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

The enrollee requested authorization and coverage for surgical insertion of a Superion interspinous process spacer for chronic, intractable low back pain and neurogenic claudication to the bilateral lower extremities. She cannot walk moderate distances in excess of 50 to 100 feet without severe pain. Her pain is impairing her ability to complete the basic activities of daily living. A magnetic resonance imaging scan shows evidence of lumbar spinal stenosis. Other radiographic studies show no spinal instability or remarkable scoliosis. The enrollee has failed over six months of conservative treatment, including physical therapy, home-based exercises, massage, chiropractic treatment, acupuncture, non-steroidal anti-inflammatory medications, over-the-counter non-prescription transdermal medications, oral opioids, epidural steroid injections, and attempts at bracing. Her provider indicates continued conservative treatment is not expected to yield substantive clinical improvement. Although surgical decompression is the other treatment option, the enrollee is not a good candidate for such an invasive surgical procedure, and the enrollee does not want this procedure at this time. Her physician recommended indirect decompression to the L4-L5 level. The use of an interspinous process spacer may be applicable in cases of single level stenosis. However, due to the disk space degeneration at L5-S1 and the multiple levels of degenerative spondylosis, this enrollee is not a good candidate for a Superion interspinous process spacer. A review of the literature regarding the superior interspinous spacer device, and other well-established surgical decompression procedures, shows a lack of large, randomized studies, which indicate Superion is more beneficial than other surgical treatments. The use of the Superion interspinous spacer has not yet been established as a standard of care, as superior to, or considered as first-line over other surgical options. Studies showed the use of interspinous devices, in those with or without Grade 1 spondylolisthesis, demonstrated no statistical difference in outcomes. Literature notes interspinous process spacers demonstrated no superiority in outcomes compared with traditional bony decompression. Evidence showed fewer surgical complications, but significantly higher re-operation rates.Final Result: Three of the three reviewers determined that the requested services are not likely to be more beneficial than any available standard therapy for treatment of the enrollees medical condition. Credentials/Qualifications: Two reviewers are board certified in pain management and one reviewer is board certified in neurological surgery 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

A 49-year-old female enrollee has requested compression stockings for the treatment of her varicose veins. Findings:  The physician reviewer found that the patient in this case appeared to have asymptomatic varicose veins. The record submitted for review does not include documented complaints related to venous insufficiency.  The sclerotherapy does not appear to have been performed for symptom relief.  There is no evidence of reflux.  In this patients case, there is no clinical indication for the compression stockings.
Appeal type: Experimental/Investigational
Decision: Upheld

A 40-year-old male enrollee has requested authorization and coverage for human chorionic gonadotropin (HCG) therapy for treatment of the enrollees low sex drive.  Findings:  Three physician reviewers found that the patient has a history of complaints of infertility, decreased libido, inability to perform, and low energy level for over three years. The patients serum testosterone is low normal and his LH and FSH are low in the context of his low testosterone level. The patients sperm count is reported as normal on initial evaluation, but documented seminanalysis reports show no sperm. The patient has requested authorization and coverage for human chorionic (HCG) therapy, which has been denied by the Health Plan as investigational. Symptomatic relief in terms of increased libido, energy, and mood elevation, from increased testosterone is a known benefit of standard androgen replacement. There is some data on the use of HCG over testosterone unless fertility concerns are paramount and symptoms are secondary. In this patients clinical circumstance, the HCG therapy is being requested primarily for the patients symptoms and not for improving fertility. As such, standard testosterone replacement is adequate to improve this patients symptoms, instead of HCG therapy. Accordingly, the requested therapy is not likely to be more beneficial for treatment of this patients medical condition than any available standard therapy.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested authorization and coverage for vision therapy with a developmental optometrist. Findings:  Three medical professional reviewers found that there is sufficient support for the requested services in this patients case. The Convergence Insufficiency Treatment Trial showed that office-based vision therapy is an effective treatment for convergence insufficiency. Long-term findings post therapy showed that patients maintained improvements after one year. Guidelines of the American Optometric Association state numerous studies have shown that vision therapy is the treatment of choice for convergence insufficiency. Per the guidelines, lenses alone are not sufficient to eliminate an accommodative spasm. In this case, the patient has symptoms consistent with convergence insufficiency and accommodative dysfunction. Office-based vision therapy has been demonstrated to be beneficial and is a recognized standard treatment in this clinical setting. Therefore, vision therapy with a developmental optometrist is likely to be more effective than other treatment options. Final Result: The reviewers determined that the requested services are likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: Medical professional reviewers 1, 2 and 3 are board certified in optometry 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

