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

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for residential treatment level of care for treatment of the enrollees behavioral health condition. Findings:  The physician reviewer found that the documentation submitted does not support the medical necessity of the services at issue in this clinical setting. The patient participated in groups, individual therapy, family sessions, and other treatment modalities.  The patient denied suicidal or homicidal ideation. The patients mood was lethargic.  The patients affect was flat but indicated that the migraine medication made the patient feel spacey. The patients memory and concentration were intact, as were insight and judgment. The patient demonstrated insight and was working on the ability to speak up and set boundaries. The patient had ongoing depression, anxiety, some feelings of hopelessness and difficulty motivating.  She had the ongoing fear of being unable to manage at home.  The patient presented to the patients session looking slightly disheveled. The patient indicated that was due to lack of self-care in lieu of caring for others.  The patient had ongoing migraines. Sleep was still disrupted at five hours a night and the patient reported ongoing PTSD symptoms of nightmares, flashbacks, and hypervigilance. The patient denied suicidal ideation, and she was not a danger to others.  The records show that the patient actively participated in all treatment modalities. The patient gained insight.  Although the patient continued to endorse ongoing symptoms of depression, anxiety, and PTSD, this appears to be the patients baseline. Moreover, the medication changes performed were not drastic in nature and not requiring a residential setting.  The patients parents and fiance were supportive.  The patient no longer required 24 hours per day seven days per week of monitoring in a residential setting. Based on the documentation provided, the patient could have been stepped down to a lower level of care. Therefore, residential treatment level of care was not medically necessary for the 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 psychiatry and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Repatha Sureclick 140 ng/mL for treatment of the enrollees hyperlipidemia and coronary artery disease status post myocardial infarction. Findings:  The physician reviewer found that Repatha has been approved by the U.S. Food and Drug Administration (FDA) for patients with clinical atherosclerotic cardiovascular disease who have not achieved goal LDL levels despite maximal tolerate statin doses. In 2013, the American College of Cardiology (ACC) established recommendations for treatment groups and high intensity statin moving away from specific LDL target numbers. Overall, the guidelines suggest that the evidence for benefit of treating to a certain target LDL was lacking. Colleagues reported on the FOURIER trial with outcome benefits. However, the absolute reduction was about 2% reduction in composite endpoints and this trial was not included in the ACC guidelines. This patient has reached an LDL of 88 mg/dL on high intensity statin and there is a lack of data supporting the benefits of achieving a specific target level less than 70 mg/dL as recommended by the patients provider. For these reasons, the requested Repatha Sureclick 140 ng/mL 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 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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for implantable peripheral nerve stimulation (PNS) device . In this case, the patient has chronic low back pain thought to be related to cluneal nerve entrapment based on positive response to two diagnostic injections. The provider has recommended peripheral nerve stimulation (PNS) of the cluneal nerve. Currently, there is insufficient medical evidence to support the efficacy of the requested PNS device in the medical literature with the bulk of the studies in the form of small case reports or case series. Researchers performed a review of cluneal nerve related pain syndromes and evaluated the various treatment options for this condition. The authors concluded that, While high-level evidence supporting PNS for clunealgias does not exist, several cases of successful pain relief post-implantation have been reported. Researches noted that two PNS techniques are showing promising results in clinical trials. However, there is a paucity of prospective randomized controlled trials reporting improved patient health outcomes with PNS in lieu of standard therapies. Based on the medical records for review and the current evidence-based medical literature, the requested implantable PNS device is not 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 implantable PNS device  is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the requested device 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 is board certified in anesthesiology with subspecialty certification in pain medicine and is actively practicing. Physician reviewer 2 is board certified in anesthesiology with subspecialty certification in pain medicine and is actively practicing. Physician reviewer 3 is board certified in anesthesiology with subspecialty 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: Overturned

