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

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for a brachial plexus block for a rotator cuff injury. Regional anesthesia of the upper extremity has several clinical applications and is reported to have several advantages over general anesthesia for orthopedic surgery. These advantages, such as improved postoperative pain, decreased postoperative opioid administration, and reduced recovery time, have led to widespread acceptance of a variety of regional nerve blocks. Interscalene block is the most commonly used block for shoulder surgery. Other brachial plexus nerve blocks used for orthopedic surgery of the upper extremity are supraclavicular, infraclavicular, and axillary. Interscalene block for shoulder surgery is at least as effective as general anesthesia alone or other regional anesthetic techniques for decreasing postoperative pain, the need for supplemental analgesics, episodes of nausea and vomiting, and the associated complication rate is low. Interscalene nerve blocks have been shown to be an effective option for regional anesthesia in shoulder surgery. Moreover, interscalene block use is considered a safe and effective anesthetic option. One study concluded that interscalene blocks can provide effective anesthesia for arthroscopic shoulder surgery with minimal complications. Overall, there is high quality evidence to support the effectiveness and safety of interscalene blocks. Given this support, the brachial plexus block for a rotator cuff injury was likely to be more beneficial for the treatment of the patients medical condition that any available standard therapy.Findings:  Three physician reviewers found the brachial plexus block for a rotator cuff injury.Final Result: The reviewers determined that the brachial plexus block for a rotator cuff injury.Credentials/Qualifications: Physician reviewers 1, 2 and 3 are board certified in orthopedic surgery and are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

A 64-year-old female enrollee has requested the prescription medication Actiq (400mcg lozenge, 90 per 30 days) for treatment of her pain. Findings:  The physician reviewer found that it is clear from the clinical record that standard measures have not adequately addressed the patients  severe, on-going pain. It is also clear that surgical correction of the lumbar radiculopathy or the carpal tunnel syndrome is not feasible because of other complicating medical problems. This is not a situation where high-potency narcotics are being utilized as an off-label substitute for more definitive measures to resolve the pain. Rather, this is a case in which the best available means of pain management has been employed and found to be effective.
Appeal type: Medical Necessity
Decision: Overturned

A 36-year-old female enrollee has requested for a multi-chamber programmable lymphedema pump for treatment of her medical condition. Findings:  The physician reviewer found that the requested equipment is clinically indicated and the most appropriate equipment for treatment of the patients condition.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for FoundationOne testing for evaluation of the enrollees metastatic melanoma. Findings:  Two of the three physician reviewers found that FoundationOne is a molecular assay that explores the mutations of an individuals cancer cells. The hope is that the assay will identify a specific mutation or target, which could inform the provider as to which chemotherapeutic drug would be useful.  However, there is a lack of convincing evidence that the assay adds to the decision making ability or yields a result that is reliably clinically beneficial.  There are a variety of non-randomized studies exploring the value of molecular provider. One study noted this ongoing research as well as the serious limitations of such studies. Finding the presence of a mutation does not guarantee that a treatment directed at that mutation will produce a clinically beneficial response. Final Result: The reviewers determined that the services at issue were 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 medical oncology and are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Humatrope growth hormone. The Health Plan denied the request and reported that the requested medication is not medically necessary for the treatment of this patient. At issue in this case is whether the requested Humatrope growth hormone is medically necessary for treatment of the patients medical condition. Tritos and Klibanski reported that GH therapy has beneficial effects on stature growth in several conditions characterized by GH insensitivity, including chronic renal failure, Turner syndrome, Prader-Willi syndrome, postnatal growth delay in patients with intrauterine growth retardation who do not demonstrate catch-up growth, idiopathic short stature, short stature homeobox-containing (SHOX) gene mutations, and Noonan syndrome. Per the Endocrine Society clinical practice guideline states, confirmation of GH deficiency before beginning therapy is crucial and usually involves biochemical testing. The American Association of Clinical Endocrinologists guidelines indicate that GH therapy should only be prescribed for adults with a history of hypothalamic-pituitary disease and biochemically proven GH deficiency. Cook and colleagues reported orthobiologics, including stem cells, osteoinductive growth factors, osteoconductive matrices, and anabolic agents, lack standardized outcome measures for comparison of biologic agents in clinical fracture repair trials. There is a limited understanding of the biological activity of these agents at the bone repair site, and have limited efficacy in clinical applications. In this case, the patient underwent a procedure for short stature. The medical records do not show any evidence of GH deficiency. The laboratory results showed an IGF-1 level in the normal range. There is a lack of clinical studies that document the use of GH therapy for nonunion fractures. The medical evidence does not support the requested medication in this clinical setting. Therefore, Humatrope growth hormone is not medically necessary for the 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 internal medicine with sub-specialty certification in endocrinology, diabetes and metabolism 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 58-year-old female enrollee has requested Zofran 4mg tablets, 30 per month for the treatment of her persistent nausea and vomiting. Findings:  The physician reviewer found that the medical records revealed documentation that the patient has tried multiple antiemetics in the past including Compazine and Phenergan, which were not helpful. The only medication that has relieved her symptoms is Zofran. The use of Zofran has prevented the patient from becoming dehydrated and requiring hospital care. Continued treatment with Zofran 4mg tablets, up to 30 a month, is clinically indicated
Appeal type: Experimental/Investigational
Decision: Upheld

