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

A 63-year-old male enrollee has requested a coronary CT angiography (CCTA) for an evaluation of his coronary artery disease. Findings:  Three physician reviewers found that there is no indication for coronary CT angiography based on the documentation provided. The appropriateness criteria published by Hendel and colleagues only recommend CCTA in this setting for a negative or equivocal stress test. The literature does not support the contention that the risks of stress echocardiography are so great as to warrant a CCTA. There is also the question as to the diagnostic accuracy of CT angiography for evaluation of this patients coronary artery disease. As the study by Miller and colleagues indicates, The negative and positive predictive values indicate that multidetector CT angiography cannot replace conventional coronary angiography at present.
Appeal type: Experimental/Investigational
Decision: Upheld

A 61-year-old female enrollee requested prospective authorization and coverage for intravenous Rocephin.  The Health Plan denied the request indicating that the medication at issue is considered investigational for treatment of the enrollees stated condition of Lyme disease.Findings:  Three physician reviewers found that the patient reported a 20-year history of Lyme disease. She relates ongoing symptoms of headaches, joint pain, fatigue, abdominal pain, memory loss, headaches, vision impairment, cognitive impairment, muscle pain, tremors, numbness, nausea, and anxiety. Her prior treatment has included amoxicillin, azithromycin, Flagyl, and Bicillin. The patient requested reimbursement and prospective authorization and coverage for intravenous Rocephin.  The Health Plan denied this request and reported that the medication at issue was and is investigational for the treatment of this patient.   As noted by Goroll and Mulley, Lyme disease can have three stages. Stage III infection occurs months to years after the initial infection and primarily manifests as musculoskeletal, neurologic, and skin disease. The classic manifestation of late disease is monoarticular or oligoarticular arthritis, most commonly affecting the knee or other large weight-bearing joints. Chronic arthritis can develop in about 10% of patients. Rarely, the nervous system (both central and peripheral) can be involved in late Lyme disease. A sub-acute encephalopathy characterized by memory loss, mood changes and sleep disturbances is the most common form.   The establishment of late Lyme disease requires objective evidence of clinical manifestations and evidence of disease with two-stage testing with ELISA and Western blot.  In terms of therapy, there are established treatment regimens for initial infection, neurologic disease, cardiac disease and arthritis. The prolonged use of intravenous antibiotics is not recommended. Parental therapy with Rocephin has been associated with adverse effects, including cholelithiasis. The accepted duration of therapy is two to four weeks. This patient has a long history of non-specific symptoms and has undergone previous antibiotic therapy without resolution of her symptoms. There is no indication that she would benefit from intravenous Rocephin therapy.  Thus, intravenous Rocephin is not likely to be superior over other available treatment options in this patients case.
Appeal type: Medical Necessity
Decision: Upheld

A 56-year-old female enrollee has requested custom compounded topical bioidentical hormone replacement therapy (CS-progesterone 100mg/gm cream, CS-testosterone 2mg/gm cream and CS-E2 0.4/E3 1.6mg/gm cream for treatment of her postmenopausal symptoms.  Findings:  The physician reviewer found that there is a lack of evidence regarding the safety and efficacy of compounded bioidentical hormones.  Due to issues related to compounding, dosing is frequently inconsistent.  There are numerous FDA-approved hormone therapies available, with oral and non-oral route options.  There are a number of oral choices that have not been tried. Non-oral options include transdermal patches, gels and sprays and vaginal rings.  According to the record, it appears that she tried such an option on only one occasion.  There is no evidence from the submitted documentation that alternate covered treatments have been tried and failed.  All told, the requested custom compounded topical bioidentical hormone replacement therapy (CS-progesterone 100mg/gm cream, CS-testosterone 2mg/gm cream and CS-E2 0.4/E3 1.6mg/gm cream) is not medically indicated for this patient.
Appeal type: Medical Necessity
Decision: Upheld

A 37-year-old female enrollee has requested Topamax for treatment of her low back pain.  Findings:  The physician reviewer found that Topamax is an anticonvulsant medication used to treat certain epilepsies as well as other conditions such as mood disorders and migraine headaches. Kline and colleagues indicate that there is some evidence that Topamax may be useful in managing certain patients with painful diabetic neuropathies. Nonetheless, this patient does not exhibit any clinical symptoms or physical findings that suggest neuropathic pain. Her symptoms are axial and responsive to facet injections, thus most likely representing mechanical pain. There is no convincing evidence that such pain is responsive to Topamax or any other anticonvulsant medications.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for a Volara system oscillation and lung expansion device (E1399). Chest physiotherapy devices, such as oral oscillating devices, high frequency chest wall oscillating devices, external percussion vests, and intrapulmonary percussive ventilation such as the Volara system, have been the cornerstone of mucous clearance in the management of cystic fibrosis and other forms of bronchiectasis. However, data supporting the use of chest physiotherapy devices in the management of COPD is limited. Given the lack of support in current medical evidence supporting the efficacy of a Volara system in this clinical setting, the requested device is not medically indicated. Therefore, a Volara system oscillation and lung expansion device (E1399) is not medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested device 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 certifications in pulmonary disease and in 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