A 55-year-old male enrollee has requested right hip replacement surgery for treatment of his osteoarthritis of the right hip. Findings:  The physician reviewer found that the medical literature suggests the generally accepted indications for hip replacement surgery include the presence of arthritis documented by radiographic evidence that is not relieved by an extended course of non-surgical management including non-steroidal anti-inflammatory drugs (NSAIDs), walking aids, and other modalities as indicated. Optimally, the patients age should generally be over 55 years, but in some situations, younger patients may be appropriate candidates. While obesity is a relative contra-indication for the procedure with an increased incidence of complications, including infections, dislocations, and a higher rate of revisions, these are reported to occur more frequently in females than males. As the increased risk of infection in the obese patient exists, the scientific data does not establish that a patients pre-operative body mass index (BMI) is a predictor of complications or outcome. Thus, despite obesity as a relative contra-indication to total hip replacement surgery, this patients osteoarthritis has been documented by x-ray and MRI studies and has failed to respond to conservative management. The records indicate the patient has been treated with injections, crutch use, NSAIDs, and narcotics, but his continued pain and limited function have persisted despite this care. In addition, the records and photographs provided demonstrate successful weight loss. Overall, the medical necessity of the requested right hip replacement has been documented in this patients chart.
Appeal type: Medical Necessity
Decision: Overturned

The patient is a 74-year-old female with a long-standing history of lower back pain due to scoliosis. She is status post several spinal surgeries with relief only resulting from the first surgery in the 1960s. Her most recent spinal surgery occurred in January 1980 and she has been treated with intramuscular (IM) morphine sulfate since that time. She has been unable to tolerate Demerol, Duragesic patch, and MS Contin secondary to side effects. She apparently does not have side effects from the IM morphine sulfate, which she takes 15mg/ml morphine (0.5 to 2ml) every 3-6 hours as needed. The patient is currently requesting authorization and coverage for self-injectable morphine sulfate. The Health Plan has denied the patients request on the basis that the requested medication is not medically necessary.Review of the submitted information indicates the patient has been treated for the past 25 years with IM morphine sulfate for her severe intractable lower back pain. Despite her severe kyphoscoliosis and back pain she was able to remain functional using IM morphine therapy. The patient had been maintaining a narcotics contract from her pain physician over the years. There is no documentation of any adverse side effects from the treatment. In light of the effectiveness and duration of the treatment, continued use of IM morphine sulfate is medically appropriate and indicated. However, the patient needs to continue to be on a narcotics contract for as long as she requires morphine therapy and should be followed by a pain specialist.Based upon the information set forth above, I have determined that the requested medication is medically necessary for treatment of the patients medical condition. The Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Overturned

A 60-year-old female enrollee has requested for the FlexiTouch for treatment of her lymphedema secondary to treatment for endometrial cancer.  Findings:  The physician reviewer found that in the medical literature, a pilot prospective study of maintenance treatment of breast cancer associated lymphedema concluded that the FlexiTouch system may provide better maintenance control than self management (Wilburn, et al). In addition, a review of common treatments for edema secondary to breast cancer found that intensive therapies including pneumatic compression pumps yielded greater volume reduction as compared to self treatments including massage, compression garments or elevation (Moseley, et al). As such, intermittent compression pumps are becoming the standard of care for treatment of refractory lymphedema secondary to cancer therapies.
Appeal type: Medical Necessity
Decision: Upheld