A 46-year-old male enrollee has requested hyperbaric oxygen therapy treatments for treatment of his early onset Parkinsons disease. Findings:  Three physician reviewers found that hyperbaric oxygen (HBO) is a reasonable therapy in severe decompression sickness or arterial gas embolism and carbon monoxide therapy. HBO may be useful in the care of patients with cyanide poisoning, severe anemia, actinomycotic brain abscesses, acute crush injuries, prior radiation therapy, aggressive soft tissue infections, nonhealing ulcers, or compromised skin grafts and flaps. At present, there is limited evidence about the impact of hyperbaric oxygen on Parkinsons disease. Large, randomized clinical trials with long-term follow-up are required to demonstrate that hyperbaric oxygen provides health benefits, to define the clinical role of HBO, and to establish patient selection criteria. There is a paucity of such studies being performed in the available peer reviewed medical literature. As such, there is insufficient scientific data to support the use of HBO for the treatment of Parkisons disease.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for an adalimumab assay (CPT 80145) provided by Lab Corporation of America. In this case, the records noted that the patient had been diagnosed with Crohns disease, was status post ileocecal resection, and was asymptomatic postoperatively. The records noted a recurrence, and the patient started Humira. He then developed a neck abscess of unclear etiology and stopped Humira therapy. The records noted that the patient was reluctant to resume Humira during the COVID-19 outbreak. Due to the reported side effects and the noted reluctance to continue on Humira during the pandemic, it was unlikely that the patient would continue on Humira.  In this clinical setting, given that the provider was likely switching the patient to a medication of another class with a better side effect/adverse effect profile that would not be as immunosuppressive, the testing at issue was not likely to alter this patients outcomes. The documentation does not show that the service at issue provided a safer or more effective evaluation than a standard clinical assessment to make medical therapy changes as part of conventional disease management. Therefore, the adalimumab assay (CPT 80145) provided by Lab Corporation of America was not likely to have been more beneficial for evaluation of the patients condition than any available standard therapy.Findings:  Three of the three physician reviewers found the adalimumab assay (CPT 80145) provided by Lab Corporation of America at issue was not 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 not 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 upheld. Credentials/Qualifications: Physician reviewers 1, 2, and 3 are board certified in internal medicine with sub-specialty certification in gastroenterology and are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for computed tomography (CT) of heart without contrast (CPT 75571). This patient reports chest pain and shortness of breath, but few risk factors for cardiovascular disease. She has a family history of cardiovascular disease in her father, but the records do not state that his condition was premature or early onset. For this patient, coronary CT calcium scanning for evaluation of chest pain or shortness of breath is not consistent with the guideline recommendations. Coronary CT scanning can evaluate patients with borderline cardiovascular risk when considering pharmacologic therapy with statin. This patients records do not include a lipid profile for review. She has not been risk stratified and there is no current plan for consideration of statin therapy. Therefore, the requested CT of heart without contrast (CPT 75571) is not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Findings:  Three of the three physician reviewers found the requested CT of heart without contrast (CPT 75571) is not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the requested services are 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 reviewers 1, 2, and 3 are board certified in internal medicine with subspecialty certification in cardiovascular disease and are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

The parent of a female enrollee requested eight hours per week of applied behavioral analysis (ABA) therapy for medical treatment of the enrollees behavior disorder.   Findings:  Two physician reviewers found that based on the documentation submitted for review, a diagnosis of autism has not been established.   ABA therapy is not medically necessary for the diagnosis of behavior disorder. In sum, this patient presents with findings consistent with behavior disorder; therefore, the requested services are not medically necessary in this clinical setting.
Appeal type: Experimental/Investigational
Decision: Overturned

