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

Nature of Statutory Criteria/Case Summary: The enrollee has requested reimbursement for applications of Apligraf graft product for treatment of the enrollees unspecified left leg wound due to a dog bite.  Findings:  The physician reviewer found that Apligraf has been shown to be effective in the treatment of chronic venous wounds and wounds associated with surgical excisions (Eaglstein and Falanga). It has also been shown to be effective in diabetic non-healing ulcers (Edmonds, et al). The U.S. Food and Drug Administration (FDA) has approved Apligraf for use in diabetic foot wounds and venous ulcers (Keller). However, the use of Apligraf in patients with a dog bite wound is not clinically indicated or the standard of care. Given the lack of medical literature supporting the services at issue in this clinical setting, the Apligraf graft product was not 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 not likely to be 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 reviewer number one is board certified in family medicine with sub-specialty expertise in wound care 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.Physician reviewer number two is board certified in internal medicine with sub-specialty certification in infectious 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.Physician reviewer number three is board certified in internal medicine with sub-specialty certification in infectious 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: Upheld

A 46-year-old female enrollee requested breast tomosynthesis for medical evaluation of her medical condition.  Findings:  Three physician reviewers found that the medical literature does not support the services at issue in this clinical setting. In this case, the patient is asymptomatic with no reports of dense breast tissue. Although breast tomosynthesis has a role in screening as an adjunct in a select group of patients, this is not the case in this clinical setting. Therefore the services at issue were not likely to be more beneficial for evaluation of the patients medical condition than any available standard.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/ Case Summary: This is patient with diagnoses of gastritis, osteopenia, and chronic bilateral hip and back pain from degenerative disc disease.The patients primary care physician (PCP) noted she was having trouble sleeping and having to limit her activity due to her chronic pain in the hips, back and other joints. Celebrex 200 mg capsules were recommended as other non-steroidal anti-inflammatories are contraindicated due to her history of gastritis confirmed by endoscopy in 2018. Another provider reported that ibuprofen taken over the prior two months was not effective for her chronic pain and recommended Celebrex. At issue is whether the requested medication, Celebrex (celecoxib) 200 mg is medically necessary to treat the patients medical condition. Based on the medical record showing the lack of benefit with ibuprofen, the potential risk of GI complications, the relief of her chronic pain with Celebrex without GI complications, and the need to manage the patients chronic pain, Celebrex is appropriate for the patient. Final Result: The reviewer determined that the requested service is medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The physician reviewer is board certified in in physical medicine & rehabilitation, sports and 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 similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

A 50-year-old female enrollee has requested for Botox injections for treatment of her migraine headaches.  Findings:  The physician reviewer found that there is ample medical literature supporting its use in select cases of migraine. A portion of these data are found in the publications cited above. In this particular case, the patient has failed multiple first-line therapies for headache including multiple abortive and preventative medications
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested inpatient psychiatric hospitalization for treatment of her behavioral health condition. Findings: The physician reviewer found that according to the documentation submitted for review, the patient did not meet criteria to support ongoing treatment at the inpatient psychiatric hospitalization level of care. Inpatient hospitalization was initially safe, reasonable and consistent with good medical practice. The patient was not psychotic. She was not cognitively impaired. She was sleeping an adequate amount per night. She was consuming 100% of reported meals. She was tolerating her medications well and they were provisionally helpful. The patient denied any anxiety or depression. She was resistive to meet with a social worker to discuss disability benefits. She was not fully engaged with unit activities, suggestive that the setting did not fully align with her clinical needs. In sum, the acute psychiatric syndrome that prompted the admission had resolved. In conclusion, placement at the inpatient psychiatric hospitalization level of care was not and is not medically necessary for treatment of the patients medical condition.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 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: Medical Necessity
Decision: Overturned