Nature of Statutory Criteria/Case Summary: The patients parent has requested authorization and coverage for six months of two sessions per week of in-person, outpatient occupational therapy services to provide caregiver/parent education, home management, and training (inclusive of feeding and toilet-training) or six months of one session per week of the above services. Researchers note, Children with autism spectrum disorder (ASD) have a range of occupational and performance problems that interfere with their full participation in school, home, and community activities. Predominant characteristics of autism that are often the focus of intervention include limited social interaction, delayed or deficit language, behavioral problems, and sensory-processing difficulties. The authors further state that with its focus on sensory integration and sensory-based interventions, relationship-based and interactive interventions, and developmental skill-based programs, occupational therapy (OT) may provide a leading role in affecting positive change in children with ASD. In this case, the records noted that the patient made good progress in previous therapy programs, and was most recently noted to have achieved all established goals. However, given that she continues to have deficits in multiple areas including fine and gross motor skills, self-regulation, performance of self-care skills, and tolerating a varied diet, ongoing OT is medically indicated. Therefore, six months of two sessions per week of in-person, outpatient occupational therapy services to provide caregiver/parent education, home management, and training (inclusive of feeding and toilet-training) are medically necessary for the treatment of this patient.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 pediatrics with sub-specialty certification in pediatric critical care 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: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement and prospective authorization and coverage for Verzenio. The records provided for review document that this patient presents with glioblastoma located in the right frontal lobe. The patients providers have recommended treatment with Verzenio, which was started on 11/26/21. The U.S. Food and Drug Administration (FDA) has not approved Verzenio for the treatment of patients with glioblastoma. In addition, the National Comprehensive Cancer Network (NCCN) guidelines do not support the use of Verzenio as safe and effective for management of patients with glioblastoma. Furthermore, data are lacking from phase 3 clinical trials demonstrating improved patient health outcomes with Verzenio as compared to other available therapies. Therefore, Verzenio was not and is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Findings: Three of the three physician reviewers found the Verzenio was not and is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the medication at issue was not and 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 is board certified in internal medicine with subspecialty certifications in medical oncology and hematology and is actively practicing. Physician reviewer 2 is board certified in internal medicine with subspecialty certification in medical oncology and is actively practicing. Physician reviewer 3 is board certified in medical oncology with subspecialty certifications in hematology and internal 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

A 27-year-old female enrollee has requested for Provigil 200mg for treatment of her sleep disorder with idiopathic hypersomnolence. Findings:  The physician reviewer found that there is documentation of treatment failure of Ritalin/amphetamines. There is documentation of effectiveness allowing the patient to function at an extremely high level, despite her hypersomnolence.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a 2-year-old male enrollee has requested occupational therapy for treatment of the enrollees autism. Findings:  The physician reviewer found that the submitted documentation establishes the medical necessity of the requested services. Occupational therapy is indicated when deficits exist in functional skills or occupational performance in the areas of play and leisure, self-maintenance, school tasks, or activities of daily living (Case-Smith and Arbesman). This patient has identified fine motor and adaptive skill deficits of 30% or greater. Sensory integration therapy is often used alone or as part of a broader program of occupational therapy for children with autism spectrum disorder. Furthermore, when feeding difficulties are noted within this population, synthesis of the evidence suggests that various feeding approaches may result in positive outcomes in the areas of feeding performance, feeding interaction, and feeding competence of parents and children (Howe and Wang). This patient is an appropriate candidate for occupational therapy to treat his fine motor deficits, adaptive skills and feeding difficulties noted above. All told, the medical necessity of the requested services has been established.
Appeal type: Experimental/Investigational
Decision: Overturned

A 41-year-old female enrollee has requested a full body positron emission tomography/computed tomography (PET/CT) scan for evaluation of her malignant neoplasm of the endocervix.  Findings:  Three physician reviewers found that to date, there is no other test to evaluate tumor reoccurrence in patients with cervical cancer aside from the requested PET/CT scan. The sensitivity and specificity of PET/CT to detect recurrence is superior to other standard imaging alternatives. Moreover, the peer reviewed medical literature supports the utility of the PET/CT scan as within the standard of care within the medical community in the evaluation and treatment of patients with cervical cancer (Mittra, et al). Thus, the requested diagnostic procedure should be approved as it is likely to provide novel data that will prove useful in this patients care.
Appeal type: Experimental/Investigational
Decision: Upheld

A 51-year-old female enrollee has requested two single photon emission computed tomography (SPECT) scans for an evaluation of her impairment of cognitive and memory functions secondary to toxic mold exposure. Findings:  Two physician reviewers found that SPECT scanning is not typically used by neurologists except in the differential diagnosis of dementia. In this case, the provider states he ordered diagnostic testing with SPECT to document the patients brain impairment due to toxic mold exposure. The superiority of SPECT in this context is not supported by peer-reviewed literature. Information about the patients cognitive impairments could have been obtained by standard methods such as neuropsychological testing. There is no evidence that the results of the SPECT scans were likely to alter the course of the patients treatment.
Appeal type: Experimental/Investigational
Decision: Overturned

