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

A 31-year-old female enrollee has requested buprenorphine (Subutex) for treatment of her opioid dependence. Findings:  The physician reviewer found that the medication at issue was not medically necessary in this patients case.  Subutex is an opioid agonist with antagonist effects at higher doses.  Per the medical literature, Subutex serves as an effective bridge to Suboxone as it prevents withdrawal.  However, when used alone for opioid dependence, higher doses must be prescribed to achieve its antagonist effects.  Suboxone is supported in the medical literature as the preferred medication for opioid dependence because it is a combination opioid agonist and antagonist at any dose.  All told, the medication buprenorphine (Subutex) was not medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Viekira Pak and Sovaldi for 24 weeks. Findings:  The physician reviewer found that, according to the most recent joint guidelines issued by the American Association for the Study of Liver Diseases (AASLD) and the Infectious Diseases Society of America (IDSA), Deferral of treatment is recommended, pending availability of data for patients with HCV genotype 1, regardless of subtype, in whom previous treatment with any HCV nonstructural protein 5A (NS5A) inhibitors has failed, who do not have cirrhosis, and do not have reasons for urgent retreatment. In this case, the patient does not have cirrhosis, and no other reason for urgent re-treatment compatible with the high-urgency group in the guidelines is provided. All told, the requested Viekira Pak and Sovaldi for 24 weeks is not supported as medically necessary for the re-treatment of this patients HCV. 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 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: Upheld

A 65-year-old female enrollee has requested a 4-wheeled walker with a seat for treatment of her sacroiliac joint dysfunction.  Findings:  The physician reviewer found that the Centers for Medicare and Medicaid Services (CMS) guidelines indicate that multiple aids are available to assist patients with mobility difficulty. Depending on the severity of the patients limitation, one type of assistive device may be more beneficial than another (Braddom, et al). Since this patient is able to safely ambulate using a cane or a walker while at home, she can be expected to use one of these assistive devices to ameliorate her personal deficits that may impair her participation in mobility-related activities of daily living within her home. The practice guidelines do not support the medical necessity of a four-wheeled walker with a seat in this clinical setting as the patient does not require the use of the requested device within the home. Thus, the requested four-wheeled walker with a seat has not been shown to be medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned

A 50-year-old female enrollee has requested gastric bypass surgery for the treatment of her obesity. Findings:  The physician reviewer found that the patient meets the recommendation set by the National Institutes for Health for weight loss surgery. The Health Plan has instituted a 10% preoperative weight loss prior to surgical intervention. Their own provided technology review document reports that the data in support of this position is lacking.  There is one blinded study with less than 70 patients to support this argument. The patient should be authorized to have weight loss surgery, as the requested procedure is medically appropriate and indicated.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested acupuncture services treatment of the enrollee who has been diagnosed with malignant stage 4 glioblastoma. Findings: The physician reviewer found that there is a lack of evidence based studies supporting acupuncture as an effective analgesic adjunctive method for cancer patients or for chemotherapy induced peripheral neuropathy. The medical literature suggests that more research needs to be performed as to the efficacy of acupuncture in the treatment of cancer patients. In addition, the submitted documentation, in this patients case, does not support an objective improvement in the use of acupuncture. Therefore, the acupuncture services rendered were not and are not medically necessary for treatment of this patients medical condition.Final Result: The reviewer determined that the services at issue were not and 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 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.
Appeal type: Experimental/Investigational
Decision: Overturned

