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

A 64-year-old male enrollee has requested cervical spine surgery for treatment of his multilevel degenerative disc disease.  Findings:  The physician reviewer found that in a review of the surgical management of cervical myelopathy, Hillard and Apfelbaum summarized the indications and techniques for multilevel cervical discectomy. The authors concluded that multilevel cervical discectomy and fusion has proven to be very effective in decompressing and stabilizing the spine for treatment of cervical myelopathy. They defined myelopathy as impaired motor and sensory functionality including, clumsiness of the hand, difficulty walking, impaired balance and coordination, and sensory complaints of numbness or tingling in the hands and feet. While this patient does have some clinical evidence of myelopathy, his history and radiographic findings are more consistent with a thoracic level etiology rather than a cervical one. He therefore does not require multilevel anterior discectomy with fusion in the cervical region. Anterior cervical discectomies are also sometimes indicated for cervical radiculopathies.  In a systematic review of the literature, Matz and colleagues sought to define the indications for anterior cervical decompression for the treatment of cervical degenerative radiculopathy. The authors noted that, Cervical radiculopathy presents with a combination of arm pain, sensory dysfunction, and motor function loss. Also common is associated neck pain. While this patient does have some neck pain, he does not have any significant complaints of arm pain and on exam, has no arm weakness and no reflex abnormalities. He does have decreased pinprick in the left anterior upper arm area, but there is no radiographic evidence for significant nerve root compression at the expected corresponding level, which is C5. He therefore does not require an anterior cervical discectomy for radiculopathy either.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for sodium hyaluronate injection to bilateral knees. Current medical literature pertaining to viscosupplementation reveals mixed results. Evidence indicate that although viscosupplementation may relieve knee pain in some individuals with osteoarthritis, it is not known as to which individuals will benefit. Different studies have tried mixing hyaluronic acid with corticosteroids, platelet rich plasma, and other agents to make it more effective. The current evidence is limited and guidelines from organizations such as the American Academy of Orthopedic Surgeons indicate that the evidence is not conclusive. As such, the Academy does not currently support viscosupplementation as standard treatment for osteoarthritis of the knees. In light of the foregoing, viscosupplementation can only be recommended in individuals with a history of lasting benefit from prior injections and in carefully selected cases when everything else has been tried and the options are limited. The patients options are limited. The patient has failed surgeries of the knee. There is documentation of chondral loss with progressive patellofemoral arthritis and severe pain. The provider has recommended viscosupplementation of both knees with sodium hyaluronate. The enrollee has tried and failed other conservative as well as surgical treatments with the alternative being a total knee arthroplasty. However, only the patellofemoral compartment is involved in this case, and a total knee arthroplasty is not indicated. Under these circumstances, the request for sodium hyaluronate injections of both knees is reasonable, appropriate, and medically necessary for management of patellofemoral arthritis associated with severe pain. Therefore, the requested sodium hyaluronate injection to bilateral knees is medically necessary for treatment of the patients medical condition.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 enrollees parent has requested authorization and coverage for tofacitinib. This pediatric patient has a five-year history of alopecia areata that has substantially affected her quality of life. The records document that the patients condition has persisted despite treatment with long-term topical steroids, which over time has caused atrophy of her skin. She was also treated with topical anthralin and topical squaric acid. She previously experienced some improvement with these agents. However, these medications are no longer effective for her, and she is exhibiting areas of atrophy from chronic steroid use. Her provider recommended tofacitinib due to the failure of typical first- and second-line therapies. There are recent studies demonstrating successful patient health outcomes with use of tofacitinib in resistant alopecia areata. As this patients alopecia areata has been refractory to multiple standard therapies, the requested tofacitinib is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Findings:  Two of the three physician reviewers found the requested tofacitinib 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 medication is 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 dermatology with subspecialty certification in dermatopathology and is actively practicing. Physician reviewer 2 is board certified in dermatology and is actively practicing. Physician reviewer 3 is board certified in dermatology with subspecialty certification in dermatopathology 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: Experimental/Investigational
Decision: Overturned

A 54-year-old female enrollee has requested Sutent for the treatment of her metastatic thyroid cancer. Findings:  Two physician reviewers found that in patients with metastatic thyroid carcinoma who are refractory to radioactive iodine, there are no effective therapies. Small molecule tyrosine kinase inhibitors, such as Sutent, have demonstrated clinical responses with tolerable treatment. Based on these studies and the lack of other established treatment options, the National Comprehensive Cancer Network consensus panel noted that treatment with small molecule tyrosine kinase inhibitors should be considered in this patient population. Thus, Sutent is a medically reasonable and appropriate option in this setting, particularly in light of the limited treatment options.
Appeal type: Experimental/Investigational
Decision: Upheld

