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

A 38-year-old female enrollee has requested Lyrica for the treatment of her nerve entrapment secondary to abdominoplasty. Findings:  The physician reviewer found that neuropathic pain is a condition developed after nerve injury, either central or peripheral, has occurred. It is often associated with poor response to conventional treatments. Anticonvulsants such as gabapentin and Lyrica have shown statistically significant success in managing pain arising from conditions such as diabetic neuropathy and post-herpetic neuralgia. Other neuropathies such as entrapment neuropathies probably share a similar pathophysiology and therefore are likely to respond to these medications as well. This patient has been diagnosed with neuropathic pain resulting from neural entrapment by scar tissue secondary to abdominoplasty. It should be noted that she has already failed a trial with gabapentin and has experienced good pain relief with return to a better functional status after being treated with Lyrica.
Appeal type: Experimental/Investigational
Decision: Upheld

A 52-year-old male has requested proton beam radiation therapy for the treatment of prostate cancer.  Findings:  Two physician reviewers found that based on the patients clinical stage, Gleason score, and PSA value, he would be deemed a low-recurrence risk according to the 2007 NCCN Clinical Practice Guidelines, with a life expectancy greater than ten years. Initial treatment options include expectant management, radiation therapy (3-D CRT, or brachytherapy) or radical prostatectomy.  3-D conformal or IMRT techniques would be employed under the NCCN Guidelines. Furthermore, doses of 7000 to 7500 cGy to the prostate in 35 to 41 fractions are appropriate for patients with low-risk cancer.  For patients with intermediate or high-risk disease, dosages between 7500 and 8000 cGy appear to improve PSA levels and overall disease control. The current recommendation (proton beam) is to deliver 8100 cGy, and this dosage falls outside of the NCCN dosage guidelines and seems excessive for a patient with low-risk disease. Additionally, NCCN Guidelines do not list proton beam irradiation as a standard option for patients with early-stage prostate cancer. The patient was appropriately started on conventional treatment with IMRT and there is nothing in the record to indicate that he would be better served with proton beam irradiation.
Appeal type: Medical Necessity
Decision: Overturned

A 62-year-old female enrollee has requested chiropractic manipulation and PT therapeutic activities for the treatment of her degenerative disc disease and stenosis of her cervical spine. Findings:  Two physician reviewers found that there was documented improved cervical range of motion, less pain and improved function. The patient has ossification of the posterior longitudinal ligament which is an uncommon condition that can benefit from such treatment. Facetogenic pain related to cervical spondylosis can also respond to such treatment. However, this patient did not require 6 months of chiropractic manipulation. For patients with this type of neck pain, a short course of treatment (either chiropractic or physical therapy) is indicated. Usually, after several weeks of treatment, a home exercise/stretching regimen is appropriate. Therefore, an additional 4 weeks (or 8 sessions) of the continued chiropractic treatment should be reimbursed.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Ativan for treatment of his behavioral health conditions. Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested medication.  The records indicate that the patient has been taking the disputed medication.  This makes the overall duration of the medication use approximately 10 months.  During this time, the patient has been documented to have escalated his dose against physician advice.  He has recently requested numerous refills of the medication.  His providers have advised him against long-term use of this medication and advised him against use of this medication with other benzodiazepine medications that he has been taking. The treatment center he has been going to has advised him to continue psychotherapy along with medication management.  The patient was noted to have not been in psychotherapy.  The disputed medication is not medically appropriate for long-term use.  The documentation indicates that his providers have discussed adverse effects of this medication as well.  The current medical evidence does not support the requested medication in this clinical setting.  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 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: Urgent Care
Decision: Upheld

