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

A 41-year-old female enrollee has requested IVIG infusion and coverage for future IVIG infusions for treatment of her recurrent miscarriages.  Findings:  Three physician reviewers found that the American College of Obstetrics and Gynecology Practice Bulletin concluded that IVIG is not effective in preventing recurrent pregnancy loss.  A review of current literature and meta-analyses indicates inconsistent and very poor results with IVIG for recurrent pregnancy loss.  In addition, the only patients in whom there is a report of possible improvement are those with secondary recurrent miscarriage, or miscarriages following a successful pregnancy.  In primary recurrent miscarriage, where a woman has not had a prior successful pregnancy, treatment with IVIG has shown no improvement compared to placebo therapy.  Porter and colleagues concluded that IVIG treatment provides no significant beneficial effect over placebo in improving the live birth rate.  In conclusion, studies to date do not support IVIG as therapy for this condition, with results indicating no more efficacy than placebo.  In addition, it is not clear that other causes, such as chromosomal abnormalities, have been excluded.  Therefore, IVIG infusions were not and are not likely to be superior over all other treatment alternatives.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for a medication increase, Humira injection pen (four pens per 28 days). Findings: The American College of Rheumatology (ACR) guideline for the treatment of rheumatoid arthritis, recommends the addition of a biologic disease-modifying antirheumatic drugs (DMARD), such as Humira, or a target synthetic DMARD, such as Xeljanz, for patients who have not achieved control with maximally tolerated doses of methotrexate. In this case, the patient is on methotrexate 15 mg weekly, with uncontrolled rheumatoid arthritis. The provider reported that the patients methotrexate dosage was being optimized. Given that ACR guidelines recommend optimizing the methotrexate dose while continuing Humira every other week, or two pens per month, the requested medication regimen is not medically indicated. Therefore, a medication increase, Humira injection pen (four pens per 28 days), is not medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested medication regimen 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 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 Soma, Norco 10 mg, cough syrup with codeine and Ativan 10 mg for treatment of her knee pain and migraine headaches. The physician reviewer found that the requested medications are not medically necessary for treatment of the patients medical conditions. In this case, the patient presents with chronic low back pain, shoulder pain, knee pain and headaches. The patient also has a diagnosis of bipolar disorder including recent substance abuse and manic episodes. According to the documentation submitted for review, the patient has been non-compliant in psychological treatments and tested positive for methamphetamine, cocaine, and marijuana. In addition, the medications in question are notable for the fact that all of the requested medications are Schedule II or III medications. Based on the documentation submitted for review, given the patients recent substance abuse, manic episodes and non-compliance of me psychological treatments the requested medications are not medically necessary. Final Result: The reviewer determined that the requested medications 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 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: Experimental/Investigational
Decision: Overturned

A 55-year-old male enrollee has requested a functional electrical stimulator (prosthetic WalkAide System) for treatment of his foot drop. Findings:  Two physician reviewers found that this patient has a documented benefit from the use of a WalkAide for his right lower extremity. There is documented improvement in his gait and stabilization of his palpable sclerosis. He has bilateral foot drop. There are several studies that have documented the benefit of a functional electrical stimulation for patients with foot drop. Given the functional benefit that he has seen from the device on his right leg, as well as the evidence in the literature to support its use, a prosthetic WalkAide System is likely to be superior to any standard device/modality.
Appeal type: Medical Necessity
Decision: Overturned

The patient is a diabetic 56-year-old male who has undergone left below-the-knee amputation in 2004 as well as a right superficial femoral and peroneal artery angioplasty followed by a right great toe amputation in January 2006. The amputation site has not healed. An arteriogram shows multiple tibial artery stenosis.  The patient consulted a vascular surgeon who feels that an attempt at limb salvage using either percutaneous atherectomy (the Silverhawk device) or distal bypass to the pedal vessels using lesser saphenous vein, arm vein, or homograft vein would be appropriate. At issue is whether percutaneous atherectomy or small distal bypass is medically necessary for treatment of the patients medical condition.Percutaneous atherectomy with the Silverhawk device has not been proven to be equivalent to standard, open surgical bypass for this patients condition and therefore, is not medically necessary.  Although the Silverhawk device is FDA approved, there are no randomized, controlled trials with long-term follow-up to prove the safety and efficacy of this device.  A recent article by Rubin reviewing the current literature on the Silverhawk device concludes, Like many endovascular technologies, reports have focused on rates of initial technical success and short-term outcomes, but long-term results remain unknown. This report reviews selected published or presented results of plaque excision, touches on areas of concern or controversy regarding both the device and some of its proponents, and suggests clinical or anatomic settings in which plaque excision appears most effective. The ultimate utility of this technology will depend on confirmation of its acute and long-term outcomes through unbiased, well-designed clinical trials.Although there is insufficient evidence to support percutaneous atherectomy for this patient, below-the-knee amputation is not the patients only option. The consulting vascular surgeon has determined that standard treatment (distal bypass) is a valid treatment option for this patient. In a patient with a contralateral amputation, aggressive attempts at revascularization of the remaining limb for limb salvage are warranted. As such, small distal bypass is within the standard of care and medically necessary for treatment of the patients condition.For the reasons set forth above, I have determined that percutaneous atherectomy is not medically necessary for treatment of your medical condition, but small distal bypass is medically necessary for treatment of your medical condition. Therefore, the Health Plans denial should be partially overturned.
Appeal type: Medical Necessity
Decision: Upheld