An enrollee has requested authorization and coverage for transoral incisionless fundoplication (TIF) with placement of the EsophyX device. This patient has GERD and reports some symptoms despite adequate trials of treatment with PPI therapy. His provider recommended a TIF procedure with placement of the EsophyX device. TIF is an endoscopic procedure performed under general anesthesia to create a full-thickness serosa-to-serosa plication that is 3 to 5 cm in length and 200 to 300 degrees in circumference. TIF can be performed in patients with typical GERD symptoms, no or only low-grade erosive esophagitis, and a small hiatal hernia measuring no more than 2 cm. Although TIF is associated with fewer postoperative adverse effects such as gas bloating and dysphagia compared with surgery fundoplication, the durability of TIF is inferior to surgery. Therefore, the requested TIF with placement of the EsophyX 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 services are not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: Physician reviewers 1, 2, and 3 are board certified in internal medicine with subspecialty certification in gastroenterology 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 parent of a four-year-old male enrollee has requested continued ABA therapy for the treatment of his autism. Findings:  The physician reviewer found that ABA therapy has been shown to be efficacious in the treatment of autism and autism spectrum disorders. Improvements as a result of intensive early intervention with ABA therapy have been demonstrated in terms of measured IQ as well as in adaptive, social and communicative skills in comparison to control patients who did not have ABA treatment. These gains have been shown to be sustained over time, with documented follow-up of as long as 6 years in one follow-up study. Further, these findings have been replicated by other studies. In the case of the enrollee, progress with the ABA therapy has been documented with regard to his communication skills (particularly receptive language) and adaptive functional skills. There is no alternative treatment modality that would be as effective for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for peroral endoscopic myotomy (POEM) procedure. This patient presents with significant ongoing symptoms, including dysphagia and regurgitation, which have not responded durably to esophageal dilation. A barium swallow study confirmed the inability for the barium tablet to pass through the patients esophagogastric junction. The patients provider has recommended treatment with the POEM procedure. As noted in the medical literature, POEM is a minimally invasive endoscopic procedure that allows for the treatment of esophageal disorders without chest surgery (Chandan, et al.). POEM has been demonstrated to be safe and effective in multiple studies for patients with jackhammer esophagus and other related spastic esophageal disorders (Khashab, et al.; Bechara, et al.; Kandulski, et al.; Feng, et al.). Given this support, the requested POEM is supported as 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 internal medicine with subspecialty certification in gastroenterology 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 41-year-old female enrollee has requested revision gastric bypass surgery with placement of a Lap-Band over the bypass for treatment of her obesity.  Findings:  The physician reviewer found that there is little documented dietary or behavioral post-op follow-up, however, the records provided do not document any overt complications of her prior RYGBP. In addition, the requested revisional band over gastric bypass has not been demonstrated in the available medical literature to be safe and effective in long-term (greater than two years) follow-up. Although technically feasible, the requested surgery remains of unproven efficacy. As noted by Bessler and colleagues, As with all revisional procedures, the complication rates appear to be increased compared with a similar primary operation. For these reasons, aggressive dietary and behavioral measures to manage weight loss are likely to result in a better outcome in this setting than the proposed revisional surgery.
Appeal type: Medical Necessity
Decision: Upheld