A 33-year-old female enrollee has requested emergency services for the treatment of her medical condition. Findings:  The physician reviewer found that this patient presented to the Emergency Department and reported four weeks of nasal congestion. She had seen her family physician the previous week and was treated with Sudafed, Zyrtec and Afrin nasal spray. The review of systems was negative. The patients vital signs were normal. There was no fever or hypoxia. Physical examination was normal, and the patient was discharged in stable condition. An emergency medical condition involves acute symptoms of such severity that the absence of immediate medical treatment would result in placing the patients health in serious jeopardy, seriously impairing bodily functions or causing serious dysfunction of any bodily organ or part. Review of the submitted clinical evidence demonstrates that this patient was uncomfortable and unable to sleep, but she was not in respiratory distress.  The patient had normal vital signs, including temperature and pulse oximetry. Her symptoms were not acute, as they had been present for four weeks. The patients symptoms did not meet prudent layperson criteria for emergency care. A prudent layperson with an average knowledge of medicine would not reasonably expect the absence of emergency care to jeopardize her health in this situation.
Appeal type: Medical Necessity
Decision: Overturned

The parent of an 11-year-old female enrollee has requested Lexapro, 10mg tablets for treatment of the enrollees behavioral health issues. Findings:  The physician reviewer found that a review of the relevant scientific data suggests that Lexapro has been prescribed with significant improvement in adolescent patients and is approved by the Food and Drug Administration (FDA) for treatment of adolescent patients with this diagnosis. A randomized controlled study published by Emslie and colleagues in 2009 studied young patients with major depressive disorder who were treated with Lexapro and found Lexapro to be efficacious and well tolerated. Additionally, Lexapro is the second selective serotonin reuptake inhibitor (SSRI) approved by the FDA for use in treating adolescents with MDD, with the first being Prozac (Yang and Scott). To switch this patient to another medication given her positive response to Lexapro would place the patient at risk for an exacerbation of her illness and is clinically unreasonable. Moreover, alternative medications such as Paxil and Effexor are not FDA approved specifically for adolescent depression and could generate adverse side effects, especially when taken in conjunction with her cardiac medication. For these reasons, the requested Lexapro, 10 mg daily has been demonstrated to be medically necessary for treatment of this patients condition and should be approved.
Appeal type: Medical Necessity
Decision: Overturned

The patient has been diagnosed with right knee osteoarthritis, and is requesting authorization and coverage for Orthovisc injections in the right knee. Findings: Medical literature pertaining to viscosupplementation reveals mixed results. Although viscosupplementation may relieve knee pain in some patients with osteoarthritis, it is unknown which patients will benefit. Considering the foregoing, viscosupplementation can only be recommended for patients with a history of lasting benefit from prior injections and in carefully selected cases when everything else has been tried and the options are limited. In this case, the patient has a history of benefit from prior viscosupplementation injections. The patient has also tried and failed other treatments, including previous surgical procedures on the right knee, with the alternative being a total knee arthroplasty. The medical evidence supports the requested services in this clinical setting. Therefore, Orthovisc injections in the right knee are medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested services 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 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: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Zephyr Endobrachial Valve replacement procedure (CPT 31647 x 2 and CPT 31651 x 2 with a four-day inpatient stay). Based on a review of the chart and peer-reviewed medical literature on bronchoscopic lung volume reduction, the requested procedure is appropriate for this patient and likely to be more beneficial than standard alternatives. The patient does not have any collateral ventilation and his pulmonary function testing results are within the parameters recommended by the FDA for treatment with the Zephyr device. Further, the patient has completed pulmonary rehabilitation. Current studies reported data that the Zephyr device provides modest improvement in symptoms and lung function. Based on these findings, the requested Zephyr Endobrachial Valve replacement procedure (CPT 31647 x 2 and CPT 31651 x 2 with a four-day inpatient stay) is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Findings:  Three of the three physician reviewers found the requested Zephyr Endobrachial Valve replacement procedure (CPT 31647 x 2 and CPT 31651 x 2 with a four-day inpatient stay) is likely to be more beneficial for treatment 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 treatment 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 subspecialty certifications in pulmonary disease and critical care medicine and is actively practicing. Physician reviewer 2 is board certified in board certified in internal medicine with subspecialty certification in pulmonary disease and is actively practicing. Physician reviewer 3 is board certified in board certified in internal medicine with subspecialty certification in pulmonary disease 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