A 59-year-old male enrollee has requested authorization and coverage for a lumbar traction unit for in-home use for treatment of chronic low back pain.   Findings:  Two physician reviewers found that the patient has been diagnosed with chronic low back pain, which has worsened recently. The patient has a herniated disc at L4-5 and underwent a physical therapy assessment and physical therapy in conjunction with a home exercise program was recommended. A few weeks later it was noted that the patient has had good relief of his pain with a trial of home traction and a home lumbar traction device was recommended, along with continuation of his current rehabilitation program. The patient has requested a home lumbar traction unit, which has been denied by the Health Plan. Lumbar traction is not likely to be more beneficial than available standard therapies for the treatment of this patients condition. There is insufficient scientific evidence to clearly demonstrate the benefit of lumbar traction versus the available standard therapies. The peer reviewed medical literature provides contradictory evidence on the effectiveness of a wide range of commonly used treatments for low back pain including traction. Based on the current evidence, intermittent or continuous traction as a single treatment for low back pain cannot be recommended for mixed groups of patients with low back pain with and without sciatica (Clarke, et al.). In sum, the inconsistencies in the peer-reviewed medical literature and the fact that there are other available therapies that have been proven efficacious in the treatment of low back pain, demonstrate that there is insufficient evidence to prove that a traction device would be more beneficial for treatment of this patients medical condition than any available standard therapy. Further studies are needed to prove the safety and efficacy of the requested device in the treatment of low back pain. Therefore, the Health Plans denial was appropriate.
Appeal type: Medical Necessity
Decision: Upheld

The enrollee is requesting authorization and coverage for acupuncture. The enrollee has anxiety, insomnia, fatigue, major depressive disorder, and developmental disorder. The enrollee has a therapist but declines medications. He reports that acupuncture has helped in the past. The enrollee reports he has been under severe stress and cannot concentrate enough to even read a book. The enrollee also has depression and has trouble falling asleep at night.  A governmental organization reports there is not enough evidence to determine if acupuncture can help people with depression. Researchers reviewed a number of therapy approaches for depression, but acupuncture was not one of them. A professional society does not recommend acupuncture for the treatment of depression. A literature review showed that, though depression severity was less with acupuncture than with no treatment, the quality of evidence was low, and the effect of acupuncture compared to psychological therapy was unclear. The risk of adverse events with acupuncture was also unclear. The authors report high-quality randomized controlled trials are needed to determine the effectiveness of acupunctureFinal Result: The reviewer determined that the requested service is not medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The physician reviewer is a licensed acupuncturist 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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for cardiac defibrillator implantation for treatment of the enrollees hypertrophic cardiomyopathy. Findings:  The 3 physician reviewers found that this patient presents with a history of hypertrophic cardiomyopathy and symptomatic non-sustained ventricular tachycardia. In this circumstance, accepted criteria for prophylactic defibrillator placement include the presence of at least two clinical risk factors. These factors include unexplained syncope, non-sustained ventricular tachycardia, family history of sudden death in a first degree relative, abnormal blood pressure response to exercise and left ventricular wall thickness greater than 30 mm. In addition, most guidelines suggest that in circumstances of uncertainty such as the presence of only one risk factor, that the identification of late gadolinium enhancement by cardiac magnetic resonance indicative of myocardial fibrosis or marked left ventricular outflow tract obstruction at rest can be used to help aid decision-making on an individual basis. Since this patient has both non-sustained ventricular tachycardia and myocardial fibrosis by cardiac MRI, the requested cardiac defibrillator implantation is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Final Result: The 3 reviewers determined that the requested service is 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 number one is board certified in internal medicine with sub-specialty certification in cardiovascular disease 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 internal medicine with sub-specialty certification in cardiovascular disease 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 internal medicine with sub-specialty certification in cardiovascular disease 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 60-year-old male enrollee has requested for Synvisc injections for treatment of his osteoarthritis of the right hip. Findings:  Two physician reviewers found that the current medical evidence does not support Synvisc injections in this clinical scenario. There is a lack of long-term, controlled, double-blinded studies validating viscosupplementation injections into the hip.  This patient appears to have end-stage osteoarthritis of the right hip. Although concerns have been expressed with proceeding with surgery in light of the patients need for immunosuppressive medications, the use of Synvisc in this setting is not likely to be an effective therapeutic intervention. Currently, the relatively low evidence level limits recommendation of viscosupplementation as a therapy for hip osteoarthritis.
Appeal type: Experimental/Investigational
Decision: Upheld

A 41-year-old female enrollee has requested tongue repose surgery (glossopexy) for treatment of her obstructive sleep apnea. Findings:  Three physician reviewers found that there is a paucity of medical articles reporting on the outcomes of the proposed surgery alone for the treatment of sleep apnea. There are no randomized controlled trials that compare multilevel surgical procedures to other therapies for the treatment of obstructive sleep apnea. All published studies are prospective or retrospective case series with no control groups. For this patients condition, CPAP is the benchmark treatment. While CPAP can initially be difficult to tolerate, practitioners often recommend that patients make continued efforts to accommodate CPAP therapy as it is a preferred approach compared to surgery. In summary, the medical literature does not support the contention that the probable benefits of the proposed surgery will outweigh its risks or that it would be likely to be more beneficial for this patient than the standard available alternative treatment options.
Appeal type: Experimental/Investigational
Decision: Overturned

