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

Nature of Statutory Criteria/Case Summary: The parent of a pre-adolescent enrollee has requested shoe inserts for treatment of the enrollees bilateral pes planus.  Findings: The physician reviewer found that after a review of the medical literature on this issue, the requested custom made orthotics are not medically necessary. The patient has a congenital flatfoot condition that is symptomatic, causing her foot, leg, and hip discomfort, as well as problems with balance. Her BMI of 19.3, which classifies her as overweight as well. On examination by her podiatrist, she is also noted to have an equinus bilaterally, which often accompanies a flexible flatfoot in children and contributes to her painful symptoms. Symptomatic flatfoot in children, particularly those accompanied by an equinus, require treatment consisting of proper shoe gear with a supportive arch, daily stretching exercises of the posterior leg muscles to reduce the equinus, weight management, and arch supports. However, the current peer-reviewed medical literature does not support the exclusive use of custom made orthotic devices and suggests that over the counter or pre-fabricated arch supports are just as effective as custom made devices in the treatment of this condition. Overall, there is a lack of significant evidence in the scientific data to support the use of custom orthotics over appropriate over the counter devices, or pre-fabricated orthotics for the treatment of this patients condition. Thus, the requested shoe inserts are not medically necessary for treatment of this patients medical condition.Final Result: The reviewer determined that the requested equipment 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 podiatry 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 reimbursement for residential treatment center services for treatment of the enrollees behavioral health condition.  Findings:  The physician reviewer found that based on the Level of Care Utilization System (LOCUS) criteria, the patient met criteria for treatment in a less restrictive environment. The patients risk of harm scores is two (2), mild risk of harm. The patient does not have a history of suicide attempts or suicidal ideation. The patients history includes binge drinking. The patients functional status score is three (3), moderate impairment. The patient is currently unemployed. The patient has interpersonal issues with family when actively drinking. However, the family is supportive of sobriety. The patients medical, addictive and psychiatric co-morbidity score is three (3), significant co-morbidity. The patient has a significant co-morbidity of alcohol use disorder, anxiety, and depression. The patient has a history of elevated liver function tests (LFT) and enlarged liver. However, these medical conditions do not require 24-hour observation. The patients recovery environment score is two (2), mildly stressful environment. Per documentation, the patient does some ongoing interpersonal conflicts with others and family, typically in context of the patients alcohol use. The patients level of support score is two (2), supportive environment. The patient has a spoouse and two children who are supportive of the patients sobriety. The patients treatment history score is three (3), equivocal response to treatment and recovery. Previous treatment had kept the patient sober. However, the patient stopped going to Alcoholics Anonymous (AA) meetings after 180 days and stopped his Vivitrol and Naltrexone. The patients engagement and recovery status score is two (2), positive engagement and recovery. The patient is cooperative and compliant with treatment. The patient feels that the patient can be treated in a less restrictive environment, so the patient can be with his spouse and children. Based on these criteria, the patient has a total score of 17 and would meet criteria for in a less restrictive environment such as an intensive outpatient program (IOP). The patient continued to need treatment for alcohol use disorder, but the patient had improved enough to be treated in a less restrictive environment. Therefore, the RTC services provided were not medically necessary for treatment of the 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 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 44-year-old female enrollee has requested pulsed radiofrequency (RF) nerve lesioning (and related services for treatment of her complex regional pain syndrome (CRPS).   Findings:  Three physician reviewers found that there is no documentation in the literature indicating pulsed RF lesioning is a standard therapy for CRPS. No single treatment is uniformly effective. Recommended therapies include physical therapy, pharmacotherapeutic agents (corticosteroids, tricyclic antidepressants, anticonvulsants, opioids and topical agents), sympathetic blocks, regional and neuraxial blockade and neuromodulation. The literature to date is limited to only a few controlled trials involving the treatment of trigeminal neuralgia and lumbar facet arthropathy. The use of pulsed RF lesioning in the treatment of CRPS is considered investigational. Studies are needed to determine the mechanism of action of this modality and to compare pulsed RF with conventional RF. The consensus to date is that successful treatment of this syndrome relies on an aggressive multidisciplinary approach that focuses on pain relief, physical rehabilitation and control of psychological dysfunction.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: A 40-year-old male enrollee has requested authorization and coverage for Otezla 30 mg for treatment of the enrollees plaque psoriasis. Findings:  The physician reviewer found that this patient presents with a history of plaque psoriasis affecting the scalp, face and body. He has failed therapy with topical steroids and topical vitamin D analogues. The patient has not tried and failed treatment with methotrexate, cyclosporine, or the preferred injectable biologic agents. As there is no documentation of contraindications or side effects from the use of these medications, the requested Otezla is not supported as medically necessary as the Health Plans formulary options are likely to be as or more beneficial in the treatment of the patients plaque psoriasis. Thus, the requested Otezla 30 mg is not medically necessary for treatment of this patients plaque psoriasis. 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 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: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Jardiance 10 mg tablets. Jardiance is a sodium-glucose cotransporter-2 (SGLT-2) inhibitor that is U.S. Food and Drug Administration (FDA) approved for management of type 2 diabetes. Data from the American Diabetes Association and the European Association for the Study of Diabetes has demonstrated that starting a SGLT-2 inhibitor can be beneficial to improve glycemic control in patients with established type 2 diabetes. In this case, the Health Plan has authorized alternatives to Jardiance including metformin, glipizide, glyburide, glimepiride and/or pioglitazone. This patient demonstrated intolerance to metformin therapy, thus its use is contraindicated. In addition, sulfonylureas are not first-line therapies for management of type 2 diabetes. Further, pioglitazone has a side effect profile including weight gain and pedal edema, thus is not suited as a first-line therapy. Given these findings, Jardiance 10 mg tablets are medically necessary for managing this patients type 2 diabetes.Final Result: The reviewer determined that the services at issue 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 internal medicine with sub-specialty certification in endocrinology, diabetes and metabolism 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 continued partial hospitalization program (PHP) services for treatment of his behavioral health condition. Findings: The physician reviewer found that a comprehensive aftercare plan has been developed consisting of intensive outpatient programming, individual therapy, psychiatric services, couples counseling and continued community programming. The patients willingness and ability to address issues from his past signifies meaningful therapeutic progress commonly seen in sustained sobriety. The further pursuit of reconciling intrapsychic conflicts via insight-oriented or psychodynamic therapy, or on-going relapse prevention efforts for that matter, do not require the partial hospital level of care. Based on the data provided, the comprehensive treatment plan developed by the Health Plan is safe, appropriate and consistent with good medical practice. Thus, an extension of services at the PHP level of care is not medically necessary. Final Result: The reviewer determined that the requested services are not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in 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: Experimental/Investigational
Decision: Upheld

