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

Physician 1: The patient is a 62-year-old female with a long history of back pain. She has attempted physical therapy and medications without sustained relief. The medications caused her to have side effects. In November 2004, the patient received an epidural injection.  The Health Plan has denied coverage for the procedures at issue on the basis they are considered experimental.Though the patients chronic pain warranted the epidural injection she received, the other procedures performed were not indicated or warranted. The procedure codes are considered experimental and were not required or indicated. Accordingly, I have determined that the procedures at issue were 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.Physician 2: The patient is a 62-year-old female with chronic low back pain. The patient failed conservative treatment options and continued to have severe low back pain. In November 2004, the patient received an epidural injection. At issue is whether these procedures were likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. I agree with the Health Plans decision to deny coverage for the procedures at issue. The specific interventions at issue were not likely to be more beneficial than standard treatment options. Adhesion lysis is generally considered investigational. None of the procedure codes at issue were within the standard of care or medically warranted. Therefore, I have determined that the procedures at issue were not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Plans denial should be upheld.Physician 3: The patient is a 62-year-old female with chronic low back pain who underwent an epidural injection in November 2004. At issue is whether the procedure codes at issue were likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Plans denial should be upheld. There is no evidence the procedures at issue were medically warranted for treatment of the patients chronic pain. While an epidural was appropriate, the procedures at issue are either unproven or are not indicated for patients such as this patient. Therefore, I have determined that the procedures at issue were not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Elidel 1% cream for treatment of the enrollees seborrheic dermatitis. Findings:  The physician reviewer found that the submitted documentation supports the medical necessity of the requested medication. The patient has tried and failed therapy with ketoconazole cream and desonide cream.  Thus, he has already tried and failed therapy with a topical steroid and a topical antifungal cream, and he has involvement of the face.  Long-term use of topical steroids on thin skin, such as on the face, can lead to skin atrophy and other side effects including telangiectasias.  In this clinical setting, Elidel 1% cream is likely to be safe and effective in the long-term. Therefore, Elidel 1% cream 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

A 37-year-old female has requested transcranial magnetic stimulation (TMS) therapy for treatment of her mental health condition.  Findings:  Two physician reviewers found that the patient is currently diagnosed with bipolar II, depressed type. She has not benefitted from prior psychopharmacological medications. The provider states that she has been treated with Depakote, Risperdal, Remeron, Wellbutrin, Klonopin, Lexapro, Prozac, Effexor, Zoloft, Seroquel, lithium, and Abilify, as well as Paxil, amitriptyline, Trazodone, and Zyprexa. The provider reports that augmentation strategies caused side effects including involuntary orofacial movements, severe urinary retention, and emotional lability. There is no mention of intensive psychotherapy in her treatment regimen. The patients current symptoms are reported to include chronic suicidal ideation, chronic urges to cut herself and bang her head against walls, low mood, hopelessness, low appetite, numbness and experiencing food as tasteless. Per the provider, the patient is a candidate for treatment with transcranial magnetic stimulation (TMS) as a safe and effective treatment that improves depressive symptoms in patients who have failed to respond to medical therapy. The Health Plan indicates that the requested therapy is considered investigational for the treatment of depression, schizophrenia, and migraine headaches. In the peer reviewed medical literature, TMS is supported and FDA approved as a specific treatment for severe depression. Additionally, the American Psychiatric Association (APA) has now included TMS in their 2010 guidelines as an appropriate acute phase treatment option for patients who do not respond adequately to medication therapy. Although this patient has some symptoms of depression, her formal diagnosis given by her attending psychiatrist is bipolar II, depressed type. While some research is currently being conducted regarding the efficacy of TMS in patients with bipolar disorder, there is no FDA approval for using TMS for treatment of patients with this diagnosis. Further, the APA does not advocate the use of TMS for treatment of bipolar disorder. This patients current symptoms, as described by the provider, include chronic suicidal ideation, chronic urges to cut herself, and bang her head against walls. These symptoms are most often seen in patients with borderline personality disorder. There is no mention in the record that the patient has had a thorough evaluation to rule out this disorder. The treatment for this disorder would be psychotherapy, and more specifically, dialectical behavioral therapy (DBT). Further, a thorough psychological evaluation may help in identifying other treatment options not previously utilized. All told, the requested TMS therapy is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.
Appeal type: Medical Necessity
Decision: Upheld

