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

A 47-year-old female has requested surgery consisting of lumbar spinal fusion, anterior approach, exploratory retroperitoneal, insertion vertebral device anterior 2-3 segments, application of spine prosthetic device, and extensive fluoroscope exam for treatment of her back and leg pain.   Findings:  The physician reviewer found that in the most comprehensive review to date of the medical literature pertaining to lumbar fusion for disc herniation and radiculopathy, Resnick, et al. examined 389 titles and abstracts. References were identified that provided either direct or supporting evidence relevant to the use of fusion as a treatment for lumbar disc herniations. These papers were pulled and reviewed, and relevant references from their bibliographies were identified.  Neither treatment standards nor guidelines could be formulated due to a lack of high quality studies. Instead, five treatment options were identified as follows: 1) Lumbar spinal fusion is not recommended as routine treatment following primary disc excision in patients with a herniated lumbar disc causing radiculopathy. 2) Lumbar spinal fusion is recommended as a potential surgical adjunct in patients with a herniated disc in whom there is evidence of preoperative lumbar spinal deformity or instability. 3) Lumbar spinal fusion is recommended as a potential surgical adjunct in patients with significant chronic axial low-back pain associated with radiculopathy due to a herniated lumbar disc. 4) Reoperative discectomy is recommended as a treatment option in patients with a recurrent lumbar disc herniation. 5) Reoperative discectomy combined with fusion is recommended as a treatment option in patients with a recurrent disc herniation associated with lumbar instability, deformity, or chronic axial low-back pain.The American Pain Society (APS) has also developed evidence-based recommendations on the use of interventional diagnostic tests and therapies, surgeries, and interdisciplinary rehabilitation for low back pain of any duration, with or without leg pain (Chou, et al). A multidisciplinary panel developed a total of eight recommendations on treatment. The recommendation applicable to this patient states that, In patients with persistent and disabling radiculopathy due to herniated lumbar disc or persistent and disabling leg pain due to spinal stenosis, it is recommended that clinicians discuss risks and benefits of surgery as an option (strong recommendation, high-quality evidence). It is recommended that shared decision-making regarding surgery include a specific discussion about moderate average benefits, which appear to decrease over time in patients who undergo surgery. Surgery, in this context, specifically refers to discectomy, not fusion. Based on these two comprehensive literature reviews, the requested surgical fusion at the L4-5 level is not medically necessary for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Xeljanz tablets. Findings: A study notes that open-label studies of ruxolitinib and tofacitinib (brand name Xeljanz) showed dramatic clinical responses in patients with moderate-to-severe alopecia areata. Another study reported that treatment with Janus kinase (JAK) inhibitors for 24 weeks in patients with alopecia areata was efficacious and generally well tolerated. Treatment of alopecia totalis includes systemic steroids, methotrexate, cyclosporine, JAK kinase inhibition, and contact sensitization with DPCP or Squaric acid. In this case, the patient has a diagnosis of severe alopecia totalis and has failed treatment with corticosteroid injections. Given that current medical literature supports the use of Janus kinase (JAK) inhibitors following failed treatments of first and second line therapies, in this clinical setting, the requested medication is medically indicated. Therefore, Xeljanz tablets are medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested medication is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in 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

The parent of a 17-year-old male has requested coverage for dental anesthesia services for treatment of his dental anxiety.  Findings:  The physician reviewer found that per the American Dental Association, sedation for dental procedures can fall into the following categories local anesthesia, minimal sedation, use of nitrous oxide/oxygen (when used in combination with sedative agents may provide minimal, moderate, deep sedation or general anesthesia), moderate sedation, deep sedation, and general anesthesia. The American Society of Anesthesiologists (ASA) discussed the definitions of moderate sedation, deep sedation, and general anesthesia. Moderate sedation is a drug-induced depression of consciousness during which patients respond purposefully to verbal commands, either alone or accompanied by light tactile stimulation. No interventions are required to maintain a patent airway, and spontaneous ventilation is adequate. Deep sedation is a drug-induced depression of consciousness during which patients cannot be easily aroused but respond purposefully following repeated or painful stimulation. The ability to independently maintain ventilatory function may be impaired and patients may require assistance in maintaining a patent airway. General anesthesia is described as a drug-induced loss of consciousness during which patients are not arousable, even by painful stimulation. The ability to independently maintain ventilatory function is often impaired. Patients often require assistance in maintaining a patent airway, and positive pressure ventilation may be required because of depressed spontaneous ventilation or drug-induced depression of neuromuscular function. In addition, cardiovascular function may be impaired.Monitored anesthesia care (MAC) is directly provided by anesthesia personnel and may include varying levels of sedation, analgesics, and anxiolysis. Per the standards of the ASA, MAC should be provided by qualified anesthesia personnel who must be present continuously to monitor the patient and provide anesthesia care. MAC care includes all aspects of anesthesia care with a pre-procedure visit, intra-procedure care, and post-procedure anesthesia management. This patients records do not support the use of the requested general anesthesia as medically necessary for the proposed dental procedure. Specifically, there is no indication for general anesthesia for the recommended procedure. The patient is hemodynamically stable and there is no documentation of any developmental disability. His cardiac condition is stable and he is able to fully participate in sports. There is no indication he cannot undergo the procedure with local, minimal sedation, use of nitrous oxide/oxygen, moderate, or deep sedation. All told, the requested general anesthesia with MAC is not medically necessary for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld

