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

Nature of Statutory Criteria/Case Summary:  An enrollee has requested transcranial magnetic stimulation therapy for treatment of his behavioral health conditions.  Findings:  The physician reviewer found that transcranial magnetic stimulation is a novel, non-invasive, neuro-stimulatory intervention endorsed by the American Psychiatric Association for the treatment of acute phase depression in the adult population. A typical treatment course for transcranial magnetic stimulation typically includes 30 to 40 sessions delivered over a course of four to six weeks.  It appears that the patient had a positive response and was tapered from the intervention.  However, there was no recent clinical documentation submitted for review. In sum, the medical evidence does not support continuing transcranial magnetic stimulation therapy while the medical records do not illustrate that standard therapies have been exhausted.  Thus, the requested transcranial magnetic stimulation therapy is not medically indicated for the treatment of this patient.Final Result: The reviewer determined that the 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 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: Experimental/Investigational
Decision: Overturned

A 48-year-old male enrollee has requested for whole body skin photography for evaluation of his hyperpigmented macules. Findings:  Two physician reviewers found that patients with this condition have a higher risk for developing melanoma.  While isolated lesions can be biopsied, this becomes problematic in patients with numerous nevi or large, clinically atypical nevi.  Effective approaches to early melanoma detection should identify and evaluate both new and changing nevi.  Whole Body Skin Photography is a standard of care approach to early diagnosis of melanoma in such patients.  In this clinical setting, Whole Body Skin Photography was likely to have been more efficacious than other methods of evaluating this patient.
Appeal type: Medical Necessity
Decision: Overturned

A 44-year-old male enrollee has requested the prescription drug Lyrica for the treatment of his shingles. Findings:  The physician reviewer found that Lyrica has an FDA approved indication for this disease. The patient has achieved acceptable pain relief on this level of medication. The Health Plan refuses to cover this medication since a trial of gabapentin was not performed first. Since the patient is now pain free, it is unreasonable to ask the patient to re-experience the pain of postherpetic neuralgia in a trial of the first line drug gabapentin. Both drugs are acceptable first line treatment. Additionally, the dosage prescribed is in the range of those used in randomized, placebo-controlled trials and is appropriate.
Appeal type: Medical Necessity
Decision: Overturned

A 60-year-old female enrollee has requested authorization for removal of bilateral breast implants and bilateral reduction mammoplasty for treatment of her intracapsular rupture.  Findings:  The physician reviewer found that although the literature does not support routine breast implant removal for ruptured implants, the FDA Advisory Panel, in agreement with breast implant maker Inameds recommendations, has stated that ruptured silicone implants should be routinely removed, and this portion of the patient's request is medically necessary.  However, mastopexies are commonly performed following implant removal to improve the appearance of the breasts. This patients reduction is too small to have any significant impact on her musculoskeletal pain. The reduction is actually a cosmetic breast lift and is not eligible for coverage.
Appeal type: Medical Necessity
Decision: Upheld

A 68-year-old female enrollee has requested Forteo 750mcg injectable for the treatment of her osteoporosis. Findings:  The physician reviewer found that the patients provider feels that osteoporosis would impair healing of the proposed fusion surgery and that Forteo would improve it. However, there is no information as to how long the patient would have to take Forteo before it would be appropriate to proceed with the fusion (i.e., three months, one year, or two years?). There are other methods that would suggest response to treatment within three months such as measurement of urinary N-telopeptide. All told, the submitted evidence does not support the use of Forteo in this setting.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for lidocaine 5% patch. Findings:  The physician reviewer found that patient presents status post right inguinal hernia repair with resulting abdominal wall seroma that has required repeat drainage. The patient has been treated with lidocaine patch 5% and her provider has recommended continued treatment with this medication. The U.S. Food and Drug Administration (FDA) has approved the lidocaine patch 5% for the treatment of patients with post-herpetic neuralgia and diabetic neuropathy. McColgan and colleagues found that there is a lack of evidence to support the use of lidocaine patches for musculoskeletal pain. Similarly, Santana and colleagues evaluated the medical evidence supporting the use of lidocaine patches for chronic low back pain. The authors assessed seven clinical studies and concluded that, We found no randomized controlled trials with substantial evidence to support the use of 5% lidocaine patch in chronic low back pain. For this patient, the lidocaine patch was recommended for musculoskeletal pain. Currently the FDA has not approved the patches for this use and the recent reviews on this subject reinforce the lack of evidence demonstrating the safety and efficacy of lidocaine patches in musculoskeletal related chronic pain. Given these findings, the requested lidocaine 5% patch 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 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 40-year-old female enrollee has requested the MammaPrint Gene Test for evaluation of her breast cancer.  Findings:  Three physician reviewers found the MammaPrint assay uses a 70 gene profile from frozen breast tumor tissue to select patients more likely to develop recurrent disease. The MammaPrint assay is similar to the OncotypeDx and reports a low or high risk. The MammaPrint assay has been approved by the U.S. Food and Drug Administration (FDA). In this low risk patient, the test was used as a predictive marker. Given the clinical utility of the findings, the testing at issue is supported as likely to have been more beneficial for evaluation of this patients medical condition than any available standard therapy.
Appeal type: Medical Necessity
Decision: Upheld