The parent of a 14-year-old male enrollee has requested a knee brace for the treatment of the enrollees knee pain. Findings:  The physician reviewer found that this patients MRI did not demonstrate any evidence of collateral ligament injury or pathology. Serial examinations by two orthopedic surgeons on five separate occasions failed to demonstrate any evidence of medial collateral ligament (MCL), lateral collateral ligament (LCL), anterior cruciate ligament (ACL), or posterior cruciate ligament (PCL) instability. Thus, it would appear that the brace was prescribed in a prophylactic capacity only. The review article by France and Paulos provides an overview of knee braces including prophylactic devices. With regards to prophylactic knee braces, the authors conclude that currently there is no consensus pertaining to the need for prophylactic knee bracing, although there are limited indications for prophylactic knee bracing. They indicate that single upright braces with long lever arms are most effective in reducing knee ligament forces during lateral impacts to the knee. In this context, France and Paulos are indicating that such a brace would potentially be of benefit in protecting the MCL. This potentially protective effect was felt to be of particular value in specific situations, primarily athletes at risk for lateral impact injuries to the knee. The patient had no clinical or radiographic evidence of an MCL injury. His pathology was confined to the medial meniscus. There is no documented evidence indicating a protective value of any brace in this patients condition.
Appeal type: Medical Necessity
Decision: Overturned

The patient has requested reimbursement for fertility preservation services. Currently, fertility preservation is a basic medical need for all reproductive aged patients newly diagnosed with cancer undergoing chemotherapy. Chemotherapy is a gonadotoxic treatment that results in infertility. For reproductive aged patients with newly diagnosed cancer, it is within in the current standard of care to provide counseling about their options fertility preservation. As noted by the American Society for Reproductive Medicine (ASRM), fertility preservation requires individualization. Established techniques for fertility preservation such as cryopreservation of embryos and oocytes are associated with the greatest likelihood of successfully generating offspring. As this patient was diagnosed with Ewing sarcoma and was planned to undergo gonadotoxic therapy, the fertility preservation services were medically necessary for 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 obstetrics and gynecology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a two-year-old female enrollee has requested for speech therapy for treatment of the enrollees speech delay.  Findings:  The physician reviewer found that Gallagher and Chiat evaluated speech and language interventions for 24 preschool children with specific language impairment. The authors reported statistically greater improvement with intensive direct speech and language therapy delivered by speech and language therapists over an 8-month period when compared to no intervention or nursery-based intervention. This patient continues to display expressive and receptive language impairment with decreased acquisition of language skills. Based on the foregoing discussion, the requested speech therapy is medically necessary in the treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for residential treatment center services. The submitted documentation supports the medical necessity of a portion of the services at issue. Modern psychiatric practice favors treatment in the community as outcome measures and therapeutic gains are optimized in this environment. In this patients case, he was motivated for care. He self-referred for treatment and had safe housing. Prior to the admission, he had just started counseling and was going to see the therapist individually as well. This patient reported a history of complicated alcohol withdrawal. Thus, an extended period of observation at the outset was reasonably expected to prevent a more serious episode of illness. The patient rated his alcohol craving. His craving went down.  The patient was discharged from detoxification sub-specialty services. In sum, the record does not reflect that comprehensive, evidence-based services provided in a less restrictive setting would have been unsafe or inadequate. Thus, a portion of the residential treatment center services at issue were medically necessary.  Final Result: The reviewer determined a portion of the services at issue was medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be partially 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 sofosbuvir/velpatasvir (Epclusa) 400/100 mg once a day for a duration of 12 weeks for treatment of the enrollees chronic hepatitis C virus (HCV) genotype 3a. Findings:  The physician reviewer found that according to joint guidelines issued by the American Association for the Study of Liver Diseases (AASLD) and the Infectious Diseases Society of America (IDSA), all patients with chronic hepatitis C should be treated except those with life expectancy less than 12 months due to non-liver-related conditions. This applies in all cases, regardless of fibrosis stage. Per the guidelines, Epclusa for 12 weeks is recommended as a first-line regimen for non-cirrhotic treatment naive genotype 3 patients. This is based on the ASTRAL-3 trial for Epclusa, which showed a high cure rate of 98%. The AASLD/IDSA guidelines cite data showing reduced survival with delayed treatment. For these reasons, the requested treatment with Epclusa 400/100 mg once a day for a duration of 12 weeks is supported as medically necessary for the treatment of this patients hepatitis C infection.  Final Result: The reviewer determined that the requested medication 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 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: Overturned