A 46-year-old male enrollee has requested coverage for laser therapy for treatment of hi psoriasis. Findings:  Three physician reviewers found that the Excimer laser stimulates broadband UVB in individual psoriasis plaques. It is specifically indicated for treating a few plaques, which is precisely the situation in this case. The patient has localized plaques that are painful. Given the failure of standard topical therapies and ultraviolet treatment, laser therapy is medically appropriate and has a greater likelihood of success than any other modalities.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary:  An enrollee has requested intensity modulated radiation therapy (IMRT) for treatment of his medical condition.  Findings:  Three physician reviewers found that IMRT is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Three-dimensional conformal radiotherapy (3DCRT) for the treatment of mesothelioma is an inefficient process. The matching of the electron beams and photon blocks can be inaccurate, thus coverage of the treatment volume is compromised. However, IMRT is optimal in providing adequate coverage of a curved treatment volume. These factors have led to 3DCRT for mesothelioma being largely being abandoned by the radiation oncology medical community. The use of IMRT allows the treating clinician more control over where the radiation falls over within the target volume compared to 3DCRT (Patel, et al). Buduhan and colleagues evaluated a retrospective cohort of 46 patients with mesothelioma over a 10-year period that were treated with neoadjuvant chemotherapy followed by extrapleural pneumonectomy. Twenty-four of these patients then received 3DCRT, and 14 received IMRT. Local recurrence rates with 3DCRT was 41.7%, and only 14.3% IMRT. In addition, Krayenbuehl and colleagues retrospectively analyzed 39 patient treated with neoadjuvant chemotherapy followed by extrapleural pneumonectomy. Local recurrence rates were significantly improved from 72.7% to 27.3% in the 14 patients that received IMRT versus the 25 that received 3DCRT. Given the inability of 3DCRT to provide adequate dose coverage of a curved treatment volume, IMRT is a superior treatment in this clinical setting.   Final Result: Three reviewers determined that the requested services are likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned.  Credentials/Qualifications:  All three reviewers are board certified in radiation oncology 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

At issue is whether a genicular nerve block and medial branch nerve radiofrequency ablation are likely to be more beneficial for treatment of the patients condition than any available standard therapy. The enrollee has been diagnosed with chronic left knee pain.  In this case, the patient has tried and failed multiple forms of conservative management, including physical therapy, joint bracing, intra-articular steroid injections, and viscosupplementation injections.  Pain and functionality has not been improved with medication management, including acetaminophen, tramadol, and gabapentin. The patient is not able to use nonsteroidal anti-inflammatory drugs. Her provider noted that the patient was not a good surgical candidate for joint replacement therapy due to venous status and her comorbid conditions.   Genicular nerve blocks RFA provide a minimally invasive treatment to bring pain relief to patients with chronic knee pain. Genicular nerve blocks RFA has been shown to provide significant benefit to well-selected patients by relieving knee pain, increasing functionality, and decreasing the need for pain medication.  Based on the review of literature, a genicular nerve block and medial branch nerve RFA are likely to be more beneficial for treatment of the patient's medical condition than any available standard therapy.Final Result: The reviewers determined that the requested treatment is 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: Physician reviewers 1, 2 and 3 are board certified in anesthesiology with sub-specialty certification in pain management, 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: Overturned

The patient is a 42-year-old female with a history of knee pain with grinding and clicking for six months. There is no history of prior trauma. Physical exam showed a positive McMurrays test. Clinically, there is concern of a meniscal tear. MRI of the knee has been requested to evaluate the patient for possible meniscal tear.  The Health Plan has denied this request indicating an MRI is not medically necessary in this clinical setting.Upon review of the submitted clinical information, the patient meets medical necessity criteria for an MRI of the knee. According to National Imaging Associates (NIA) guidelines on knee MRI, knee pain persisting for greater than three days with physical findings of meniscal injury including positive McMurrays sign is an accepted diagnosis for an MRI of the knee. As this patient has had knee pain for six months and was found to have positive McMurrys sign on physical exam, an MRI of the knee is medically appropriate and indicated. Therefore, I have determined the requested MRI is medically necessary for evaluation of the patients medical condition. The Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for hyaluronan (Supartz) injections every six months. There is sufficient support for the requested services in this clinical setting. The evidence-based literature supports the use of viscosupplementation injections for the treatment of pain in patients with osteoarthritis of the knee. Repeat viscosupplementation injections have been found to be safe and effective and allow for delay of knee replacement surgery. In this case, the patient has been diagnosed with bilateral knee osteoarthritis. He reports significant functional limitations in ambulation, exercise tolerance and work activities. Conservative treatment has included activity modification, bracing, and medications, without adequate relief. He has received multiple series of Supartz injections to both knees that have provided significant pain relief and functional restoration allowing for work and activities of daily living for at least six months over the past five years. Therefore, the requested hyaluronan (Supartz) injections every six months are medically necessary for the treatment of this patient. 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.