A 36-year-old female enrollee has requested Duragesic (fentanyl) patches for treatment of her low back and hip pain. Findings:  The physician reviewer found that review of the submitted documentation and relevant literature fails to demonstrate the medical necessity of the requested medication. Current standard of care for chronic pain associated with lumbar radiculopathy is treatment in a multidisciplinary practice to include physical therapy, massage therapy, behavioral therapy, and injections to help reduce pain. There are a variety of anti-convulsants and anti-depressants considered adjunctive to this therapy (Fishman). Baron and McDonald 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. Long-term opiates are more likely to cause adverse outcomes and therefore the patients request for Duragesic patch is not indicated. Ballantyne and Mao reported that prolonged use of high dose opiates might induce tolerance, and abnormal pain sensitivity. The aim of current guidelines is to protect patients from the adverse effects of opioid therapy. The Duragesic patch as requested by the patient would be contradictory to providing safe and effective healthcare. Based on the documentation submitted for review and the peer-reviewed literature cited above, the requested medication is not medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld

The enrollees parent is requesting authorization and coverage for laser hair removal for a history of pilonidal disease, status post incision and drainage. The records indicate the enrollee underwent a procedure of incision and drainage (I&D) for an eight centimeter abscess, and an antibiotic course of Ancef. A follow up visit indicated the wound was closed and education was provided including possibility of elective pilonidal cyst excision in the future, good hygiene and hair removal with waxing, Nair or laser hair removal. Follow up at the surgery clinic indicated drainage from the incision site was clear but a 10 day course of antibiotic was prescribed for prophylaxis, and aggressive hygiene and hair removal was advised. At a subsequent follow-up visit, there was no longer any drainage or pain at the incision site and instructions were to return to the clinic as needed. She was doing waxing for hair removal. History at the next visit indicated the enrollee had recently made an appointment for laser hair removal but had also started to notice some increased pain at her coccyx. Five days of prophylactic Bactrim was prescribed. She was given clearance to proceed with laser hair removal. The record does not support the medical necessity of laser hair removal as there are other depilatory methods to remove hair.  The literature is not definitive in its recommendation regarding laser hair depilation for the treatment of pilonidal cyst disease.  Laser hair depilation has shown promise in a small series of patients with pilonidal disease and concluded that laser hair depilation is a promising therapy in the management of pilonidal disease but additional research is needed to determine its effectiveness in preventing recurrence. The medical recommendation for laser depilation for the treatment of pilonidal disease is weak due to poor quality research. There is ongoing research to study the effectiveness of laser hair depilation for the prevention of disease recurrence in adolescents and young adults with pilonidal disease. The physician reviewer found that there is no definitive study to show that laser therapy is medically necessary to treat pilonidal cyst disease. The pilonidal cyst does not constitute an abnormal structure of the enrollees body. The etiology of a pilonidal disease was thought to be congenital due to abnormal skin in the gluteal cleft.  However contemporary theory considers it acquired rather than congenital as the tendency of pilonidal disease to recur following an extensive surgical resection supports the theory that it is acquired. The requested laser hair removal is not being performed to improve function or create a normal appearance to the extent possible.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested reimbursement and prospective authorization and coverage for occupational therapy services from an occupational therapist located within approximately 5 miles or 10 minutes from his residence for treatment of the enrollees gross motor delays. Findings:  The physician reviewer found that the submitted documentation supports the medical necessity of the services at issue. This patient has deficits in many areas of functioning, including, but not limited to, fine motor skills, motor planning skills, coordination and balance, visual motor integration, speech and language skills, postural stability, and performance of age-appropriate self-help skills. His care is managed by pediatric neurology, but he does not yet carry a unifying diagnosis. He has been receiving occupational therapy in a facility close to home, with documented progress and a well-established relationship with the therapist. However, he has not yet achieved age-appropriate functional skills, and ongoing therapy has been recommended. Based on the current standard of care, ongoing occupational therapy services are medically necessary and appropriate. Provision of such services should be achieved in the least restrictive environment to allow the child to participate fully and benefit maximally. With an established relationship in a facility close to home, this child has the best opportunity to flourish. Occupational therapy services at the closest facility with which the child and family have a relationship are thus medically necessary and appropriate. Final Result: The reviewer determined that the services at issue were and are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in pediatrics 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