The parent of an 11-year-old male enrollee has requested occupational therapy 2 times per week for 1 hour sessions for treatment of the enrollees autism.  Findings:  The physician reviewer found that occupational therapy (OT) is medically necessary for this patient given his functional deficits. Case-Smith, et al. involved controlled studies of occupational therapy interventions in autistic children with reports of benefit in this population. The submitted documentation reveals below average results in fine motor control and manual coordination. In addition, the patient is functioning below-average on all subtests of motor coordination, fine motor integration and body coordination deficit. All told, the evidence provided demonstrates occupational therapy is a medically necessary modality for this patient. The patient should receive occupational therapy at the requested frequency of twice weekly one-hour sessions.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for magnetic resonance imaging (MRI) of the pelvis and abdomen. Findings:  The physician reviewer found that Prolonged postoperative pain after recurrent inguinal hernia repair can represent technical failings of mesh movement or other anatomic abnormality. Per Andresen and Rosenberg, The optimal management of chronic pain following inguinal hernia surgery should begin with a thorough clinical examination to rule out other causes of chronic pain and to rule out a recurrence. This patients records document a history of recurrent inguinal hernia. The patient underwent surgical repair of the hernia. However, he then presented with postoperative pain. Treatment included medical therapy and a local nerve block without substantial control over his pain. Given the efforts at medical as well as interventional treatments without improvement, evaluation with MRI was indicated to rule out a technical or anatomic abnormality. Therefore, the MRI of the pelvis and abdomen was medically necessary for this patient. Final Result: The reviewer determined that the services at issue were 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 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: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement and prospective authorization and coverage for blood glucose testing four (4) times a day from December 2020 and forward utilizing True Metrix strips and lancets.Self-monitoring of blood glucose (SMBG) is recommended as an integral component of diabetes therapy.  Studies have shown that its use is linked to better clinical outcomes and more effective control of blood glucose levels, reducing the risk of diabetes-related complications. Current recommendations state that for individuals injecting insulin more than two times per day, SMBG should be done at least three times per day. However, there is insufficient evidence on the number of times SMBG needs to be done in individuals who are taking oral antidiabetic agents, rather than insulin. According to medical literature, some studies have demonstrated that once daily SMBG is helpful to maintain glycemic control in non-insulin-treated type 2 diabetes. In this case, the patient has been diagnosed with type 2 diabetes. Records show that the patient is taking glipizide, which is an anti-diabetic medication. As such, there is insufficient evidence supporting blood glucose testing four times per day in this case. Thus, blood glucose testing four (4) times a day from December 2020 and forward utilizing True Metrix strips and lancets was not and is not medically necessary for the treatment of the patients medical condition.Final Result: The reviewer determined that the equipment at issue was not and 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

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for oxycodone-acetaminophen (Percocet), (Percocet) 7.5mg-325mg 90 tablets for 30 days. Findings:  The physician reviewer found that the current Centers for Disease Control and Prevention (CDC) guidelines state that if opioids are used for chronic pain that they should be used at the lowest possible dose, after or with alternative non pharmacologic or non-opioid therapy, and monitored closing with a pain contract and regular urine drug screens. In this case, the patient has a chronic pain condition that has been non-responsive to conservative measures. The patient is using a low dose of opioid (37.5 MED) which is lower than the 50 MED the CDC recommends as a ceiling dose. In addition, the patient has been tried on multiple other therapies. Further, the patient is currently on a non-steroidal anti-inflammatory drug (NSAID) and pregabalin. Lastly, the patient has a pain contract on file and has agreed to random compliance testing with no evidence of aberrant behavior. Overall, the requested opioid has been provided pursuant to the CDC guidelines. Given these findings, the Percocet 7.5mg-325mg 90 tablets for 30 days is medically necessary for management of this patients chronic pain. 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 anesthesiology with a 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: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested an annual genetic homocysteine lab test. Findings:  The physician reviewer found that there is a lack of utility in testing homocysteine or folate based on this patients genetic test result. The American College of Medical Genetics (ACMG) recommends against testing for polymorphisms in the MTHFR gene, including in those with a known family history of these changes. In fact, the ACMG included MTHFR testing in their Choosing Wisely campaign, highlighting the recommendation that this testing not be done. There is a suggestion to consider testing of fasting homocysteine in those homozygous for the C677T polymorphism, as those with two copies of this change are at higher risk for elevated homocysteine. However, this patient does not have two copies of this polymorphism. In addition, the patient has had repeated homocysteine measurements that have been normal. Given the above, the requested services are not clinically indicated for evaluation of the patients medical condition.Final Result: The reviewer determined that the requested services are not medically necessary for evaluation of the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The physician reviewer is board certified in clinical biochemical genetics, 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 49-year-old female enrollee has requested for an artificial disc replacement for treatment of her low back pain. Findings:  Three physician reviewers found that there are no long-term studies that have proven that lumbar artificial disc replacements are more effective in the treatment of discogenic pain than standard modes of treatment. Further studies are needed before the long-term safety and efficacy of the proposed procedure can be adequately determined.
Appeal type: Experimental/Investigational
Decision: Upheld