A 57-year-old female enrollee requested authorization and coverage of an increase in the quantity and dosage of her monthly Vioxx prescription for treatment of chronic myofascial pain.  The Health Plan denied the enrollees request indicating that the requested increase in quantity and dosage of the prescription is not medically necessary.One physician reviewer performed a medical necessity Independent Medical Review.  The physician reviewer upheld the health plans denial on the basis that the requested medication is not medically necessary.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/ Case Summary:  The enrollee is requesting authorization and coverage for Supartz, for history of arthritic left knee pain.  A magnetic resonance of the left lower extremity joint without contrast was suggestive of degenerative osteoarthritis, radial tear at the junction of posterior horn with posterior root of the medial meniscus, sprain pattern without tear, and moderate to large joint effusion with a leaking popliteal cyst.  She received a Depo-Medrol injection in the left knee and reported minimal relief. Her orthopedist prescribed Supartz. A magnetic resonance imaging report of the left knee revealed high grade loss of articular cartilage with subarticular fibro-osseous changes and stress marrow edema medial and patellofemoral compartments. These findings suggest degenerative osteoarthritis. On follow up evaluation for left knee pain with her orthopedist, physical examination of the left knee revealed no increased pain with passive range of motion. Although, the enrollee has positive findings on MRI and is diagnosed with osteoarthritis, there is no evidence in the record she has not responded adequately to conservative treatments, such as exercise, and non-steroidal anti-inflammatory drugs. The enrollee did try corticosteroids with minimal relief, but there is no support to show the other conservative treatment options have been tried and failed. Review of the literature indicates several clinical trials have been developing many hyaluronic acid (HA) preparations and investigating their efficacy and safety. Although many studies have demonstrated the use of intra-articular HA injection would be a beneficial, non-surgical option for osteoarthritis and may delay the need for joint replacement, there is an ongoing controversy over the clinical effectiveness and sustainability of intra-articular injection of HA for OA patients. It has been demonstrated  there is not any significant difference between the intra-articular injection of HA and injection of physiological saline in patients with knee OA. The efficacy of HA injections for knee OA remains disputed with meta-analyses and societal clinical guidelines drawing different conclusions. A recently published best-evidence systematic review concluded that available data did not support the routine use of HA for knee osteoarthritis. Final 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 board certified in orthopedic sports medicine and orthopedics 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: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for individual counseling. In one study of parents of children with autism spectrum disorder (ASD) diagnoses, Alnazly and Abojedi noted that, ASD has profound impacts on the lives of family members including the roles and responsibilities assumed in caring for individuals with ASD. Caring for children with ASD is associated with a higher incidence of parental stress, anxiety, and depression than caring for children with other developmental and physical disabilities and affects marital relationships and family functioning. In addition to experiencing several economic, physical, social, and psychological burdens, parents of children with ASD often report poor psychological wellbeing. Similarly, the American Psychiatrist Association (APA) noted that the use of quantitative measures can have a number of potential harms. Overreliance on quantitative measures may lead other key elements of the patients symptoms and life circumstances to be overlooked. In this case, the patient requested outpatient psychotherapy to address conflict with her in-laws as well as anxiety associated with caring for two young children, including one with ASD. The patient was evaluated and the provider determined that her test scores did not support an indication for the requested therapy. In addition to providing support for the patients current stressors, regular sessions with a therapist could also prevent further deterioration of her mental health. Given these findings, the requested individual counseling is medically necessary for 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 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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Euflexxa injections in the left knee. The submitted documentation supports the medical necessity of the requested services. The current literature continues to support the use of viscosupplementation for osteoarthritis of the knees.There is good evidence that intraarticular hyaluronic acid injections reduce pain and increase function in knee osteoarthritis, and the benefits are long-lasting. Evidence from real-life studies of repeat courses of intraarticular hyaluronic acid demonstrates an improvement in pain or function lasting up to 40 months, a reduction in use of concomitant analgesia by up to 50%, and suggests that there may be a delay in the need for total knee replacement of around 2 years. Reviewer found that the current highest level of evidence suggests that intraarticular hyaluronic acid is a viable option for knee osteoarthritis and that its use results in improvements in knee pain and function that can persist for up to 26 weeks. Viscosupplementation has a good safety profile, and its use should be considered in patients with knee osteoarthritis. There is sufficient support for the requested services in this clinical setting. Therefore, Euflexxa injections in the left knee 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.
Appeal type: Experimental/Investigational
Decision: Upheld

An enrollee has requested reimbursement for the DecisionDx-Melanoma assay gene test. The DecisionDx-Melanoma test is not within the standard of care for the evaluation and treatment of patients with melanoma. In addition, the National Comprehensive Cancer Network (NCCN) guidelines do not support use of the DecisionDx-Melanoma results to direct patient treatment. There is a paucity of clinical trials demonstrating the clinical utility of the results to improve patient health outcomes. Moreover, the test results would not have changed this patients management. Based on current peer-reviewed medical literature and guidelines, the recommendation for this patient includes a wide local excision and follow-up skin surveillance. Given these findings, the DecisionDx-Melanoma assay gene test was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Findings:  The reviewers found the DecisionDx-Melanoma assay gene test was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the services at issue were not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld

A 55-year-old female enrollee has requested Nuvigil 250 mg. for treatment of her medical condition of excessive sleepiness.  Findings:  The physician reviewer found that upon reviewing this patients records, there does not appear to be evidence of a diagnosis of obstructive sleep apnea, narcolepsy or shift work sleep disorder. In the current medical literature, there is insufficient support for the effectiveness of this therapy in patients without any of these diagnoses. As reported by De Waele and Van Belle, additional randomized, placebo-controlled trials are needed to determine the benefit of these and other drugs in the treatment of cancer related fatigue. Thus, although Nuvigil is used for excessive sleepiness, the available scientific data has only established its utility and safety in patients with obstructive sleep apnea, narcolepsy or shift work sleep disorder. To date, there remains a need for prospective, randomized, properly controlled studies to identify other possible off-label indications for Nuvigil. As such, the medical necessity of Nuvigil has not been established in this clinical setting.
Appeal type: Experimental/Investigational
Decision: Upheld

A 37-year-old male enrollee requested authorization and coverage of percutaneous disc decompression (nucleoplasty) for the treatment of low back pain.  The health plan denied the enrollees request indicating that the requested treatment is experimental.Three physician reviewers performed an experimental/investigational Independent Medical Review.  Each of the three physician reviewers concluded that percutaneous disc decompression (nucleoplasty) is not likely to be more beneficial for treatment of the enrollees low back pain than any available standard therapy.  Because all three physician reviewers concluded that the requested treatment is not likely to be more beneficial for treatment of the enrollees medical condition than any available standard therapy, the review organization upheld the health plans denial.