A 61-year-old female enrollee has requested Lovaza for the treatment of her lumbar spinal stenosis. Findings:  The physician reviewer found that an article by Chou and colleagues indicates that short courses of non-opioid analgesic medications such as acetaminophen or nonsteroidal anti-inflammatory drugs (NSAIDs) are generally considered first-line treatment for acute exacerbations of chronic low back pain. Lovaza is currently only FDA approved for treatment of hypertriglyceridemia. There is a paucity of literature studying the role of Omega-3 fatty acid in the treatment of low back pain. The only study of some significance was performed by Maroon and Bost. This was a small retrospective, non-placebo-controlled, non-randomized study without long-term follow-up. Without support for use in chronic back pain in the medical literature or in current practice, Lovaza is not medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a six-year-old male enrollee has requested for speech therapy for the treatment of the enrollees articulation disorder. Findings:  The physician reviewer found that this patient has documented speech articulation dysfunction which placed him in the 16th percentile. He was noted as intellectually bright with normal receptive and expressive speech abilities. The origin of this deficiency is congenital. Speech therapy is medically indicated and appropriate for this patient.
Appeal type: Medical Necessity
Decision: Overturned

An enrollee has requested a 12 week course of Harvoni 90/400 mg tablets for treatment of his hepatitis C virus.  Nature of Statutory Criteria/Case Summary: Three physician reviewers found that according to the American Association for the Study of Liver Diseases (AASLD) and Infectious Diseases Society of America (IDSA) guidelines 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. 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, the patient should be approved for Harvoni for 12 weeks to prevent further development and progression of fibrosis due to ongoing HCV infection and prevent potential complications of advanced liver disease, long-term. The patient already has F2 fibrosis, delaying treatment in this case would result in further progression of fibrosis. Final Result: All three reviewers determined that the requested medication is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: One reviewer is board certified in internal medicine with sub-specialty certification in gastroenterology and is actively practicing. Two reviewers are board certified in gastroenterology and are actively practicing. All three reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for balloon ostial dilation. Findings:  Two of the three physician reviewers found Sinus ostial dilation is a therapeutic option for selected patients with chronic rhinosinusitis and recurrent acute rhinosinusitis who have failed appropriate medical therapy. Clinical diagnosis of chronic rhinosinusitis and recurrent acute rhinosinusitis should be based on symptoms of sinusitis and supported by nasal endoscopy documenting sinonasal abnormality or mucosal thickening on CT of the paranasal sinuses. Recurrent acute sinusitis was documented in this patients case. There was evidence of acute and chronic disease on CT scan. Additionally, there was evidence of sinus disease on endoscopy. Researchers noted that balloon dilation produces faster recovery, less postoperative pain and fewer debridements than functional endoscopic sinus surgery. In sum, balloon ostial dilation was likely to have been of greater benefit than other treatment options.  Final Result: The reviewers determined that the services at issue were 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 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

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for anesthesia services provided during an endoscopy for evaluation of the enrollees change in bowel habits. Findings:  The physician reviewer found that the patient has an American Society of Anesthesiology (ASA) preoperative physical status classification score of 1. In this clinical setting, intravenous sedation performed by a non-anesthesiologist and non-certified registered nurse anesthetist is well supported in both clinical practice and in the research given a low preoperative physical status classification score. Final Result: The reviewer determined that the services at issue were not medically necessary for evaluation 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.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary:  An enrollee has requested cervical spine magnetic resonance imaging (MRI) neurogram and an upper extremity MRI neurogram for evaluation of his left brachial plexus injury.  Findings:  Two physician reviewers found that the request for cervical spine MRI neurogram and an upper extremity MRI neurogram is likely to be more beneficial for evaluation of the patients medical condition than available standard modalities. Magnetic resonance (MR) imaging is an excellent tool for the evaluation of peripheral nerves in children not only because of its excellent soft tissue contrast resolution but also because it is noninvasive and does not use ionizing radiation. In non-conclusive cases, MR neurography can be complementary to physical examination and electromyography in identifying a specific affected nerve and the site of the lesion. Moreover, researchers state MR neurography is an extremely useful modality to image the traumatized brachial plexus. It influences both surgical planning and outcome/prognosis. Thus, there is support in the medical literature for the use of MR neurography for the evaluation of peripheral nerve injury and consideration for surgery. All told, the requested diagnostic procedures are likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Final Result: Two reviewers determined that the requested diagnostic procedures are likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned.  Credentials/Qualifications:  All three reviewers are board certified in diagnostic radiology and are actively practicing. 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: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested inpatient mental health treatment and electroconvulsive therapy for treatment of her behavioral health conditions.   Findings:  The physician reviewer found that the medical record indicates that the patient continued to have many of the symptoms that prompted the admission.  She was scheduled for electroconvulsive therapy the next morning.  Thus, it was safe, appropriate and consistent with good medical practice to have the patient remain in the hospital overnight.  The following day, the electroconvulsive therapy was well tolerated.  The documentation indicated that the patient had no side effects from this course of therapy and although she remained depressed and anxious, her mood was improved.  Thus, it appears the acute psychiatric syndrome had resolved.  Further, she was stable on her medications, well-supported at home and familiar with electroconvulsive therapy, which can be safely delivered in the outpatient setting.  In sum, inpatient mental health treatment and electroconvulsive therapy provided initially was medically necessary as they were reasonably expected to improve the patients condition and prevent a more serious episode of illness or prompt re-admission.  However, the medical records fail to demonstrate the medical necessity of the services at issue provided subsequent to the initial course of treatment.  Final Result: The reviewer determined that a portion of the services at issue was 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 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: Overturned