The parent of a six-year-old male enrollee has requested vision therapy for the treatment of the enrollees ocular motor dysfunction. Findings:  Three physician reviewers found that this patient had a normal eye exam with no evidence of strabismus. The documents submitted do not demonstrate the presence of an ocular disorder that is likely to benefit from vision therapy. For this patient, vision therapy is of unproven value and lacks a sound scientific basis. There is no scientifically proven link between eye movement and reading difficulties. Furthermore, there is no scientific documentation that training in eye tracking and movement results in any long-term benefits. Thus, there is insufficient support for the efficacy of vision therapy to support its use in this particular setting.
Appeal type: Medical Necessity
Decision: Overturned

A 33-year-old male enrollee has requested for mental health outpatient therapy for treatment of his behavioral health condition. Findings:  The physician reviewer found that Leichsenring and Rabung provide evidence that individuals with chronic and complex mental illnesses improve with long-term psychotherapy, and that a greater number of sessions is associated with better outcomes. Furthermore, Bolton and colleagues provide evidence that anxiety disorders (including PTSD) independently increase the risk for suicidal behavior. Although a medication adjustment could certainly be attempted and may indeed augment this patients psychotherapy, it is not an alternative, but a compliment to the therapy. All told, this patient is extremely ill and suffering from multiple psychiatric conditions. He requires an ongoing intensive multi-pronged approach including medication management, attending AA, and individual psychotherapy twice per week in order to improve his functioning and reduce his risk for suicide.
Appeal type: Medical Necessity
Decision: Upheld

A 55-year-old male enrollee has requested surgery to reattach his torn bicep tendon to the bone for treatment of his medical condition. Findings:  The physician reviewer found that in this case, the patient experienced a rupture of the long head of the biceps muscle. A tenotomy (surgical detachment of the tendon), would mimic the effect of spontaneous rupture of the long head of the biceps. A study by Koh and colleagues studied 48 tenodesis procedures (surgical reattachment of tendon) and 41 tenotomy procedures with assessment of Popeye deformity, cramping, pain and measurement of elbow flexion power. In comparing outcomes of the two procedures, the authors documented a slight difference in incidence of Popeye deformity, which is a cosmetic issue. Otherwise, there were no significant differences between tenodesis and tenotomy. Of further note, based on the evidence provided, it is not entirely clear that the patients torn tendon is the primary cause of his shoulder pain. Additional pain generators could be subacromial impingement syndrome, rotator cuff tendinosis (which is suspected by the patients providers) and referred pain from the base of the cervical spine to the shoulder; the proposed procedure is not an appropriate treatment for any of these conditions and would not result in clinical benefit.
Appeal type: Medical Necessity
Decision: Upheld