The patient has requested authorization and coverage for Morphine sulfate ER 30 mg, four times daily and Dilaudid 4 mg, four times daily. The Centers for Disease Control and Prevention (CDC) state that when opioids are started, providers should prescribe the lowest effective dosage. The CDC also states that providers should use caution when prescribing opioids at any dosage. Providers should carefully reassess evidence of individual benefits and risks when considering increasing dosage to equivalent to 50 morphine milligram equivalents (MME) per day, and should avoid increasing dosage equivalent to 90 MME per day without a specific plan to titrate dosage (Dowell, et al.). In this case, the records available for review do not include objective treatment goals for pain and function consistent with the CDC guidelines. The patient was being treated with more than 90 MME per day and he is requesting to continue on this pain medication regimen, especially given the presence of sleep apnea. The physician reviewer found that the records do not include a specific medical evidence-based rationale to support this high of a daily MME. Further, there is no mention of behavior therapy documented despite much research to support its use (Lee, et al.). For these reasons, the requested morphine sulfate ER 30 mg, four times daily, and Dilaudid 4 mg, four times a day, are not medically necessary for treatment of the patients medical condition.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.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a 10-year-old male enrollee has requested the test of variables attention (TOVA) and a second consult with a neurologist for treatment of the enrollees attention deficit hyperactivity disorder (ADHD).  Findings:  The physician reviewer found that the relevant published literature and published case series suggest that behavior rating scales are subject to observer bias for virtually every variable assessed.  Given the equivocal or negative of this patients biologic response to Methylin, performing a TOVA is reasonable for this patient and represents the best medical practice. It will require the expertise of a specialist in this field in order to obtain an unequivocal diagnosis. Further, the provider should be able to explore the possibility of treatment with appropriate pharmacotherapy (stimulant based or with another primary mechanism of action related to the patients biologic problem). Therefore, the requested evaluation with a neurologist to perform the TOVA to better assess this patients condition and his likelihood to respond to medical therapy has been shown to be clinically indicated should be approved.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a five-year-old male enrollee has requested speech therapy and occupational therapy for the treatment of the enrollees autistic disorder. Findings:  Three physician reviewers found that autism remains a complex neurological disorder whose etiology remains unknown, and it often involves profound communication problems. Myers and colleagues noted that speech therapy can be medically effective for children with autism. The same report indicates that occupational therapy is valuable for children with autism, but mentions that it is of unproven benefit due to methodological difficulties in establishing control groups in this population. Schaaf and Miller note the value of sensory integration by occupational therapists in this population. Most authorities recommend extensive occupational and speech therapy for autistic children. All told, the scientific evidence supports speech therapy and occupational therapy for patients such as this patient. Two hours per week of speech therapy and two hours per week of occupational therapy are medically indicated and appropriate for treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: A 61-year-old male enrollee has requested reimbursement for carotid duplex scan for evaluation of the enrollee who had presented to his provider for annual examination. Findings:  The physician reviewer found that The submitted documentation fails to demonstrate the medical necessity of the services at issue in this clinical setting. Since many strokes are due to atherosclerotic disease involving the carotid vessels within the neck, routine physical examinations will involve closely evaluating the patients for carotid bruits. Once discovered, a carotid bruit necessitates further evaluation. The American College of Radiology has established Appropriateness Criteria to direct providers to the most efficacious means to evaluate these vessels.  At the top of the list is carotid duplex sonography (CDS). The American Institute for Ultrasound in Medicine (AIUM), a national ultrasound society, has developed appropriate indications for carotid duplex ultrasonography.  Of note is that neither organization has recommended CDS for the routine evaluation of asymptomatic patients. Similarly, CDS has not been recommended for patients with simple hypercholesterolemia. In this patients case, he has had negative carotid duplex evaluations for the two prior years.  Minor degrees of stenosis would not necessitate any interventions.  One would nevertheless treat the patients hypercholesterolemia. The records do not indicate that this patient was reporting symptoms or signs related to his carotid arteries or neurologic status. The only indicator of possible vascular disease was hypercholesterolemia.  In summary, the medical literature does not support a yearly carotid duplex ultrasound studies in asymptomatic individuals. Therefore, the carotid duplex scan that was performed was not medically necessary for the evaluation of this patients medical condition. Final Result: The reviewer determined that the services at issue were not medically necessary for evaluation of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in diagnostic radiology 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 patients language skills as assessed by the Clinical Evaluation of Language fundamentals-5 were within the typical range of development. An assessment of fluency was also within the typical range of development, although monitoring was suggested. The primary area of concern was speech sound development. Testing that utilized the Goldman Fristoe Test of Articulation-3 noted errors that included the following sounds: /r/; vocalic /r/; /th/, /dz/, as well as some idiosyncratic errors on /t/ and /b/. He also had a rapid rate of speech, which decreased intelligibility. Progress reports documented limited progress in the acquisition of the /r/ and vocalic /r/ sounds, and noted improvement in the production of multisyllabic words /th/ sound and reduction of the rate of speech. Daily notes documented that in many sessions he was unable to produce an approximation of the /r/ and vocalic /r/ sounds. Based on current medical literature and the American Speech-Language-Hearing Association, this patient does not meet the criteria for speech and language therapy. There is no updated standardized testing with a qualifying score that substantiates the need for continued speech therapy services. The last testing completed was over one year old. Additionally, this patient has made little progress in the acquisition of the /r/ and vocalic /r/ sounds. This is likely because these are inappropriate targets for this patients age. The acquisition of the /r/ and vocalic /r/ sounds are typically the last sounds acquired as they require the highest integrity of the tongue muscles. Moreover, the patient does not have an illness or injury to support an indication for services. The target sounds are inappropriate for his age. Therefore, speech and language therapy sessions are not medically necessary for treatment of this patients medical conditionFinal Result: The reviewer determined that the 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 Ph.D. with certificate of clinical competence in speech-language pathology, 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 patient has requested authorization and coverage for Monovisc injections in both knees. Evidence from systematic reviews and randomized controlled trials indicate that although viscosupplementation may relieve knee pain in some patients with osteoarthritis, data has not established which patients will benefit. Guidelines from the American Academy of Orthopedic Surgeons (AAOS) indicate that the data on safety and efficacy of viscosupplementation remain inconclusive. As such, the AAOS does not currently recommend viscosupplementation as routine treatment for osteoarthritis of the knees. Viscosupplementation is reserved for patients with a history of lasting benefit from prior injections and in cases where the remaining options are limited. In this case, the patient has a history of excellent long-term relief with prior viscosupplementation, lasting over six months. The patients treatment options are limited. The patient has been treated with and failed multiple conservative treatments including bracing, taping, NSAIDs, physical therapy, and corticosteroid injections, with the alternative being bilateral total knee arthroplasties. Given these findings, the requested Monovisc injections in both knees are medically necessary for 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: Medical Necessity
Decision: Overturned