The parent of a four-year-old male enrollee has requested for speech therapy for treatment of the enrollees speech production impairment. Findings:  The physician reviewer found that abnormalities in oral structures and anterior placement of the tongue with tongue thrust are functionally involved. It is highly likely that the same abnormalities in oral motor function that have resulted in articulation deficits are also the cause of his swallowing difficulties. Given his history of hypotonia and tactile defensiveness, it is possible that his oral motor dysfunction is due to a combination of structural and neurologic abnormalities.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for transcatheter placement of intravascular stent(s), cervical carotid artery, percutaneous, with distal embolic protection (CPT code 37215). Findings: Three of the three physician reviewers found that the medical literature and submitted medical documentation support the present request. Internal carotid artery dissection is a major cause of acute ischemic stroke in the young and is responsible for 1025% of all strokes occurring in this population. Anticoagulation is the mainstay of treatment, but in patients who fail anticoagulation or have contraindications to anticoagulation, intervention is often considered. Open surgical repair had historically been the traditional therapy of choice, but percutaneous therapy with stent placement has become increasingly commonplace. No randomized trials exist regarding optimal surgical management of carotid artery dissection. Current literature supports both open and endovascular treatment as safe and effective for carotid artery dissection. In this patient with recurrent strokes, failure of anticoagulation, and a very high lesion not amenable to surgery, stenting is an appropriate option. Therefore, transcatheter placement of intravascular stent(s), cervical carotid artery, percutaneous, with distal embolic protection (CPT code 37215) is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the requested service is 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: Physician reviewer number one is actively practicing and is board certified in diagnostic radiology and interventional radiology. Physician reviewer number two is actively practicing and is board certified in surgery and vascular surgery. Physician reviewer number three is actively practicing and is board certified in diagnostic radiology. 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: Upheld

A 56-year-old female enrollee has requested for bariatric surgery consultation, bariatric surgery, and aquatic/pool therapy (pre, post or in lieu of bariatric surgery) for treatment of her morbid obesity. Findings:  The physician reviewer found that the current medical evidence does not support the requested bariatric surgery in this patients case. The medical necessity of the requested aquatic/pool therapy has not been established. Medical clearance in support of aquatic therapy was not provided.  In general, there is no consensus regarding the use of aqua exercise for cardiac patients, as some studies show increased cardiac work.  At this time, further published data is needed to document the improved outcomes of aquatic therapy in this clinical setting.  All told, the requested bariatric surgery consultation, bariatric surgery, and aquatic/pool therapy (pre, post or in lieu of bariatric surgery) are not medically indicated in this patients case.
Appeal type: Experimental/Investigational
Decision: Upheld

