared to discuss fertility preservation options. Literature indicates sperm and embryo preservation, as well as egg preservation, are considered standard practice and are widely available. This enrollee is being treated for breast cancer and is at risk of developing ovarian failure. The standard of care is to proceed with egg or embryo cryopreservation.Final Result: The reviewer determined that the requested service is medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The physician reviewer is board certified in obstetrics and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or similar medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned

An enrollee has requested authorization and coverage for a spinal cord stimulator trial. There are is a lack of large randomized controlled studies establishing the efficacy of spinal and dorsal root ganglion stimulation for type 2 trigeminal neuralgia. However, there are studies that have demonstrated that spinal cord stimulation allows patients with trigeminal neuralgia to experience pain reduction and improved quality of life. Based on the analysis of this patients treatment history with extensive oral neuromodulators, multiple surgical interventions, and gamma surgery ablation, she has a case of a refractory trigeminal neuralgia. A trial with spinal cord stimulation is appropriate for refractory trigeminal neuralgia and can make a substantial difference in terms of chronic pain reduction. A retrospective case series found that 75% of implanted patients continued to derive benefit for up to 10 years after implantation. A recent retrospective single-center series of 12 patients with trigeminal neuropathy were treated with upper cervical spinal cord stimulation reported an average of 57.1% pain reduction with this treatment modality. All told, a spinal cord stimulator trial is 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 spinal cord stimulator trial is 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 likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: Physician reviewers 1, 2, and 3 are board certified in neurology and are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

The patient is a 54-year-old woman with abdominal pain as a result of multiple conditions including irritable bowel syndrome, partial small bowel obstruction secondary to radiation for Hodgkins disease, and biliary dyskinesia. The patient reports Zelnorm has been effective for treatment of her abdominal symptoms. She has requested authorization and coverage for a longer duration of Zelnorm. The Health Plan has denied the request on the basis that continued use of Zelnorm is not medically indicated. Upon review of the information provided it does not appear the patient has undergone a complete gastrointestinal workup. The patient has a complex medical history and the submitted information does not demonstrate the exact etiology of the patients abdominal symptoms. Additional diagnostic testing including an EGD and/or colonoscopy is needed for further characterization of the patients pain and to determine optimal therapy. Thus, the gastroenterology evaluation and testing recommended by the Health Plan is medically reasonable and appropriate. Continued use of Zelnorm is not medically indicated at this time. Based upon the information set forth above, I have determined that the requested medication is not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned

A 58-year-old male enrollee has requested Provigil 100mg for treatment of his multisystem atrophy.  Findings:  The physician reviewer found that provigil has been recommended to manage this patients fatigue.  Fatigue can be a disabling symptom in many neurologic disorders, and can be very difficult to treat, with a lack of therapies that are well-proven or uniformly effective.  Per the current medical literature, a significant improvement in excessive daytime sleepiness was seen in a small trial of patients with Parkinsons disease.  In a randomized, placebo-controlled trial of patients with Parkinsons disease, Adler and colleagues noted that modafinil was very well-tolerated and was associated with few side effects.  This patient has tried and failed other medications used for fatigue, without benefit.  The current medical evidence supports the requested medication in this clinical situation. All told, Provigil 100mg is medically indicated for the treatment of this patient.
Appeal type: Experimental/Investigational
Decision: Upheld

A 33-year-old female enrollee has requested for stereotactic radiosurgery for treatment of her C2 vertebral body metastasis, new right cerebellar and L5 metastasis.   Findings:  Two physician reviewers found that the only service in question now is treatment of L5. Conventional radiation is customary treatment for this lesion, and it is not followed by severe complications. There is no medical indication to treat this patients current condition with the requested radiosurgery.
Appeal type: Medical Necessity
Decision: Upheld

The representative of a 59-year-old male has requested Selective Internal Radiation Therapy (SIRT) for treatment of liver metastases from colon cancer.  Findings:  The physician reviewer found that this patient has had a partial hepatectomy and has exhausted chemotherapy choices. The radiofrequency approach was also attempted for hepatic tumor ablation. A stent was placed to relieve his biliary obstruction, and this was also unsuccessful. His options appear to have been nearly exhausted. The hepatic metastases are growing, and he now has an osseous metastasis in the right femur. His bilirubin and creatinine are increasing. A request has been made for SIRT. SIRT is not indicated in patients with advancing disease. It appears that this patient does not qualify for this therapy.
Appeal type: Medical Necessity
Decision: Upheld

A 61-year-old male enrollee has requested Lipitor 20mg for the treatment of his hyperlipidemia. Findings:  The physician reviewer found that there is no documentation of side effects with any formulary statin, and there is no treatment failure. Current National Cholesterol Education Program guidelines recommend an LDL of less than 160mg/dl with only one other risk factor (hypertension, in this case). A more aggressive goal may be an LDL of less than 130mg/dl. In either case, this goal is achieved on the current Pravastatin dose. There is no evidence to support improved outcomes by lowering the LDL further than noted above in this setting of primary prevention with only one other cardiac risk factor.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Percocet (acetaminophen and oxycodone) 15 mg for treatment of the enrollees pain. Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested medication. It is unusual to require narcotics three months after bunionectomy surgery. Self-escalation of dosage as well as a past history of alcohol abuse are red flags in prescribing opioids. The lack of urine toxicology screens or an ongoing opioid maintenance agreement are also of concern.  The clinical practice guideline does not support ongoing opiate prescribing in this clinical setting.  All told, Percocet (acetaminophen and oxycodone) 15 mg is not medically necessary for the treatment of this patient. 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 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.