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

A male enrollee requested the attended nocturnal polysomnogram and continuous positive airway pressure (CPAP) titration nocturnal polysomnogram for medical treatment of his mild obstructive sleep apnea.   Findings:  The physician reviewer found that The American Academy of Sleep Medicine guidelines indicate that home testing should be performed on patients with high pretest probability of moderate to severe obstructive sleep apnea. This patients pre-test probability for moderate to severe obstructive sleep apnea is low. As such, this is a case where the sensitivity of in-lab testing was important and indicated. Thus, attended nocturnal polysomnogram was appropriate to assist in this patients diagnosis.
Appeal type: Medical Necessity
Decision: Overturned

The patients parent has requested reimbursement for inpatient psychiatric treatment program services.  The American Academy of Child and Adolescent Psychiatry and the American Association of Community Psychiatrists Child and Adolescent Level of Care Utilization System (CALOCUS) provides a reliable framework for determining the appropriate level of care for adolescents needing mental health treatment. Using CALOCUS, providers score patients on a scale of 1-5 using a six-pronged Dimensional Rating System. The six dimensions include: (1) risk of harm; (2) functional status; (3) developmental, medical, substance use and psychiatric comorbidity; (4) recovery environment (a. stressors and b. supports); (5) treatment and recovery history; and (6) engagement. The composite score is then used to determine the level of care needed. Based on CALOCUS criteria, this patient met the criteria for inpatient psychiatric treatment program services. The patients composite score is consistent with medically monitored residence based services. However, the patients score for risk of harm and functional status, supports treatment at the inpatient psychiatric level of care. Given these findings, the inpatient psychiatric treatment program services were medically necessary for 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 with subspecialty certification in child and adolescent 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 23-year-old female enrollee has requested culture followed by appropriate antibiotic treatment, monthly kenalog injections (from 10mg per cc up to 40mg per cc as needed), and destruction of hair follicles with laser hair removal utilizing 1064 YAG or Alexandrite (4-8 treatments) for treatment of her hidradenitis suppurativa. Findings:  The physician reviewer found that most patients respond only partially to treatment, or the disease rapidly reoccurs after drug cessation. HS can be managed by a number of different treatments, including antibiotics, immunosuppressive drugs, TNF-alpha inhibitors, surgery, and radiation. Intralesional therapy with triamcinolone (kenalog) may also be helpful. The procedure often reduces pain and discomfort rapidly due to the resolution of inflammation (Yazdanyar and Jemec). Nd:YAG laser was shown to be an effective treatment for patients with stage II to stage III HS (Rambhatla, et al). All told, the requested services including culture followed by appropriate antibiotic treatment, monthly kenalog injections (from 10mg per cc up to 40mg per cc as needed), and destruction of hair follicles with laser hair removal utilizing 1064 YAG or Alexandrite (4-8 treatments) is supported as medically necessary for this patients medical condition and should be approved.
Appeal type: Experimental/Investigational
Decision: Upheld