A 51-year-old female enrollee has requested use of a continuous passive motion machine for the treatment of her medical condition, status post left total knee replacement. Findings:  The physician reviewer found that the benefit of the use of a continuous passive motion machine following total knee replacement has been the subject of debate for many years. While there is some consensus for its usefulness in the early postoperative period, there is little support in the literature for continued employment of the continued passive motion machine for longer periods of time. The use of a home continuous passive motion machine was not indicated for treatment of this patient.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary:  An enrollee has requested reimbursement for left knee genicular nerve injection (CPT 64454) provided on 1/12/21 and left knee genicular nerve destruction (CPT 64624) provided on 2/09/21.Findings: Three out of three physician reviewers found that left knee genicular nerve injection (CPT 64454) provided on 1/12/21 and left knee genicular nerve destruction (CPT 64624) provided on 2/09/21 were likely to have been more beneficial for you than any available standard therapy.Cankurtaran and colleagues compared the effectiveness of ultrasound-guided versus blind genicular nerve block for the treatment of osteoarthritis. The authors noted, Both ultrasound-guided and blind genicular nerve block, in the treatment of knee osteoarthritis, were effective in reducing symptoms and improving physical function. Konya and colleagues found that visual analogue scale (VAS) scores were significantly lower after genicular radiofrequency ablation. The report noted that genicular radiofrequency ablation reduced the need for opioids and nonsteroidal anti-inflammatory drugs (NSAIDs). Further, the authors concluded, In chronic refractory knee pain due to osteoarthritis, the application of radiofrequency ablation to the genicular nerve is an effective and safe treatment option in the medium to long term. Finally, El-Hakeim and colleagues reported superior pain relief in patients treated with radiofrequency ablation than in patients undergoing conservative management consisting of oral acetaminophen, diclofenac, and physical therapy. In this case, the patient has chronic knee pain with magnetic resonance imaging confirming severe osteoarthritis. The patient has tried and failed conservative care options, including intra-articular steroid injections, viscosupplementation injections, and physical therapy. There is evidence in the literature to suggest radiofrequency ablation is effective for treating knee pain and that this therapy is superior to conservative therapy. Therefore, left knee genicular nerve injection (CPT 64454) provided on 1/12/21 and left knee genicular nerve destruction (CPT 64624) provided on 2/09/21 were likely to have been more beneficial for treatment of the patients condition than any available standard therapy.Final Result: The reviewers determined that the services at issue were likely to have been more beneficial than any available standard treatment for the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer 1, reviewer 2, and reviewer 3 are board certified in anesthesiology with sub-specialty certification in pain medicine. All reviewers 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

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for the administration of the Rituxan 500 mg/50 mL medication at a hospital outpatient setting. Neuromyelitis optica is an immune-mediated chronic inflammatory disease of the central nervous system. It presents with optic neuritis and myelitis, which can cause blindness and paralysis, respectively. Medical literatures note that therapy for neuromyelitis optica should be initiated early, and that rituximab is regarded as an established first-line treatment with long-term efficacy and an acceptable safety profile. However, rituximab is also a high risk therapy with multiple potential adverse side effects. Researchers report that while rituximab is a standard treatment for neuromyelitis optica, there is the risk of infusion-related reactions. The U.S. Food and Drug Administration (FDA) prescribing information notes that rituximab administration may result in serious, including fatal, infusion-related reactions, tumor lysis syndrome, severe mucocutaneous reactions, and progressive multifocal leukoencephalopathy. The FDA notes that fatal infusion reactions within 24-hours of infusion may occur and advises that patients be monitored for severe reactions. In this case, the records note that the patient experienced a rash shortly after receiving infusion in the past. In a letter, the provider reports that the patient is high risk for anaphylaxis. In this clinical setting, given the recommendations for close monitoring of patients while receiving therapy, the requested service is medically indicated. Therefore, the administration of the Rituxan 500 mg/50 mL medication at a hospital outpatient setting is medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested service 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 internal medicine with sub-specialty certification in rheumatology 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 OxyContin 20 mg ER tablets (60 per 30 days). The submitted documentation fails to demonstrate the medical necessity of the requested medication. She has tried and failed Ultram in the past. Thus, tramadol extended-release is not medically reasonable. However, fentanyl transdermal patches are a medically reasonable treatment option. While the Centers for Disease Control and Prevention has recommended tapering patients off opiates for non-cancer pain, this patient has opiate responsive pain, and a trial of fentanyl transdermal patch is medically appropriate. Therefore, OxyContin 20 mg ER tablets (60 per 30 days) is not medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested medication is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is board certified in anesthesiology with sub-specialty certification in pain medicine and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

 Nature of Statutory Criteria/Case Summary:   An enrollee has requested morphine concentrate (Roxanol) for treatment of her medical condition. Findings:  The physician reviewer found that morphine concentrate (Roxanol) is not medically necessary for treatment of the patients medical condition. The current standard of care for chronic pain is treatment in a multidisciplinary practice to include physical therapy, massage therapy, behavioral therapy, and injections to help reduce pain.  Researchers reported that high dose and short acting opiates might contribute to pain sensitization via opioid-induced hyperalgesia, decreasing patient pain threshold and potentially masking resolution of a preexisting pain condition. In this retrospective study, the majority of patients undergoing detoxification of high dose opiates for chronic pain reported a significant decrease in pain at the end of the study, further supporting the theory of opioid-induced hyperalgesia. In sum, Roxanol is not clinically indicated for treatment of the 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 physician 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.