A 59-year-old male has requested total disc arthroplasty with the ProDisc-C for treatment of his myeloradiculopathy and cervical degenerative disc disease at the C5 and C6 levels with foraminal stenosis.  Findings:  Three physician reviewers found that the patient has a history of cervical myeloradiculopathy and cervical degenerative disc disease at C5 and C6 with foraminal stenosis. He has tried physical therapy, acupuncture, various medications, heat/cold therapies, and epidural steroid injections, all without substantial pain relief. On neurological testing, his motor examination is left biceps 4/5, triceps 4/-5, intrinsics 4/5, and grip 4+/5. All other muscle groups are 5/5. A cervical spine magnetic resonance imaging (MRI) revealed facet arthropathy causing moderate right and mild left neural foraminal narrowing at both C3-4 and C4-5, as well as facet arthropathy and a left disc osteophyte causing moderate to severe left neural foraminal narrowing at C5-6. This patients record documents the presence of multi-level cervical disease both radiographically at C3-4, C4-5 and C5-6, and on neurological testing as noted in the biceps, triceps, intrinsics and grip weakness. Additionally, his multi-level disease involves the facet joints. The medical literature and manufacturer do not recommend the use of the ProDisc-C device in patients with more than one vertebral level with facet joint disease or degeneration. All told, arthroplasty is not likely to provide this patient with multi-level facet disease with an improved health outcome when compared with standard available therapies.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a two-year-old female has requested speech therapy services, once per week, for one hour for treatment of her speech delay.  Findings:  The physician reviewer found that the submitted documentation demonstrates the medical necessity of the requested services.  As noted by Nelson and colleagues, speech and language development is considered by experts to be a useful indicator of a childs overall development and cognitive ability and is related to school success.  The authors noted that identification of children at risk for developmental delay or related problems may lead to intervention services and family assistance at a young age when chances for improvement are best.  Speech and language delay must be taken seriously in young children, because the long-term consequences may be substantial.  According to Law and colleagues, approximately 6% of children have speech and language difficulties.  The authors noted that children whose difficulties persist into primary school may have long-term problems concerning literacy, socialization, behavior, and school attainment.  These reviewers concluded that there is a positive effect of speech and language therapy interventions for children with expressive phonological and expressive vocabulary difficulties.  In this patients case, she has significant receptive and expressive language delay, and this is impacting her ability to communicate effectively and function socially.  Based on the literature, speech therapy services, once per week, for one hour, are medically indicated for the treatment of this patient.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary:  An enrollee requested bilateral breast magnetic resonance imaging (MRI) for evaluation of her lobular carcinoma in situ.  Findings:  Two physician reviewers found that in this patients case, the requested services are not likely to be of greater benefit than other methods of evaluation.  In regards to the management of patients with lobular carcinoma in situ, the medical literature noted that the routine use of MRI does not result in increased cancer detection rates (short-term), nor does it result in earlier stage at diagnosis, illustrating the importance of defining optimal screening strategies for high-risk patients based on tumor biology rather than numerical risk.  The medical literature reported that MRI can detect breast cancer in high-risk patients, but is associated with a significant false-positive rate resulting in unnecessary breast biopsies. More data are needed to define the role of MRI screening for specific high-risk groups.  Since the routine use of breast MRI does not result in increased cancer detection rates for patients, nor does it result in earlier stage at diagnosis, the requested bilateral breast MRI is not likely to be more beneficial for evaluation of this patient than other available options.Final Result: Two 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: Reviewers 1, 2, and 3 are board certified in diagnostic radiology and is actively practicing. The reviewers are an 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 male enrollee has requested Avodart for the treatment of his benign prostate hyperplasia. Findings:  The physician reviewer found that Proscar and Avodart inhibit the conversion of testosterone to dihydrotestosterone. The latter hormone is the active form of testosterone stimulating growth of the prostate glands. There has been no direct trial comparing both drugs. This patient cites a figure of 18.5% as the incidence of impotence as cause for concern regarding potential side effects. However, as noted in the Proscar Side Effects and Interactions article, in a 4-year placebo-controlled study, 18.5% was in fact the incidence of impotence with Proscar, but the placebo arm of the study reported 12.2% impotence. The literature shows similar improvement of urinary symptoms and similar reduction of the prostate volume with both drugs; there is no evidence to support a finding that Avodart is superior to Proscar.
Appeal type: Medical Necessity
Decision: Upheld

A 63-year-old female enrollee has requested Sovaldi and Olysio for treatment of her hepatitis C virus (HCV). Findings:  Three physician reviewers found that HCV treatment is medically necessary for treatment of the patients medical condition. While HCV treatment is necessary, the requested treatment of Sovaldi and Olysio is class B, and not class A per the latest American Association for the Study of Liver Diseases (AASLD) and the Infectious Diseases Society of America (IDSA) guidelines. Newer treatment options exist for this patient with similar efficacy recommended for patients with HCV genotype 1a infection who do not have cirrhosis, in whom prior peg-interferon and ribavirin treatment has failed. The first treatment option is the fixed-dose combination of ledipasvir/sofosbuvir for 12 weeks. The second option is treatment with daily fixed-dose combination of paritaprevir/ritonavir/ombitasvir plus twice-daily dasabuvir and weight-based ribavirin for 12 weeks. Although the requested treatment is appropriate, it should be considered after either one of the two newer options has been considered. Given that there is no documentation provided indicating that the newer treatment options have been considered, the requested medication combination is not medically necessary at this time.