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

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for the S-ICD System subcutaneous implantable cardioverter defibrillator (CPT 33270). S-ICD lead placement is a reasonable and recommended option in patients with vascular access issues. Younger, active patients have a higher likelihood of an intravascular lead failure sometime during their lifetime, requiring lead extraction and replacement with the associated risks attached. The current medical evidence supports the safety and efficacy of the requested device in this clinical setting. In this case, the patient has a definitive indication for prophylactic implantable cardioverter-defibrillator (ICD) implantation for treatment of hypertrophic cardiomyopathy under guidelines from the American Heart Association (AHA), American College of Cardiology (ACC), and Heart Rhythm Society (HRS) based on a family history of sudden death and late gadolinium enhancement. Due to her young age and active lifestyle, with a conventional ICD lead, the patient is likely to be at a higher risk of ICD lead failure or fracture, requiring lead extraction and the substantial additional risks related to extraction and replacement. Based on the current medical literature and this patients specific clinical situation, the requested device is medically indicated. Therefore, the S-ICD System subcutaneous implantable cardioverter defibrillator (CPT 33270) is medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested device 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: Medical Necessity
Decision: Upheld

A 54-year-old male enrollee requested acupuncture for treatment of his low back pain.  Findings:  The physician reviewer found that this patient underwent 19 acupuncture sessions in the past without any significant, sustained, objective improvement documented. The records do not demonstrate substantial functional improvement, medication reduction, or reduced work restrictions. The medical literature supports acupuncture for chronic back pain but also indicates that extension of acupuncture care could be medically necessary if functional gains are clearly documented as improvement in activities of daily living, reduction in work restrictions, or reduction in medication intake (Furlan, et al). Without evidence of significant quantifiable response to treatment obtained with previous acupuncture care, a request for additional acupuncture is not supported as medically necessary.
Appeal type: Medical Necessity
Decision: Upheld

A 49-year-old female enrollee has requested brachytherapy and hyperthermia radiation treatments for treatment of her vulvovaginal cancer.  Findings:  The physician reviewer found that recurrent gynecologic cancers are challenging tumors to treat, particularly when surgical options are not available, as with this patient. The standard treatment option is chemotherapy.  Other available options include re-irradiation, hyperthermia (usually with radiation), radiofrequency ablation and cryotherapy.  The latter two are generally not viable options for patients with nodal spread.  For re-radiation, several techniques can be used to minimize normal tissue exposure, including IMRT, IGRT, SBRT or proton therapy. There are few published studies describing the use of hyperthermia and radiation for gynecologic cancers. Furthermore, there are scant publications describing brachytherapy plus hyperthermia for salvage therapy of recurrent gynecologic cancer. There are no National Comprehensive Cancer Network guidelines for vulvar or vaginal cancer, presumably due to the rarity of these tumors.  For patients with recurrent cervical cancer (which is similar to recurrent vaginal or vulvar cancer), or newly diagnosed cervical cancer, hyperthermia is not listed in the National Comprehensive Cancer Network guidelines as an appropriate treatment option. In this patients case, the requested brachytherapy and hyperthermia radiation treatments are not established as effective treatment options in the scientific literature. There is insufficient medical evidence supporting the requested services in this clinical scenario and therefore the proposed treatment is not medically necessary.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Orthovisc injections for treatment of the enrollees osteoarthritis of the right knee. Findings: The physician reviewer found that the evidence based medical peer reviewed literature supports the use of viscosupplementation injections for the treatment of pain in patients with osteoarthritis of the knee. Viscosupplementation has been found to be safe and effective and allows for delay of total knee replacement. A meta-analysis conducted by Bannuru and colleagues found that hyaluronic acid was the best pharmacologic intervention for knee osteoarthritis. Hyaluronic acid was found to be better than injected placebo or injected corticosteroids. Pagnano and Westrich conducted a systematic review on the efficacy and safety of repeat courses of hyaluronan therapy in patients with osteoarthritis of the knee and concluded that repeat courses of the hyaluronans were safe and effective in the treatment of pain associated with osteoarthritis of the knee. Moreover, a study performed by Turajane and colleagues concluded that repeated cycles of intra-articular sodium hyaluronate treatment to delay time to total knee replacement in patients with knee osteoarthritis which failed conservative treatment was found efficacious during a 54 month follow up period. Viscosupplementation has been found to be safe and effective and allow for delay of total knee replacement. In this patients case, the clinical examination findings were consistent with imaging evidence of right knee medial compartment osteoarthritis. The record indicates that prior corticosteroid injections have not provided relief of symptoms. However, it was noted that prior viscosupplementation injections have provided significant pain relief for up to one year. The provider had recommended Orthovisc injections to delay total knee replacement. Therefore, Orthovisc injections for treatment of this patients medical condition is medically necessary.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: Upheld