A 63-year-old female has requested coverage for a positron emission tomography (PET) scan, or PET scan with computed tomography (CT) attenuation for evaluation of her metastatic breast cancer.  Findings:  Two physician reviewers found that the patient has a remote history of breast cancer discovered and treated in 1995 with known prior axillary spread. She was told she was cured but developed hip and pelvic pain. She was discovered to have metastatic bone disease in 2008 and is being treated for skeletal metastases. Her treating oncologist has requested positron emission tomography/computed tomography (PET/CT) for follow-up of the skeletal lesions to assess treatment success and also to screen the entire body. This patient has evidence of recurrence of her original breast cancer even after 16 years since her initial diagnosis. The tumor has metastasized to bone and the oncologist has requested a PET/CT to assess treatment success. In this patients case, she has had success on most of the bone lesions but there is a spine lesion which has been increasing in metabolic activity suggestive of active metastasis. In addition, this single test (PET/CT) will permit the radiologist to screen the patients other organ systems for metastasis at the same time. Clearly these findings will be relevant in terms of treatment decision making. No other single test allows such multi-system evaluation. For these reasons, the requested PET/CT scan is likely to be more beneficial for evaluation and treatment of this patients medical condition when compared with standard therapies.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for clindamycin phosphate 1% gel daily. Epidermal inclusion cysts are common vulvar cutaneous lesions that are typically skin-colored dermal nodules ranging in size from a few millimeters to several centimeters in diameter. Infected, fluctuant cysts tend to be larger, more erythematous, and more painful than sterile inflamed cysts, which may resolve spontaneously without therapy but are prone to recurrence. Treatment options include excision or injection with steroids to hasten the resolution of inflammation, although treatment is not necessary unless desired by the patient. In this case, the patient has recurrent vulvar epidermal inclusion cysts. Although the patient underwent excision, the condition has recurred. Topical clindamycin is frequently prescribed for hidradenitis suppurativa (HS), and Clemmensen notes that in a study of 30 patients with recurrent HS, the overall effect of clindamycin treatment based on patients' assessments, number of abscesses, inflammatory nodules and pustules was significantly better than placebo at each monthly evaluation. Although frequently prescribed, data to support the efficacy of topical clindamycin is limited for the treatment of HS or other vulvar lesions. Given the lack of evidence and data in current medical literature to support the use of topical clindamycin in this clinical setting, the requested medication is not medically indicated. Therefore, clindamycin phosphate 1% gel daily 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 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 male enrollee requested anterior interbody fusion at the diseased levels, followed by stabilization and decompression as needed posteriorly for medical treatment of his low back pain.  Findings:  The physician reviewer found that the patient does not meet the established criteria for lumbar fusion surgery. There is no documented fracture or instability. There are no red flags for lumbar fusion surgery such as fracture, tumor, or progressive neurologic deficit. All told, the request for anterior interbody fusion at the diseased levels, followed by stabilization and decompression as needed posteriorly is not supported as medically necessary.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: A patient has requested reimbursement for the intensive outpatient program (IOP) services received at the Recovery Road Medical Center. The Health Plan has denied this request indicating that the services at issue were not medically necessary for treatment of the patients behavioral health conditions. The submitted documentation of the patients medical needs and generally accepted standards of medical practice support the medical necessity of the services at issue. The patient was not able to commit adequately to meaningful relapse-prevention therapy, placing him at high-risk of relapse, deepening depression, and decompensation. Continued intensive therapy was medically necessary to prevent high-risk of continued self-harm through dependence on cannabis, tobacco, and benzodiazepines. Accordingly, the intensive outpatient program (IOP) services received at the Recovery Road Medical Center was medically necessary for the treatment of this patient.Final Result: The reviewer determined that the services at issue were 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 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

A 39-year-old female enrollee has requested a follow-up visit to an endocrinologist for the treatment of her medical condition. Findings:  The physician reviewer found that there is emerging evidence that keeping the TSH level to less than 2.5 in women with hypothyroidism who are pregnant or pursuing pregnancy is indicated. There are thoughts that a TSH level of greater than 2.5 may be associated with fetal loss. Certainly, TSH should be kept in the normal range and levels of 6 and 10 are above normal. The UpToDate article entitled Overview of thyroid disease in pregnancy notes that during pregnancy women with hypothyroidism need more thyroid hormone and are unable to increase thyroidal T4 and T3 secretion. The goal of therapy is to normalize the mothers serum TSH concentration. Thus, it is clear that Synthroid doses need to be increased during pregnancy. In this particular clinical situation, with the patients past history of miscarriages and her previously high TSH levels, it seems medically reasonable and appropriate that this patients needs would be better met with a follow-up visit with the endocrinologist she saw rather than her primary care physician.