The parent of a one-year, nine-month-old male enrollee has requested speech therapy for treatment of the enrollees feeding issues and language delay.  Findings:  The physician reviewer found that up to 25% of all children have some form of feeding problem, and up to 80% of developmentally delayed children experience feeding difficulties. Manikam and Perman concluded that, Overwhelming evidence indicates that abnormal feeding patterns are not solely due to organic impairment. As such, feeding disorders should be conceptualized on a continuum between psycho-social and organic factors. The authors suggested that, Assessment and treatment are best conducted by an interdisciplinary team of professionals and should include a speech therapist. In addition, Rommel and colleagues recommend a multidisciplinary team approach because combined medical and oral problems are the most frequent cause of pediatric feeding problems. Finally, Strudwicks overview reported that, Research shows that a truly collaborative multidisciplinary approach is likely to be the most successful, encompassing the nutritional, medical, psychosocial, and developmental aspects of the child. Thus, for this young ex-premature patient with both expressive language delay and feeding difficulties, speech therapy with a focus on feeding and language is medically necessary and appropriate.
Appeal type: Medical Necessity
Decision: Upheld

The patient is a 59-year-old female who possibly has bilateral lower quadrant lymphedema. She has been receiving lymphedema therapy since 1999, which resulted in improvement in her condition. Her physician has recommended she continue with lymphedema therapy. The Health Plan has denied coverage for past and future lymphedema therapy on the basis that lymphedema therapy is not medically necessary for treatment of the patients medical condition.Review of the clinical information indicates the patient is morbidly obese. The submitted photographs do suggest lymphedema. However, the submitted clinical information does not include evidence from the patients primary care provider to support the diagnosis of lymphedema. As such, the medical necessity of the therapy at issue has not been established at this time. However, if objective documentation of lymphedema is provided by the patients primary care provider, coverage for past and future lymphedema therapy should be provided by the Health Plan.Based upon the information set forth above, I have determined that the therapy at issue is not medically necessary for treatment of the patients medical condition at this time. Therefore, the Health Plans denial should be upheld at this time. However, if the patients primary care physician provides objective evidence of lymphedema, the therapy at issue should be covered by the Health Plan.
Appeal type: Experimental/Investigational
Decision: Overturned

A 53-year-old male enrollee has requested stereotactic body radiation therapy (SBRT) for treatment of his metastatic colorectal cancer.   Findings:  Three physician reviewers found that SBRT allows very high doses of radiation to be focused specifically to a specific tumor site, thus reducing excess radiation dosages to normal surrounding tissue. There are no guidelines for SBRT in relation to metastatic colorectal cancer to the lung, such as is the case with this patient. However, there is guidance regarding non-small cell lung cancer that states that SBRT can be considered for patients who are deemed medically inoperable, but who have a reasonable performance status and life expectancy. In addition, studies have shown the promise of increasing survivorship in patients treated with SBRT (Salama, et al. and Macdermed, et al.). In summary, SBRT is indicated and appropriate for this patient based on the following: he has had multiple cycles of chemotherapy as well as multiple surgical procedures; he has recuperated well from those surgeries and chemotherapy; he is still active, walking up to three miles at a time; and there are no other viable therapy alternatives in this particular setting.
Appeal type: Medical Necessity
Decision: Upheld

A 44-year-old female enrollee has requested iron infusion with Venofer for treatment of her recurrent iron deficiency anemia.  Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested medication in this clinical setting.  This patient has had persistent complaints of headache and dizziness during her clinic visits that do not appear to be related to anemia.  On the said date, she reported dizzy spells and fatigue and requested an iron infusion.  However, recent hemoglobin was normal. Iron deficiency manifests as microcytic anemia which causes symptoms of fatigue.  There are other symptoms such as pica that are unique to this nutritional deficiency and may manifest in the setting of iron deficiency without anemia.  This patients symptoms do not suggest such abnormal dietary consumption.  Per the submitted medical records, there is no rationale for infusing iron in this patient who has a serum ferritin of 178.  Ferritin levels are an extremely sensitive and specific test, and this patients value suggests replete iron stores.  All told, the requested iron infusion with Venofer is not medically indicated for the treatment of this patient.