An enrollee has requested authorization and coverage for Gel One (hyaluronic acid) injection to bilateral knees. Current medical literature pertaining to viscosupplementation reveals mixed results. Evidence from eight systematic reviews and six randomized controlled trials indicates that 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 is limited, and guidelines from organizations such as the American Academy of Orthopedic Surgeons indicate that the evidence is not conclusive. As such, the Academy does not currently support viscosupplementation as standard treatment for osteoarthritis of the knees. In light of the foregoing, viscosupplementation can only be recommended in individuals with a history of lasting benefit from prior injections, and in carefully selected cases where everything else has been tried and the options are limited. In this case, the patient has tried and failed other conservative treatments with the alternative being bilateral total knee arthroplasties. Under these circumstances, the requested Gel One (hyaluronic acid) injection to bilateral knees is medically necessary for the patients medical condition.Final Result: The reviewer determined that the requested services are medically necessary for 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: Medical Necessity
Decision: Overturned

The parent of a four-year-old male enrollee has requested coverage for resumption of speech therapy using the PROMPT method for treatment of the enrollees childhood apraxia of speech.  Findings:  The physician reviewer found that based on review of the available records, this patient has a serious developmental speech delay with a moderate expressive delay in speech and a severe articulation dysfunction. The etiology of his articulation defect or childhood apraxia of speech is due to a congenital delay in the maturation of his oral/lingual nervous system. Given his condition, the speech therapy available in the public school setting is inadequate with limited group sessions and lack of individual therapy. For any significant reasonable expectation of improvement, this patient will require individual speech therapy. Childhood apraxia of speech is a serious childhood speech deficiency. In Lewis and colleagues study, 10 children diagnosed with childhood apraxia of speech were evaluated at age 4 and reassessed at age 10. At age 10, their improvement was limited when compared to children with other speech disorders. In addition, the patients demonstrated serious deficiencies in reading and spelling. The authors recommendation was for intensive speech therapy at four years of age. There is a significant medical literature supporting speech therapy in patients who are age three and up. Sharp and Hillenbrand state that reviews of the literature demonstrate the necessity and effectiveness of speech therapy in children over the age of three years with articulation and speech dysfunction. The PROMPT method of speech therapy is based on actual hands on the muscles of the mouth and jaw as a primary adjunct combined with speech therapy (Hayden). PROMPT therapy has limited literature in the peer-reviewed medical and speech pathology literature. However, Rogers and colleagues describe the utilization of the PROMPT technique, which suggests a significant legitimacy for the technique. This patients records demonstrate improvement utilizing the PROMPT method. All told, it is medically necessary that this patient receive individual speech therapy for two hours per week for the next six months.
Appeal type: Experimental/Investigational
Decision: Overturned

An enrollee has requested authorization and coverage for computed tomography (CT) of the heart without contrast, with quantitative evaluation of coronary calcium. Based on the records provided for review, this patient has a low to intermediate 10-year risk of coronary artery disease (CAD). However, she is close to the low-density lipoprotein (LDL) cholesterol cutoff for recommending statin therapy. In addition, the patients risk is enhanced based on her strong family history of early CAD. According to the American College of Cardiology Foundation (ACCF) treatment guidelines, although she does not meet the standard requirements for starting stain therapy, she has additional risk enhancing factors consisting of a family history of early CAD and persistent LDL over 160. The patient is reticent to start lifelong statin therapy due to concern for side effects. Thus, coronary CT calcium scanning is recommended to help determine whether this patient would benefit from lifelong statin therapy. Given this support, the requested CT of the heart, without contrast, with quantitative evaluation of coronary calcium is likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.  Final Result: The reviewers determined that the requested services are likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: Physician reviewers 1, 2, and 3 are board certified in internal medicine with subspecialty certification in cardiovascular disease 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.