Findings:  The physician reviewer found that An enrollee has requested reimbursement for Guardant 360 CDx Molecular Pathology Testing. Numerous gene alterations have been identified that impact therapy selection for the treatment of non-small cell lung cancer (NSCLC). The National Comprehensive Cancer Network (NCCN) guidelines for NSCLC advises broader molecular profiling with the goal of identifying rare driver mutations for which effective drugs may already be available, or to appropriately counsel patients regarding the availability of clinical trials. Rolfo and colleagues report that the isolation and analysis of circulating cell-free tumor DNA in plasma is a powerful tool with considerable potential to improve clinical outcomes across multiple cancer types, including NSCLC. This type of testing may be considered in specific clinical circumstances, including if a patient is unable to undergo invasive tissue sampling in the initial diagnostic setting, or if following pathologic confirmation of a NSCLC diagnosis there is insufficient material for molecular analysis, and if follow-up tissue-based analysis is planned if an oncogenic driver is not identified. Thus, the testing at issue was likely to identify potentially efficacious targeted therapies as well as to identify therapies to be avoided as unlikely to provide clinical benefit. Therefore, Guardant 360 CDx Molecular Pathology 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 the Guardant 360 CDx Molecular Pathology Testing at issue was likely to have been more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the service at issue was likely to have been more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a two-year-old female has requested speech and language therapy for treatment of the enrollees receptive and expressive language delays.  Findings:  The physician reviewer found that Cerebral damage following complications of pregnancy and prematurity is an important factor in fetal and neonatal mortality. Additionally, children born prematurely are at risk for developmental and speech delay. Children with speech delay are at risk for developing reading difficulties if appropriate and early interventions are not implemented.  Van Baar and colleagues concluded that term and preterm children differed in all developmental domains. The subgroup of preterm children without school problems is characterized by less serious neonatal difficulties, better drinking capacities in the first month, faster early head growth and better early mental and motor development. Cognitive developmental course gradually diverged during the first two years between the preterm subgroups and seemed to stabilize thereafter. All told, early identification of speech delay is important to maximize the development of the child.  In this patients case, the requested speech therapy is medically indicated.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for radiofrequency neurolysis of the sacroiliac joint.Findings:  The physician reviewer found that the patient is diagnosed with lumbar spondylosis. The underwent bilateral L3-S1 facet joint injections. The injection was done with fluoroscopic guidance and conscious sedation. This was his third injection. There had been 40% relief after the first and second procedure. He had pain rated at 8/10. Facet injections had provided 50% pain relief lasting for only three days. He wanted to discuss his worsening pain. His relevant past medical history included chronic pain and gastroesophageal reflux disease. Physical examination findings included a body mass index of 28. There was no sacroiliac joint tenderness. There was a normal neurological examination. The patient requested coverage for radiofrequency neurolysis of the sacroiliac joint. Per the Health Plan the requested services are investigational for treatment of this patient.  The safety and/or effectiveness of this procedure have not been established by review of the available published peer-reviewed literature. Larger, well-designed trials are needed for comparing specific procedures in defined populations for use in sacroiliac pain and to determine the potential candidates and treatment parameters as there is no standardized technique. Radiofrequency treatment is a minimally invasive procedure that has been used for over three decades in treating various chronic pain syndromes such as trigeminal neuralgia, post-herpetic neuralgia, low back pain, and complex regional pain syndrome/reflex sympathetic dystrophy. However, it is a palliative treatment not without complications. Radiofrequency procedures have been reported to be associated with high number of complications compared with other ablative neurosurgical techniques. In terms of this patients condition, he has not exhausted conservative therapy. Conservative treatment such as medication management, compliance with a home exercise/management program, and/or chiropractic care are among the current recommendations. Therefore, radiofrequency neurolysis of the sacroiliac joint is not likely to be more efficacious than the standard options for treatment of this patient. Final Result: The reviewers determined that the requested services are not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: Physician reviewer 1,2 and 3 are board certified in anesthesiology with sub-specialty certification in pain medicine and is actively practicing. The reviewers are 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 narrowband UVB. Findings:  The physician reviewer found that this patient presents with chronic pruritus of unknown etiology which is responsive to topical and systemic steroids, but unresponsive to oral antihistamines. Chronic pruritus is difficult to treat and may result from atopic dermatitis or other underlying conditions. Narrowband UVB phototherapy has been shown to be an effective therapy which helps to minimize the risk of long-term topical or systemic steroid use. The patient has established that this is negatively impacting her quality of life. 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 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: Upheld

Nature of Statutory Criteria/Case Summary:  An enrollee requested fentanyl patches for treatment of his chronic pain.   Findings:  The physician reviewer found that according to the current peer-reviewed medical literature, first-line treatment for the management of mild-to-moderate pain includes the use of non-opioid analgesics. For moderate-to-severe pain, initiation of an opioid may be recommended. Additional options include the use of fentanyl patches for patients when the oral route is not a reasonable option or has failed. In addition, the data also indicates that the recommended opioid dosage is less than or equal to a certain morphine equivalent dose. According to the clinical records submitted for review, the patient is currently taking two opioid pain medications and fentanyl patches. The patient exceeds the morphine equivalent dose recommendation. Further, the clinical records lack documentation that the patient has previously tried and failed all first-line treatments, that oral medications are not a reasonable option for this patient, or evidence of any objective functional improvement from the use of fentanyl patches. Given these findings, the requested fentanyl patches are not medically necessary for treatment of this patients chronic pain. 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: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for testing for the amount of a type of drug (tumor necrosis factor (TNF) antagonists) in the enrollees blood for evaluation of the enrollees ulcerative colitis. Findings:  Two physician reviewers found that there is insufficient medical evidence to support the effectiveness of Prometheus Anser testing compared with conventional courses of action in the management of ulcerative colitis. The studies that discuss the use of anti-vedolizumab antibodies and serum levels are small, retrospective, and/or observational rather than controlled in nature, preventing firm conclusions about cause and effect. These small studies at best demonstrated correlations between treatment response and the presence of anti-vedolizumab antibodies, which do not allow firm conclusions regarding cause and effect. Additionally, the antibodies can be transient. Controlled studies are lacking to show that use of the test results in improved long-term health outcomes for patients with ulcerative colitis compared with conventional management. Final Result: The reviewers determined that the testing at issue was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: Reviewers 1, 2 and 3 are board certified in internal medicine with sub-specialty certification in gastroenterology and are 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