A 20-year-old female enrollee has requested thoracic outlet syndrome surgery for treatment of her nonspecific right-sided neurogenic thoracic outlet syndrome. Findings:  Two physician reviewers found that in this patients case, the requested services are likely to be of greater benefit than other treatment alternatives.  This patient has been diagnosed with nonspecific thoracic outlet syndrome.  While conservative therapy is the appropriate first approach in this clinical setting, surgical procedures have been utilized for select patients who have failed conservative therapies.  She has failed physical therapy and continues to have significant limitations in her life secondary to her symptoms.  Therefore, the requested thoracic outlet syndrome surgery is likely to be more effective than other treatment options.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: A consumer has requested authorization and coverage for Synvisc One hyaluronic acid injection to the left knee. Findings:  The physician reviewer found that there is adequate evidence that intraarticular hyaluronic acid injections reduce pain and increase function in knee osteoarthritis, and the benefits are long-lasting as compared with intraarticular corticosteroids. Viscosupplementation has a good safety profile, and its use should be considered in some patients with knee osteoarthritis. All told, the Synvisc One hyaluronic acid injection to the left knee is medically necessary for treatment of this patients knee osteoarthritis. 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 39-year-old female enrollee has requested a duodenal switch procedure for the treatment of her morbid obesity. Findings:  The physician reviewer found that the submitted clinical evidence demonstrates that the patient meets generally accepted guidelines for bariatric surgery established by the National Institutes of Health. The duodenal switch procedure is an appropriate primary treatment for morbid obesity. It has been approved by the American College of Surgeons, the American Society for Metabolic and Bariatric Surgery, the Society of American Gastrointestinal and Endoscopic Surgeons and Centers for Medicare and Medicaid Services based on scientific data including long-term follow-up of over 10 years. The available scientific literature demonstrates the duodenal switch procedure is more appropriate for this patient than any other weight loss procedure available in this setting. There is no compelling evidence that duodenal switch results in significant perioperative risks or postoperative nutritional complications.
Appeal type: Experimental/Investigational
Decision: Overturned

Findings:  The physician reviewer found that An enrollee has requested authorization and coverage for cyanoacrylate adhesion procedure of one vein in the right lower extremity. The U.S. Food and Drug Administration (FDA) approves the use of the VenaSeal closure system for the permanent closure of lower extremity superficial truncal veins, such as the great saphenous vein (GSV), through endovascular embolization with coaptation. In this case, in a letter, the provider reported that the patient had undergone proximal GSV ablation many years ago. In an undated letter, the patient reported that the previous procedure did not extend into the calf due to concerns of nerve damage due to the heat. Heat related nerve damage is more of an issue in the calf than in the thigh due to the location of the nerve. As the VenaSeal procedure does not utilize heat and poses no risk of a thermal burn to the adjacent nerve, this nonthermal option is likely to be more beneficial for the treatment of this patient over laser or radiofrequency endovenous ablation. Therefore, cyanoacrylate adhesion procedure of one vein in the right lower extremity is likely to be more beneficial for treatment of the patients condition than any available standard therapy.Findings:  Three of the three physician reviewers found the requested cyanoacrylate adhesion procedure of one vein in the right lower extremity 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.
Appeal type: Medical Necessity
Decision: Upheld

A 59-year-old female enrollee has requested Reclast for the treatment of her osteopenia. Findings:  The physician reviewer found that none of this patients fracture risk assessment tool (FRAX) scores reach levels requiring treatment with Reclast or any bisphosphonate treatment. Her T-score is not more than -2.5 standard deviations below the mean. She has not documented history of fracture. By definition, the patient does not have an osteoporotic condition requiring treatment. In a patient with this clinical presentation, the risks of Reclast outweigh the benefits.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The parent of a 17-year-old male enrollee has requested reimbursement and prospective authorization and coverage for non-surgical scoliosis services (ADL, posture, gait, and neuromuscular retraining - 97110, 97112, 97530, 97116; administration and prescribed home use of custom mechanical traction equipment - 97012, E1399; custom scoliosis brace - L1300, L1210, L1220, L1240, L1250, L1260, L1270, L1290, L0999). This patient has juvenile idiopathic scoliosis. At present, the efficacy of non-specific manual therapy in the treatment of patients with idiopathic scoliosis cannot be reliably evaluated. Studies do not show conclusively that this type of treatment in this clinical setting is beneficial. This patient had extensive therapy over the course of three years and the claims of improvement are inconsistent. All told, the non-surgical scoliosis services (ADL, posture, gait, and neuromuscular retraining - 97110, 97112, 97530, 97116; administration and prescribed home use of custom mechanical traction equipment - 97012, E1399; custom scoliosis brace - L1300, L1210, L1220, L1240, L1250, L1260, L1270, L1290, L0999) from 1/2/17 forward. The Health Plan has denied this request indicating that the services at issue were not and are not medically necessary for treatment of this patients scoliosis.  Final Result: The reviewer determined that the services at issue were not and are not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is a board certified chiropractor and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a 6-year-old male enrollee has requested speech therapy for the treatment of the enrollees delayed speech. Findings:  The physician reviewer found that it is possible that in this case the GERD and the articulation problems of the patient are related. Serious reflux can frequently result in aspiration through the larynx which in turn would cause insult to the vocal cords. Dysfunction of the vocal cords at a critical time in the neurological development of speech could readily result in disarticulation. There are many special exercises and therapies that help control vocal cord dysfunction. Speech therapy is a very important part of the treatment for vocal cord dysfunction. Special exercises can increase the patients awareness of abdominal breathing and relax the throat muscles. This enables the patient to have more control of the vocal folds and throat. Exercises are aimed at overcoming abnormal vocal cord movements, controlling the vocal folds with the breath stream, and improving airflow into the lungs. Speech therapy in this case, for this patient is medically appropriate and indicated.