A 62-year-old female enrollee has requested platelet rich plasma therapy for treatment of her plantar fasciitis. Findings:  Three physician reviewers found that platelet rich plasma has been used in a variety of conditions, and encouraging results have been reported. However, many of these studies are anecdotal or involve small numbers of patients, and there is a need for further study. There is a lack of high-level evidence and randomized clinical trials to assess the efficacy of the injections. Compared to patients with chronic tendinopathy treated with saline injections, there was no greater improvement in pain or activity. Many controlled clinical trials are underway, but the results are not yet available. Until high-level clinical evidence supporting the efficacy of platelet rich plasma is available, clinical use should be approached cautiously. Clinical studies using proper control groups, randomization, and blinding are needed.  At this time, the superior efficacy of the requested platelet rich plasma therapy has not been established.
Appeal type: Medical Necessity
Decision: Overturned

A 58-year-old male enrollee has requested Hyalgan injections for the treatment of his knee pain. Findings:  The physician reviewer found that the use of Hyalgan in the management of this patients knee condition was beneficial and appropriate. The positive effects of Hyalgan have been demonstrated through a now 10-year history of widespread clinical use. The efficacy of this treatment method is not limited to end-stage osteoarthritis. It is medically reasonable and appropriate to use Hyalgan to maintain neuromuscular control about the joint and minimize peaks of stress loading at the joint. There have been double-blind randomized studies comparing hyaluronan (Hyalgan) with corticosteroids and high molecular weight hyaluronan with lower molecular weight hyaluronans. It has also been possible over the years to perform tissue culture studies utilizing chondrocytes and synovial fibroblasts. A clear short-term benefit has been documented, both in a clinical setting and in a tissue culture setting. There is evidence of a cellular protective effect from Hyalgan in tissue culture with an anti-inflammatory, anabolic and chondroprotective effect demonstrated. All told, the use of Hyalgan in this clinical setting was medically appropriate and indicated for this patient.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/ Case Summary:  The enrollee has requested coverage for inpatient psychiatric services from 2/15/19  2/19/19. The Health Plan denied this request as not medically necessary. A review of the records indicates the enrollee with a history of Bipolar Disorder, Alcohol Use Disorder, Depression, and Body Dysmorphia Disorder presented to the hospital with reports of worsening depressive symptoms, suicidal ideation, and seven days of alcohol use.  He had reports of a past suicide attempt.  He was drinking many shots of alcohol per day for the week prior to admission.  He had reports of impaired functioning including missing work. Medications included Fluoxetine and Olanzapine.  He lived with his family. He was admitted to the inpatient mental health level of care and received medication management, group and individual therapy, and was followed by Psychiatry, Social Work and Occupational Therapy. Review of the records indicates this was a high risk patient due to his initial clinical presentation of having worsened depression with suicidal plans to overdose or cut his wrists and past reported suicide attempt.  According to the medical literature, patients with past suicide attempts are at high risk for suicide and past suicide attempts are the most reliable predictors of suicide. These patients may require more time in the hospital to better assess risk of suicide because sometimes they do not tell the truth regarding suicidal thoughts in order to leave the hospital. This enrollee was considered a high risk patient and was a candidate for inpatient acute hospital treatment as he had continued depression, had two suicidal plans on admission and a past reported suicide attempt. Notes after admission reported that his depression was still significant and was rated an 8 out of 10. He was isolative, guarded, withdrawn, and depressed. He was not interacting with peers and was still depressed. In addition to the suicidal plans, he was drinking heavily so he was also at risk for life threatening withdrawal.  The inpatient level of care was appropriate for one day.  However, as of the third day notes indicate that he denied suicidal ideation, had improved mood and was compliant with medications. A note the next day reported that he felt better and his depression was less at 3 out of 10 and he still denied suicidal ideation.  