A 42-year-old female enrollee has requested a non-standard group 2 four-wheeled scooter (in consideration of her current weight and the limitations of a standard group 1 scooter) for the treatment of her multiple medical problems. Findings:  The physician reviewer found that this patient meets Medicare guidelines for a basic group 1 power-operated vehicle (POV) as she has a mobility deficit (i.e., degenerative joint disease), poor strength in her upper and lower extremities that impairs her ability to perform MRADLs within her home independently and safely, and the patients mobility deficit cannot be corrected with a cane, walker or manual wheelchair. The requested non-standard group 2 POV is not medically necessary for this patient. A POV is considered medically necessary for use within the home, not outdoor use. The solid tires included with the requested POV are not necessary for indoor use. Additionally, the other accessories including the rear basket and special seating are for patient convenience and not medically necessary. A basic group 1 POV with a weight capacity of 500 pounds is adequate for this patient to complete MRADLs within the home safely and independently.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for digital breast tomosynthesis for evaluation of the enrollees medical condition.  Findings:  The physician reviewers found that breast tomosynthesis is a technique that was developed several years ago as a problem solving adjunct to routine mammography.  Applying the same basic concept as computed tomography (CT) scanning, the logic is that by separating the various layers of breast tissue, one can better detect abnormalities.  This has been shown to be most useful in the evaluation of dense breasts. In this particular patient, she has breasts that have been described as being very dense. It is specifically those patients who have dense breasts that can benefit most from tomosynthesis. The ability to separate out the overlapping structures enables the possibility of demonstrating an otherwise occult tumor. Final Result: All three reviewers determined that the services at issue were likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: Physician reviewers number one, two, and three are board certified in diagnostic radiology and 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

A 41-year-old female enrollee has requested transcranial magnetic stimulation (TMS) therapy for treatment of her major depressive disorder.  Findings:  The physician reviewer found that the U.S. Food and Drug Administration (FDA) has approved TMS for the treatment of adult patients with major depressive disorder who have failed to receive satisfactory improvement from one prior antidepressant medication at or above the minimal effective dose and duration in the current episode. This patients provider indicates that the patient is a candidate for TMS therapy and has failed an appropriate trial in the current episode of illness. However, there is no clinical description of the patients psychiatric symptoms or functional impairment that would demonstrate an indication for TMS therapy. Finally, psychosocial stressors and non-pharmacologic interventions related are not documented. In the absence of this information, the requested TMS therapy is not supported as medically necessary for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Brilinta 90 mg tablets. Treatment guidelines for patients with acute coronary syndrome undergoing stent placement recommend dual antiplatelet therapy for one year. Trials have compared the safety and efficacy of clopidogrel with that of newer antiplatelet therapies, such as Brilinta, and have demonstrated faster onset of action with newer agents and improved thrombotic endpoints. These advantages make new agents more suitable for the treatment of patients with a high thrombotic risk, such as this patient. These newer agents are incorporated in current guidelines. The current medical evidence supports Brilinta in this clinical setting. Therefore, Brilinta 90 mg tablets are medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested medication is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in internal medicine with sub-specialty certification in cardiovascular disease 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 therapeutic apheresis treatment for treatment of her medical condition.   Findings:  Two physician reviewers found that neuromyelitis optica (NMO) is a rare demyelinating disease for which there are no Class 1 to 2 studies. However, the available peer-reviewed literature supports the use of plasma exchange for treatment of NMO especially when azathioprine has failed. Kleiter and Gold reported that NMO spectrum disorders are important evolving entities, which have reached much attention in the recent years. NMO spectrum disorders are characterized by inflammatory lesions in the optic nerves, spinal cord, and central parts of the brain, as well as an autoimmune process directed against aquaporin-4. As disability in NMO spectrum disorders accumulate by inflammatory damage from attacks, both the treatment and prevention of attacks are decisive for long-term outcome. NMO spectrum disorders attacks are treated with high-dose intravenous corticosteroids and apheresis therapies, in particular therapeutic plasma exchange. The medical records demonstrate that this patient had good response to treatment with good functional outcome. Given the response effect and the support in the literature, the requested therapeutic apheresis treatment was and is likely to be more beneficial for this patient for the treatment of NMO than any available standard therapy. Final Result: Two reviewers determined that the services at issue were and 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: All three reviewers are board certified in internal medicine and neurology 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: Overturned