A 32-year-old female enrollee has requested percutaneous tibial nerve stimulation (PTNS) for treatment of her chronic interstitial cystitis and urinary frequency. Findings:  Three physician reviewers found that the services at issue were not likely to be more effective for this patient than other available options. The medical literature in regards to PTNS in this clinical setting remains controversial, and there are a variety of treatments that are readily available and that have wide acceptance as to the efficacy. Moreover, there is a lack of peer-reviewed literature supporting treatment of interstitial cystitis and related symptoms with PTNS. For the reasons provided, the services at issue were not likely to be more beneficial than standard medical therapy in this clinical setting.
Appeal type: Medical Necessity
Decision: Upheld

The patient has requested reimbursement for cooling and compression device rental. Recent medical literature does not support the post-operative use of cold compression over standard ice packs following shoulder arthroscopy. Colleagues reported on 40 randomized controlled trials comparing various modalities of postoperative pain control including cryotherapy. The authors concluded that interscalene nerve blocks were the most effective method to control postoperative pain after shoulder arthroscopy. Further studies have not found substantial advantages with cold compression over ice packs after arthroscopic surgery of the shoulder. Based on a review of recent medical literature, the rental of the cold compression device was not medically necessary for this patients post-operative care.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 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

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for a triamcinolone acetonide injection (Zilretta).Findings:  The physician reviewer found that (FDA) approves the use of triamcinolone acetonide extended-release (brand name Zilretta), a synthetic corticosteroid, for intra-articular use for the management of osteoarthritis pain of the knee. Langworthy and colleagues noted in a study of 170 participants that triamcinolone acetonide extended-release provided five to six months of pain relief, suggesting that it may be an effective non-opioid treatment option. The authors further noted that in a phase 3 randomized controlled trial, injections of an extended-release formulation of triamcinolone acetonide in participants with unilateral or bilateral knee osteoarthritis demonstrated substantial improvement in pain and symptoms. Triamcinolone acetonide extended-release is formulated in poly lactic-co-glycolic acid (PLGA) microspheres that slowly release triamcinolone acetonide in the synovium, providing long acting efficacy along with a decrease in systemic absorption and lessening of systemic side effects, such as blood glucose elevations. Given that triamcinolone acetonide extended-release is safe, effective, and does not accelerate the progression of osteoarthritis in these patients while delaying the need for a total knee arthroplasty, the requested service is medically indicated. Therefore, triamcinolone acetonide injection (Zilretta) is medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested service 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 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

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for Oncotype Dx Prostate genetic testing provided by Genomic Health, Inc. This patient presented with an elevated PSA as well as prostate cancer. Pathology demonstrated Gleason 3+4=7 in the right base and Gleason 3+3=6 in the left base. The patients provider recommended evaluation with Oncotype Dx Prostate testing for treatment planning. Oncotype Dx reporting demonstrated favorable intermediate risk, with 17% high-grade disease, and 19% non-organ confined disease. The NCCN guidelines for prostate cancer state that there is a lack of randomized controlled clinical trials to support the use of molecular assays to improve decision-making in newly diagnosed men considering active surveillance and in treated men considering adjuvant therapy or treatment for recurrence. Per the American Urological Association (AUA) guidelines, Among most low-risk localized prostate cancer patients, tissue based genomic biomarkers have not shown a clear role in the selection of candidates for active surveillance. Furthermore, the American Society for Clinical Oncology (ASCO) guideline indicated that molecular assays are not recommended for routine use as they have not been prospectively tested or shown to improve long-term outcomes (Eggener, et al.). While Oncotype Dx may eventually have a role in treatment planning for patients with prostate cancer, there is limited data on clinical outcomes to support its routine use. For these reasons, the Oncotype Dx Prostate genetic testing provided by Genomic Health, Inc. was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Findings:  Two of the three physician reviewers found the Oncotype Dx Prostate genetic testing provided by Genomic Health, Inc. was 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 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: Physician reviewers 1, 2, and 3 are board certified in urology 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

A 56-year-old female enrollee has requested for Avastin for treatment of her metastatic breast cancer. Findings:  The physician reviewer found that the use of Avastin and Xeloda did not yield encouraging results. The original trial revealed an increase in response rate with the combination of Xeloda and Avastin, but did not show a prolongation of time to progression. Furthermore, no survival advantage has been noted. Moreover, Avastin may result in significant side effects.
Appeal type: Medical Necessity
Decision: Upheld

A female enrollee requested an inpatient hospital stay for medical treatment of her nausea and vomiting with history of Roux-en-Y gastric bypass.   Findings:  The physician reviewer found that the records do not support that there were abnormalities, instability, or concerns to warrant hospitalization.  No imminent surgery was planned.  Accordingly, inpatient services were not medically necessary for treatment of the patients medical condition.