The patient is a 59-year-old obese female with known lumbar stenosis with active symptoms of neurogenic claudication.  She has requested a consultation for possible abdominoplasty/panniculectomy and liposuction as a treatment for her low back pain, knee pain, recurrent urinary tract infections, and urinary incontinence.  The Health Plan has denied her request based upon a determination that a plastic surgery consultation for consideration of abdominoplasty/panniculectomy and liposuction is not medically necessary.The patient consulted with a neurosurgeon with regard to her back pain and other conditions.  She was advised that her symptoms were due to spinal stenosis and were not likely to resolve with abdominoplasty/panniculectomy or liposuction.  Based on the neurosurgeons note of December 2005, the patient had no interest in definitive surgical treatment of her intrinsic lower back problem. The likelihood of panniculectomy helping her symptoms is negligibly small. With regard to symptom relief, abdominoplasty/ panniculectomy should not be considered until after lumbar surgery is completed and reviewed for efficacy. Furthermore, the patient states she had a gradual 40 pound weight loss and saw no change in her symptoms.  If she had an abdominoplasty/panniculectomy, the additional 10-pound weight reduction would not be expected to have an impact on her lower back symptoms. In consideration of other possible medical indications for panniculectomy/ abdominoplasty or liposuction, a detailed inspection of the photographs of the patient with lateral, frontal and posterior views revealed a large midline scar from umbilicus to pubis, but no discernable pannus. The lateral photos clearly do not demonstrate a pannus with skin-on-skin contact. Even with the assumption there is a pannus, there is no documentation of uncontrolled intertrigo that would make panniculectomy medically necessary. Additionally, there is no documentation of massive weight loss or evidence of a symptomatic hernia that would require surgical intervention.  In summary, there is no indication for a plastic surgery consultation and the requested services are not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Keppra and Trileptal. Findings:  The physician reviewer found that there is a lack of support in the medical literature for the requested brand name medications in this clinical setting. Several studies have examined brand versus generic anti-epileptic medication regimens. The results of that study showed that generic and brand bioequivalence were similar. Data suggests that generic products of branded modified-release products (e.g., extended release, delayed release) are bioequivalent and safely interchangeable. Results from these studies have shown no difference in bioequivalence when switching from a brand product to a generic product or between multiple generic products. For these reasons, the requested brand name medications, Keppra and Trileptal are not medically necessary for treatment of this patients medical condition.Final Result: The reviewer determined that the requested brand 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 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: Medical Necessity
Decision: Upheld

A 28-year-old female has requested a referral to an intensive eating disorder program such as the Mandometer Clinic for treatment of the enrollees eating disorder.  Findings:  The physician reviewer found that the treatment provided at the Mandometer Clinic does not fall within generally accepted standards of medical practice and is not likely to be effective for this patient. Given the severity of the patients condition, she requires a higher level of care, specifically, inpatient treatment.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has been diagnosed with obstructive sleep apnea. The patient reported difficulty sleeping, congestion, shortness of breath, and anxiety at night. The patient also reported loud snoring, pauses in breathing, and gasping arousals. A sleep study performed revealed mild obstructive sleep apnea, with a respiratory disturbance index (RDI) score of 7.1. The patient has requested reimbursement for a continuous positive airway pressure (CPAP) device (CPT E0601). The Health Plan denied the request and reported the device at issue was not medically necessary for the treatment of this patient. At issue in this case is whether a continuous positive airway pressure (CPAP) device (CPT E0601) that was provided was medically necessary for the treatment of the patients medical condition. Researchers reported obstructive sleep apnea (OSA) is the most common type of sleep apnea and caused by upper airway obstructions. Clinically, patients with OSA characteristically experience intermittent nocturnal hypoxemia and impaired sleep quality. Studies reported that CPAP treatment may help to improve physical symptoms of OSA. In this case, the patient has a history of snoring and apnea/gasping for air. A sleep study revealed mild obstructive sleep apnea with RDI of 7.1. The medical evidence supports the device at issue in this clinical setting. Therefore, a continuous positive airway pressure (CPAP) device (CPT E0601) that was provided was medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested device was 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 otolaryngology 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.