A 38-year-old male enrollee has requested artificial disc replacement surgery for treatment of his back pain.   Findings:  Three physician reviewers found that the medical records noted low back pain due to degenerative L5-S1 disc.  The Health Plan has denied coverage for the requested procedure.  The patient has appealed this denial.  The superior efficacy of the requested procedure in this clinical situation has not been established.  There are insufficient long-term, randomized, controlled trials documenting the superior efficacy and safety of lumbar disc replacement over the standard treatment, one-level lumbar arthrodesis.  The long-term adverse effects of arthroplasty materials, specifically wear debris from metals and polymers, are not known at this time.  The current medical evidence does not support the requested procedure in this patients case.  All told, the requested artificial disc replacement surgery is not likely to be more efficacious than other available treatment options in this patients case.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for FoundationOne CDx genetic testing. The development of sophisticated genetic and molecular characterization of central nervous system neoplasms has shown that histologically similar neoplasms can be characterized more accurately for prognosis and in some instances for response to different therapies. Molecular characterization of primary brain tumors/gliomas has had a substantial impact on stratification and eligibility in clinical trials for central nervous system neoplasms over the last ten years and is increasingly becoming a common part of standard neuro-oncology management. The National Comprehensive Cancer Network guidelines recommend molecular profiling to identify clinically relevant subtypes to encourage opportunities for clinical trial involvement. Given the lack of efficacious treatments available for patients with glioblastoma, there is sufficient support for the use of molecular testing, such as FoundationOne CDx genetic testing. Therefore, FoundationOne CDx genetic testing was likely to have been more beneficial for evaluation of the patients condition than any available standard therapy. Findings: Two of the three physician reviewers found FoundationOne CDx genetic testing was likely to have been more beneficial for evaluation 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 for evaluation 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 internal medicine with sub-specialty certification in medical oncology and is actively practicing. Physician reviewer 2 is board certified in internal medicine with sub-specialty certification in medical oncology and is actively practicing. Physician reviewer 3 is board certified in internal medicine with sub-specialty certification in medical oncology 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 55-year-old female enrollee has requested Zoll LifeVest for treatment of her congestive heart failure.  Findings:  Two physician reviewers found that in this patients case, the device at issue was likely to have been superior over other available treatment options.  This patient had recent onset non-ischemic cardiomyopathy with a left ventricular ejection fraction estimated at 20-25% of likely viral etiology.  There is a reasonable likelihood of recovery of near normal left ventricular function in this setting over a three to six month period.  A wearable life vest cardioverter-defibrillator can provide temporary protection from sudden death due to arrhythmia in this patient population during this interim period.  There is adequate support for the device at issue in the clinical setting.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary:  An enrollee has requested BRCA testing for evaluation of her medical condition. Findings:  Two physician reviewers found that there is sufficient support for the services at issue in this clinical setting.  This patient has a strong family history of breast cancer.  Per the current medical evidence, testing should be considered in appropriate high-risk individuals where it will impact the medical management of the tested individual and/or their at-risk family members.  In this patients case, a positive or negative test would alter how this patient is managed.  All told, BRCA testing was likely to have been superior over other modalities for evaluating this patient. Final Result: Two reviewers determined that the services at issue were likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned.  Credentials/Qualifications:  All three reviewers are board certified in internal medicine with sub-specialty certification in medical 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: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for hyaluronan injections to the left knee. Findings:  The physician reviewer found that the requested services are medically necessary for treatment of the enrollees medical condition. Therefore, the Health Plans denial should be overturned.This enrollee has osteoarthritis and has failed other treatments. The enrollee has benefitted from viscosupplementation with Synvisc One in the past. The current medical literature pertaining to viscosupplementation reveals mixed results. Although viscosupplementation may relieve knee pain in some individuals with osteoarthritis, it is not known 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 does not support viscosupplementation as a standard treatment for osteoarthritis of the knees. Viscosupplementation can only be recommended in individuals with a history of lasting benefit from prior injections and in carefully selected cases where the options are limited. In this enrollees case, prior viscosupplementation has been beneficial, and her options are limited. The enrollee has tried and failed other conservative treatments, including corticosteroid injections. Therefore, hyaluronan injections to the left knee are medically necessary for the treatment of this enrollee.Final Result: The reviewer determined that the requested services are medically necessary for treatment of the enrollees 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

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for Botox injections and prospective authorization and coverage for future Botox injections every 12 weeks for treatment of the enrollees migraines. Findings:  Two physician reviewers found that this patient carries a diagnosis of chronic migraine. The submitted medical documentation does not provide adequate information to confirm a diagnosis of chronic migraine.  No information regarding headache frequency or characteristics that would confirm migraine is included in the note.  There is also no information regarding prior preventives, other than propranolol.  Botox has been shown to be beneficial for preventive treatment of chronic migraine, and the records do not confirm this diagnosis.  Final Result: The reviewers determined that the services at issue were not and 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: The Reviewer number are board certified in neurology 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 66-year-old female has requested Xifaxan for treatment of her small intestinal bowel overgrowth.  Findings:  The physician reviewer found that SIBO is well recognized in the peer-reviewed medical literature. In terms of treatment, Rifaximin (Xifaxan) has been shown to have a higher SIBO decontamination rate than metronidazole (Lauritano, et al.). Additionally, Xifaxan was noted to have a lower number of adverse side effects, when compared with metronidazole or levofloxacin (Pimentel). The patient has met all of the diagnostic criteria specified by the Health Plan, including: documentation of two SIBO breath tests; a contraindication to three alternative antibiotics due to her pending cardiac procedure; and the patient has waited the requisite 21-day treatment cycle. As such, the patient is a candidate for an additional course of Xifaxan.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested duloxetine (Cymbalta) for treatment of his medical condition. Findings: The physician reviewer found that peer-reviewed medical literature indicates that chronic alcohol consumption produces painful peripheral neuropathy for which there is no reliable successful therapy, mainly due to lack of understanding of its pathobiology. The mechanism behind alcoholic neuropathy is not well understood, but several explanations have been proposed. These include activation of spinal cord microglia after chronic alcohol consumption, oxidative stress leading to free radical damage to nerves, activation of mGlu5 receptors in the spinal cord and activation of the sympathoadrenal and hypothalamo-pituitary-adrenal (HPA) axis. Nutritional deficiency (especially thiamine deficiency) and/or the direct toxic effect of alcohol or both have also been implicated in alcohol-induced neuropathic pain. Treatment is directed towards halting further damage to the peripheral nerves and restoring their normal functioning. Tricyclic antidepressants (TCAs) are often the first line drugs to alleviate neuropathic pain symptoms. They have central effects on pain transmission and block the active re-uptake of norepinephrine and serotonin. TCAs have been shown to relieve various neuropathic pain conditions in many trials. One recent study has confirmed the efficacy of TCAs in central pain. The serotonin/norepinephrine re-uptake inhibitors (SNRIs), duloxetine (Cymbalta) and venlafaxine, have a well-documented efficacy in painful polyneuropathy. Although duloxetine is indicated for the treatment of diabetic polyneuropathy, it has shown clinical efficacy in treating many different types of polyneuropathy including alcoholic polyneuropathy. Therefore, duloxetine (Cymbalta) has been shown to be an effective therapy in the treatment of patients diagnosed with neuropathy. Moreover, the patient also stated that he has been taking duloxetine (Cymbalta) for the last three months with good results. For all these reasons, the medication at issue was and is medically necessary for treatment of this patients polyneuropathy.  Final Result: The reviewer determined that the medication at issue was and 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 neurology 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 hyperthermia treatment; hyperthermia superficial; set radiation therapy field; and radiation treatment management times five, and 30 additional treatments including hyperthermia treatment; hyperthermia superficial; set radiation therapy field; and radiation treatment management times five. There is a paucity of high quality studies demonstrating the safety and efficacy of hyperthermia as compared to the standard of care consisting of chemoradiotherapy or infusion bacillus Calmette-Guerin (BCG) in the treatment of bladder cancer. One study examining the role of hyperthermia concluded that, given the high rate of severe side-effects leading to treatment discontinuation, as well as the limited tumor response, thermochemotherapy should be offered only in highly selected cases of recurrent non-muscle-invasive bladder cancer. In addition, the National Comprehensive Cancer Network (NCCN) guidelines do not support hyperthermia for the treatment of bladder cancer. All told, hyperthermia treatment; hyperthermia superficial; set radiation therapy field; and radiation treatment management times five, and 30 additional treatments including hyperthermia treatment; hyperthermia superficial; set radiation therapy field; and radiation treatment management times five, were not and are not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Findings:  Three physician reviewers found hyperthermia treatment; hyperthermia superficial; set radiation therapy field; and radiation treatment management times five received and 30 additional treatments including hyperthermia treatment; hyperthermia superficial; set radiation therapy field; and radiation treatment management times five were not and are 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 services at issue were not and are not likely to be more beneficial for treatment of the patient's medical condition than any available standard therapy. Therefore, the Health Plans denial should upheld. Credentials/Qualifications: Physician reviewers 1, 2 and 3 are board certified in radiation oncology 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: Experimental/Investigational
Decision: Upheld