A male enrollee requested Sovaldi 400 mg tablet formedical treatment of his hepatitis C virus.  Findings:  Two physician reviewers 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), all patients with chronic hepatitis C, regardless of fibrosis, should be treated except those with limited life expectancy (less than 12 months) due to non-liver-related comorbid conditions. In addition, the AASLD and IDSA guidelines recommendation for patients with hepatitis C genotype 2 is treatment with daily Sovaldi and weight-based ribavirin for 12 weeks. Based on published evidence of safety and efficacy in the published literature, and clinical guidelines, the requested treatment is medically necessary in this patients case.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for tongue and palate radiofrequency ablation (RFA). The records provided for review document that this patient has obstructive sleep apnea (OSA) with a body mass index (BMI) of 26 kg/m2. The patients primary sites of obstruction are the base of tongue and palate. Physical examination revealed that the patient has a long uvula and a short mandibular height. RFA of the palate and tongue base in a patient with normal BMI who cannot tolerate treatment with positive airway pressure (PAP), or an oral appliance is the treatment of choice. A study found that, Because of the wide variety of physiologic and anatomic causes of this disorder it is important to tailor the treatment to offer the patient the best possible outcome. Genioglossus, hyoid, and tongue base procedures should be considered among these treatment options. Overall, data suggest that RFA in this patients clinical setting was likely to have been of benefit as demonstrated in a randomized clinical trial and other clinical studies. Given this support, the tongue and palate RFA procedure was likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the services at issue were 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 certification in sleep medicine and is actively practicing. Physician reviewer 2 is board certified in otolaryngology with subspecialty certification in neurotology and is actively practicing. Physician reviewer 3 is board certified in otolaryngology 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: Upheld

The patient is a 63-year-old female with a history of hepatitis C on treatment and neutropenia. Shortly after beginning treatment the patients ANC dropped. Instead of reducing the dose of the patients medications, the patients provider instituted treatment with Neupogen, which resulted in an improved white blood cell count. The Health Plan indicates the provider should have reduced the dose of the patients medications prior to considering Neupogen. Therefore, the Health Plan has denied reimbursement for Neupogen.It has been established that patients who respond to hepatitis C therapy are those who take 80% of the dose of medication 80% of the time. Neutropenia is a well-known side effect of this treatment. If one is able to treat hepatitis C without having to reduce the dose, theoretically it would be beneficial for the overall SVR. However, a review of relevant literature does not reveal any large, randomized, prospective studies addressing this issue. In fact, the studies set forth above indicate that further studies are necessary and no firm conclusion can be drawn regarding this issue at this time. In this instance, it would have been reasonable for the patients provider to reduce the patients dose to 80% in an attempt to correct the patients neutropenia. It was not medically necessary for the patient to begin treatment with Neupogen without first attempting dose reduction. Therefore, I have determined the medication at issue was not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.