He was discharged one day later. Thus, the inpatient level of care was not appropriate for the subsequent two days.Final Result: The reviewer determined that the requested service was medically necessary for one of the days, but not medically necessary for the subsequent days for treatment of the enrollees medical condition. Therefore, the health plans denial should be partially overturned. Credentials/Qualifications: The physician 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 similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/ Case Summary:  The parent of an enrollee is requesting reimbursement for Residential Treatment Center (RTC) Services. The enrollee was admitted to a residential treatment center (RTC) for decompensation in her mental health. Psychiatric evaluation indicated the enrollee denied current suicidal ideations. She has had self-injurious behavior, a history of suicide attempts and multiple mental health hospitalizations. Diagnoses are major depressive disorder, post-traumatic stress disorder, attention deficit hyperactivity disorder, tobacco use disorder, panic disorder, cannabis use disorder, and unspecified feeding and eating disorder. She had no active suicidal or homicidal ideations, but had extreme distress and history of suicidal/homicidal behaviors. The residential treatment center criteria were not met with a total score of 19, Level of Care 3 - High Intensity Community Based Services.  Final Result: The reviewer determined that the requested services were not medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The physician reviewer is board certified in psychiatry and child and adolescent 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 similar medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/ Case Summary:  The enrollee is requesting reimbursement for an Immunoassay for Analyte other than infectious agent antibody or infectious agent antigen; quantitative. The enrollee was seen by her physician for complaints of mood swings, hot flashes, weight gain and bilateral knee pain. Exam showed severe aching/painful joints, severe joint swelling, and muscle and joint stiffness upon awakening. Her physician ordered a Veridia blood test due to concerns for rheumatoid arthritis. The Veridia Diagnostics revealed high C-reactive protein (CRP) levels. Findings:  The physician reviewers found that released in response to inflammation, this protein may be elevated in enrollees with type 2 diabetes, periodontal disease, sleep apnea, autoimmune disorders, women on birth control pills, or smokers. Review of the record indicates the provider ordered the Veridia test panel to rule out rheumatoid arthritis (RA). However, the enrollee did not meet rheumatoid arthritis classification criteria for this diagnosis. Her C-reactive protein (CRP), while borderline, was within normal limits. The diagnosis of RA results from a thorough history of joint pain and stiffness, and confirmation of symmetric polyarticular joint swelling (synovitis) by physical exam. Laboratory tests, such as biomarkers, are used as diagnostic confirmation of physical exam results. The Veridia test panel is not a widely accepted, standard-of-care diagnostic that has been proven to be more effective for the evaluation and treatment of this members symptoms than other diagnostics. The use of anti-cyclic citrullinated peptide antibodies (anti-CCP) testing as a diagnostic measure is routine clinical practice. There is insufficient documentation in the record supporting a diagnosis of RA and the pretest probability of having an abnormal result on the requested diagnostic was low.Final Result: Three of the three reviewers determined that the requested service was not likely to be more beneficial than any available standard therapy for treatment of the enrollees medical condition. Credentials/Qualifications: Three reviewers are board certified in rheumatology 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: Experimental/Investigational
Decision: Upheld

A 57-year-old female enrollee has requested ongoing transcranial magnetic stimulation (TMS) therapy for treatment of her bipolar type 2, major episode severe, with a history of psychotic symptoms. Findings:  Two physician reviewers found that the peer-reviewed literature addressing the topic of antidepressant treatment consists of varying reports on the efficacy, especially long-term, and potential side effect profile along with case selection for benefit of repetitive TMS therapy. There is a provided meta-analysis of studies related to this treatment modality (Gross and colleagues).  Their conclusions report that although results are suggestive that TMS has significant antidepressant effects, larger multicenter studies are necessary to confirm these trends. It was concluded that for patients with treatment-resistant depression, repetitive TMS appears to provide significant benefits in short-term treatment studies (Lam and colleagues). However, the relatively low response and remission rates, the short durations of treatment, and the relative lack of systematic follow-up studies suggest that further studies are needed before this therapy can be considered as a first-line monotherapy treatment for treatment-resistant depression. There were reported positive responses of repetitive TMS as an antidepressant treatment, but noted continued need for verification and standardization of best practices and type of patient that would benefit (Gershon and colleagues). Therefore, in this patients case, the superior efficacy of the requested TMS therapy has not been established.
Appeal type: Medical Necessity
Decision: Overturned