A 54-year-old female enrollee has requested for left hip femoral acetabular surgery for treatment of herr labral tear and hip impingement syndrome.  Findings:  Two physician reviewers found that hip impingement is a fairly recently recognized pathologic process, and femoro-acetabular impingement syndrome (FAIS) is being considered as an early cause of osteoarthritis. The condition occurs primarily in younger patients and is not usually due to trauma. The medical literature describes two different types of impingements: Cam type and Pincer type. Larson and Giveans reported on arthroscopic treatment of femoro-acetabular impingement on 100 hips treated with labral debridement or repair. There was a 6% incidence of heterotopic bone formation, and 3% of the patients underwent total hip arthroplasty at a later stage. The authors questioned the alteration of the natural progression of FAIS to osteoarthritis, and sustained pain relief as a result of arthroscopic surgery. Philippon and colleagues recommend arthroscopic management of femoro-acetabular impingement and osteoplasty techniques to be performed only in high performance athletes and high demand patients. Further, Espinosa and colleagues examined labral re-fixation after FAIS as it affects clinical and radiographic results. The authors retrospectively reviewed 52 patients in 60 hips with FAIS and found that only 28% of the resection group had excellent results, compared to 80% of the re-attachment group. Overall, the authors concluded that long-term follow-up remains necessary to prove the success rate, safety and long-term (greater than two-years) outcome of the procedure.
Appeal type: Medical Necessity
Decision: Upheld

Findings:  The physician reviewer found that The patient has requested authorization and coverage for lumbar surgery (L4-5 decompression supplemented by an instrumented fusion using autograft/allograft, a bilateral pedicle screw/rod construct and possible interbody fusion device). Spinal fusion may benefit individuals with spinal instability and chronic low back pain without response to any conservative measures, among other conditions. In this case, the records do not demonstrate evidence of spinal instability or that the patient has exhausted conservative options of at least twelve weeks in duration for the treatment of chronic low back pain. The patient has significant comorbidities, making the patient a high risk for elective spinal surgery, and is non-compliant with simple care instructions such as taking Xarelto for hypercoagulable state. The patient's severe osteoporosis makes the likelihood of a successful fusion doubtful. The submitted records suggest that ongoing back pain is not chronic in nature. While the patient reported prior back pain, similar recent symptoms are insufficient to establish a causal relationship between the two. A radiographic finding of disc desiccation is insufficient to establish a causal connection between this finding and the patients symptoms. Additionally, the requested fusion level does not appear to correlate with the radicular findings. Given that the records do not demonstrate trial and failure of conservative options or that the patients pain is chronic in nature, and given the patients comorbidities, the requested service is not medically indicated. Therefore, lumbar surgery (L4-5 decompression supplemented by an instrumented fusion using autograft/allograft, a bilateral pedicle screw/rod construct and possible interbody fusion device) is not medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested service is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.