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested authorization and coverage for 40 hours per week of direct applied behavioral analysis (CPT 97153).The submitted documentation supports that the requested services are medically necessary. The Behavior Analyst Certification Board (BACB) has established guidelines that are specific to the treatment of individuals with autism. The guidelines highlight that treatment intensity will vary with each patient and should reflect the goals of treatment, specific client needs, and response to treatment. In this case, the patient is accessing applied behavior analysis, which is required to meet their essential health needs. The treatment is consistent with the patients autism spectrum disorder diagnosis, and the requested frequency and duration are appropriate, given the rate of problem behavior and the number of goals being actively addressed (21 goals). The progress report outlines a level of need that coincides with the number of hours requested. The services are also not being provided as a convenience to the patient or the provider and are being delivered in the least restrictive environment. Under these circumstances, the requested 40 hours per week of direct applied behavioral analysis (CPT 97153) is medically necessary to treat the patients medical condition.Final Result: The reviewer determined that the requested services are medically necessary to treat the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is a licensed psychologist who is a board certified behavior analyst 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: The patient has requested authorization and coverage for lidocaine 5% patch, 30-day supply. This patient was diagnosed with lung adenocarcinoma. He underwent a thoracotomy and subsequently developed chronic post-surgical pain (CPSP) affecting the right upper chest wall with associated numbness. Attempts to manage his pain have included Norco and Gabapentin with poor efficacy. The provider has recommended a lidocaine patch to apply to the affected area. A review study by Humble and colleagues evaluated the benefits of lidocaine patches for the prevention of CPSP after thoracic surgery. The authors found that, 5% lidocaine patches and ketamine do not prevent CPSP. Another review conducted by Moisset and colleagues evaluated pharmacological and non-pharmacological treatments for neuropathic pain. The authors focused on three studies evaluating the safety and efficacy of lidocaine patches for post-surgical and neuropathic pain. The authors found that the available evidence on the use of topical lidocaine in peripheral neuropathic pain is weak. In addition, the U.S. Food and Drug Administration (FDA) has only approved the lidocaine patch for use in the treatment of patients with post-herpetic neuralgia. Overall, there is a lack of evidence in the peer-reviewed medical literature and current FDA indications to support an indication for lidocaine patches in the treatment of CPSP. This patient does not have a diagnosis of post-herpetic neuralgia. Moreover, the records do not demonstrate that the patient has failed standard therapies for the treatment of CPSP. Therefore, the requested lidocaine 5% patch, 30-day supply is not medically necessary for 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 subspecialty certification in pain management and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary:  An enrollee has requested three-dimensional (3D) breast tomosynthesis for evaluation of her medical condition.  Findings:  Three physician reviewers found that 3D breast tomosynthesis was likely to be more beneficial for the evaluation of the patients medical condition than available standard modalities. The medical literature reported the effect of integrated two-dimensional (2D) and three-dimensional (3D) mammography in the breast cancer screening population. The authors found that Integrated 2D and 3D mammography improves breast cancer detection and has the potential to reduce false positive recalls.  Thus, the literature does support the use of breast tomosynthesis over conventional mammogram due to improved cancer detection rate. Based on the support in the medical literature and the clinical documentation submitted for review, the use of breast tomosynthesis was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Final Result: Three reviewers determined that the diagnostic procedures 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 diagnostic radiology 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: Upheld

Nature of Statutory Criteria/Case Summary: The enrollee has requested authorization and coverage for acupuncture. The documentation provided does not support the requested acupuncture in this clinical setting. However, the records did not include examination findings of prior acupuncture care nor what benefits this patient had achieved from those services. Additionally, the acupuncture evaluation and a recommended plan of care performed on 8/22/17, does not appear to have been based on current evaluations of the patients history, complaints, examination findings or evidence of prior acupuncture visits. A plan of care for treatment of this patients medical condition were not provided. The provider has not documented physical or orthopedic examinations of the low back. The x-ray noted in the documentation was performed on 10/30/15. Therefore, given the lack of documentation of recent workup, acupuncture is not medically necessary for treatment of this patients medical condition.Final Result: The reviewer determined that 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 oriental 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.