A 35-year-old female enrollee requested authorization and coverage of the medication Prevacid. The Health Plan denied the request indicating that the requested medication is not medically necessary for treatment of the enrollees gastroesophageal reflux disease.One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer overturned the Health Plans denial on the basis that the requested medication is medically necessary.
Appeal type: Medical Necessity
Decision: Upheld

A 21-year-old female enrollee requested authorization and coverage of the medication Bextra. The Health Plan denied the request indicating that the requested medication is not medically necessary for treatment of the enrollees back pain.One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer upheld the Health Plans denial on the basis that the requested medication is not medically necessary.
Appeal type: Experimental/Investigational
Decision: Upheld

A male enrollee requested bronchial thermoplasty for medical treatment of his severe persistent asthma.  In an article authored by Thomson and colleagues, the authors noted that, bronchial thermoplasty has a role in the management of patients with severe asthma who have uncontrolled symptoms despite current therapies. Future studies need to identify factors that predict a beneficial clinical response. Bel indicated bronchial thermoplasty appeared to have a benefit on the quality of life and severe exacerbations. However, the author cautioned that it was unclear what phenotype of severe asthma would benefit the most, and the durability of any benefit needs to be further established to ensure that the benefits outweigh the risks and burden of the procedure. While this patient does have severe, uncontrolled, persistent asthma, the use of bronchial thermoplasty would not be the most beneficial treatment due to a lack of scientific peer-reviewed literature to support a long-term efficacy and safety of the treatment. Given these findings, the requested bronchial thermoplasty would not be likely to be more beneficial for treatment of this patients medical condition than any available standard therapy.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a five-year-old female enrollee has requested bilateral ankle foot orthotics for treatment of the enrollees idiopathic toe walking.  Findings:  The physician reviewer found that this patient has idiopathic toe walking secondary to Achilles tightness.  At the time of evaluation, she was receiving physical therapy with some improvement.  However, toe walking was still present, and she was noted to have ankle dorsiflexion on examination.  While toe walking may be considered part of normal gait in toddlers, it is considered abnormal beyond two years of age.  Idiopathic toe walking may be associated with developmental disorders such as autism spectrum disorder or neuromyopathic disorders.  Treatment options include observation, conservative measures, or surgical intervention with Achilles tendon lengthening.  Conservative measures include physical therapy/stretching, serial casting, ankle foot orthotics, and Botox injections.  All of these modalities are considered standard of care.  This patient has progressed with physical therapy, but the toe walking has not completely resolved.  The current medical evidence supports the use of the requested equipment in this setting.  All told, the requested bilateral ankle foot orthotics are medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Overturned

A 20-year-old male enrollee has requested inpatient psychiatric residential services for treatment of his multiple mental health conditions.  Findings:  The physician reviewer found that while this patient had significant anxiety and affective symptoms, it is clear that the addictive influences combined with the patients underlying pain and personality disorder were the primary vehicles of his symptoms. The American Psychiatric Association Clinical Practice Guideline on substance use and depressive disorders both support the use of residential programming in instances where less restrictive treatment settings have failed. Ultimately, the interpretation and application of clinical guidelines and patient placement criteria falls upon physicians and therapists working directly with the patient population.  In this particular case, the treatment team recommended residential treatment for this patient, as he had already attempted treatment at the outpatient, partial hospitalization and inpatient levels of care. Although he was motivated for recovery, he had failed multiple treatment settings. Thus, a 24-hour supervised setting with the benefits of a comprehensive treatment encompassing all elements of the bio-psycho-social-spiritual model was required.  Accordingly, the services at issue were consistent with good medical practice in the United States and were medically necessary for treatment of the patients medical condition.