The patient is a 59-year-old female with a history of neck pain for many years. She had a C5-6 fusion and achieved 99% relief until August 2003 when she developed axial pain. The patient had an MRI at that time and was told, everything looks good. The patient was treated with bilateral shoulder trigger point injections and her shoulder pain improved, but her neck symptoms continued. The patient was also treated for lower back and right lower extremity pain in early 2006.The patient reportedly developed vertigo and headaches in February 2006, which persisted with radiation to the left scapula, and upper extremity.  The symptoms were reported to worsen and an MRI was apparently ordered by another of the patients long-term providers due to concern(ed) about possible complications in view of the abrupt onset of the patients symptoms.  The patients orthopedic provider reviewed the MRI of the cervical spine done in March 2006 and provided additional injection treatments.  The patients request for reimbursement for the cost of the MRI was denied by the Health Plan citing a lack of medical necessity.A review of the medical records provided indicates the patient had a relatively sudden onset of neurological symptoms, which worsened over the course of several weeks.  In light of her previous cervical fusion, an MRI was appropriate for a more complete evaluation of her symptoms before proceeding with additional treatment.  Therefore, I have determined the MRI at issue was medically necessary for evaluation of the patients medical condition. The Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for eNeuras single pulse transcranial magnetic stimulation (TMS) mini device. TMS is U.S. Food and Drug Administration (FDA) approved, and supported in the medical literature as a safe and effective, for the treatment for migraines. In addition, the eNeura single pulse magnetic stimulation has obtained FDA clearance for the treatment of migraine, both abortive and preventive. Medical literature found a mean reduction in headache days from baseline and decreased acute medication use with use of the eNeura sTMS device. This patient has failed numerous prior therapeutic agents. Treatment with the eNeura sTMS device has provided her with decreased headache frequency and improved quality of life. She has a history of POTS and fibromyalgia, and her provider noted that the patient is sensitive to medications. One study found that most neuromodulation techniques are better tolerated as compared to the majority of pharmacological approaches. This patient has responded well to the eNeura sTMS device after failing multiple medications. Given these findings, the eNeuras single pulse TMS mini device is medically necessary for treatment of this patient. Final Result: The reviewer determined that the requested equipment 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 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

This patient is a six-year-old female with a diagnosis of attention deficit hyperactivity disorder, combined type. She has been evaluated by the school and the Health Plan psychiatrist and attended a social skills class. Autism spectrum disorders have been ruled out using the ADOS.  The patients Health Plan therapist and her school teacher have identified a delay in motor skills including fine and visual motor integration. A private occupational therapy evaluation noted the patient had difficulty with sensory processing including visual perception and visual motor skills and recommended direct occupational therapy one time per week for one hour over a period of six months.   The parents have requested reimbursement for the sensory integration occupational therapy already provided and continued authorization and coverage for on-going therapy. The Health Plan denied their request based on a determination that sensory integration therapy was not medically necessary for the treatment of the patients sensory processing deficits.I have reviewed the literature, and find no controlled clinical trials comparing standard occupational therapy with strict integration therapy.  There is little to no objective evidence that sensory integration therapy is beneficial in the treatment of ADHD and my observations from clinical experience are comparable. Therefore, I have determined the therapy at issue is not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned

The patient is a 49-year-old woman who underwent a total knee replacement in November 2004. Following surgery, her surgeon prescribed a CPM device that was utilized for three weeks.  The patient had continued pain; therefore her provider prescribed an additional six weeks use of the CPM device.  The patient now requests reimbursement for the additional rental cost of the device.  The Health Plan does not consider the extended use of the CPM device medically necessary, and has denied coverage.A CPM device is commonly prescribed by surgeons for postoperative rehabilitation following total knee replacement. There is no dispute that the CPM device was medically necessary for the initial three weeks following surgery.  The treating surgeon felt that additional time with the machine was indicated for this particular patient. His decision was based on the patients subjective report of her status at the end of the first three weeks and individualized to her condition at that time. Therefore, I have determined the device at issue was medically necessary for treatment of the patients medical condition. The Health Plans denial should be overturned.
Appeal type: Experimental/Investigational
Decision: Upheld

A 38-year-old male enrollee has requested extracorporeal shockwave therapy (ESWT) for treatment of his plantar fasciitis. Findings:  Three physician reviewers found that to date, there are no long-term prospective studies of the effectiveness of extracorporeal shock wave therapy for treatment of plantar fasciitis. Additionally, the current scientific literature does not adequately document the associated complications or risks of ESWT. ESWT has been approved by the Food and Drug Administration and demonstrates about a 70-85% cure rate. This rate, however, does not exceed the 90% cure rate demonstrated with a minor surgical approach such as endoscopic plantar fasciotomy. Thus, the current scientific literature provides no evidence that ESWT for treatment of plantar fasciitis is more effective than minimally invasive surgical treatment.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for gene testing for evaluation of melanoma of the left eye. Findings:  Three physician reviewers found that the gene testing was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Cytogenetic testing of uveal melanoma is an established method of laboratory evaluation of melanomas. The medical literature supports the routine use of this test for patients with uveal melanoma. The standard of care is to adjust a patients monitoring and surveillance based on the genetic profile of the tumor. In addition, the counseling and eligibility for clinical trials is based heavily on the tumor genetic profile. In sum, the testing at issue was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Final Result: The reviewers determined that the testing at issue was 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. Reviewers 1, 2 and 3 are board certified in ophthalmology 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.