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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for sphenopalatine ganglion nerve block injections. Sphenopalatine ganglion blocks have only anecdotal case reports supporting their use in this situation. Researchers surveyed the literature about refractory trigeminal neuralgia and concluded that there is insufficient evidence for peripheral techniques including nerve blocks in this clinical setting. The American Academy of Neurology (AAN) guidelines on trigeminal neuralgia do not identify the use of sphenopalatine ganglion blocks as an effective therapy. Thus, the requested ganglion nerve block injections are not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.One reviewer found that the requested sphenopalatine ganglion nerve block injections are likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: Two of the three reviewers determined that the requested services are 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:  One reviewer is board certified in neurology with sub-specialty certification in pain medicine and is actively practicing. One reviewer is board certified in anesthesiology with sub-specialty certification in pain medicine and is actively practicing.  One reviewer is board certified in anesthesiology with sub-specialty certification in pain medicine and is 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: Upheld

The patient is a 36-year-old male with a history of malignant insulinoma. The patient underwent a laparoscopic distal pancreatectomy in October 2005 and chemoembolization of a liver lesion in November 2005. According to the patients letter, the last MRI showed enlarged lymph nodes. The size and location of the lymph nodes, and the status of the liver lesion are unknown. An octreotide scan was reported negative according to a clinician note. The date of this exam is uncertain. The patients clinician has ordered a PET scan to assess surgical feasibility.At issue is whether a PET scan is medically necessary for evaluation of the patients condition.PET scan is variable in its sensitivity for pancreatic insulinomas, up to 53%. PET scan sensitivity for metastatic insulinoma is unknown. The use of standard imaging technology including CT, ultrasound, MRI, and percutaneous biopsy is appropriate to assess for recurrent metastatic disease and is likely to be of greater clinical utility than a PET scan. The use of PET scanning in this area is not the standard of care and is not medically necessary. Accordingly, the Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld

A 58-year-old male enrollee has requested outpatient psychotherapy visits once per week for treatment of his behavioral health issues. Findings:  The physician reviewer found that according to available medical records of the patients therapy, there is no support that a significant likelihood of deterioration will occur with a reduction from weekly to twice monthly psychotherapeutic sessions. In addition, there is inadequate medical literature suggesting that the current weekly therapy is medically necessary to prevent an acute deterioration of his disorder. Further, there is no evidence of any clinical concerns supporting the conclusion that the patient could not be safely treated with twice monthly therapy. For these reasons, the patient should continue to benefit towards his recovery with psychotherapy sessions twice per month as the medical necessity of more frequent sessions has not been established in this patients care.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Otezla 30 mg (maintenance dose) twice daily for treatment of the enrollees psoriatic arthritis. Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested medication.  The records do not demonstrate where the joint disease is active but it is assumed to be peripheral. The Group for Research and Assessment of Psoriasis and Psoriatic Arthritis (GRAPPA) states the following, Treatment recommendations for peripheral arthritis include non-steroidal anti-inflammatory drugs (NSAIDs), intra-articular glucocorticoid injections, disease-modifying antirheumatic drugs (DMARDs) and TNF inhibitors,. Anti-tumor necrosis factor alpha agents have been proven very effective for PsA and are disease modifying agents. They prevent progression of disease, erosions and disability and are the preferred agent for PsA (EULAR 2015 Update). Otezla (apremilast) is an orally administered phosphodiesterase-4 inhibitor available for the treatment of PsA but it is not currently known to be disease modifying at this time. As such, it is not a preferred agent for the treatment of PsA (EULAR 2015 Update).  Therefore, the request for Otezla 30 mg (maintenance dose) twice daily for this patients medical condition is not medically necessary for treatment of this patient.  Final Result: The reviewer determined that the requested medication is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in internal medicine and rheumatology 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 60-year-old male enrollee has requested Remicade injections for the treatment of his Sarcoidosis. Findings:  The physician reviewer found that there are no FDA-approved treatments for Sarcoidosis despite a long history of using immunosuppressive treatment. Remicade has recently been demonstrated to be effective in the treatment of severe Sarcoidosis that has failed traditional non-FDA approved treatments. Since there are no FDA-approved treatments and the patient continues to have severe Sarcoidosis threatening his organ function, Remicade is medically necessary and must be approved.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the upper endoscopy with radiofrequency ablation (RFA) services. Currently accepted practice guidelines from gastroenterology societies support the use of RFA in Barretts esophagus when high-grade dysplasia is present, and in some cases in which low-grade dysplasia is present. However, there are no recommendations supported by high-quality evidence to perform ablation in patients with indefinite dysplasia or non-dysplastic Barretts esophagus. Specifically, the most recent American Society for Gastrointestinal Endoscopy guideline does not recommend RFA of non-dysplastic Barretts esophagus unless a special circumstance such as family history of cancer is present. Further, the American College of Gastroenterology recommendations do not recommend RFA of Barretts esophagus without definite dysplasia. As there is no documented evidence of dysplasia of Barretts esophagus in this case, the upper endoscopy with RFA services were not likely to be more beneficial for treatment of the patients Barretts esophagus than any available standard therapy.Findings:  Three physician reviewers found the upper endoscopy with RFA services were not likely to be more beneficial for treatment of the patients Barretts esophagus than any available standard therapy.Final Result: The reviewers determined that the upper endoscopy with RFA services were not likely to be more beneficial for treatment of the patients Barretts esophagus than any available standard therapy.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: Medical Necessity
Decision: Upheld

A 49-year-old male enrollee requested authorization and for discectomy and foraminotomy. The health plan has denied this request indicating that the requested procedure is not medically necessary for treatment of the enrollees lumbar disc disease.One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer upheld the health plans denial on the basis that the requested procedure is not medically necessary.
Appeal type: Medical Necessity
Decision: Upheld

A 38-year-old male enrollee has requested Lyrica for the treatment of his spondyloarthropathy. Findings:  The physician reviewer found that there is a lack of published evidence supporting the use of Lyrica for spondyloarthropathy. One reference (Current Opinion in Rheumatology, 2005) discusses the major treatment modalities in the treatment of spondyloarthropathy, the most recent of which includes the use of the tumor necrosis factors, such as the Enbrel that the patient is taking. However, the use of Lyrica is not part of the discussed treatment approaches, and there have been no studies regarding the efficacy of the use of Lyrica for patients with pain from spondyloarthropathy. The Health Plans criteria are medically appropriate, as Lyrica is not medically indicated for this patients condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: A patient has requested authorization and coverage for Otezla. The Health Plan has denied this request indicating that the requested medication is not medically necessary for treatment of the patients psoriasis vulgaris. The submitted documentation of the patients medical needs supports the medical necessity of the requested medication. The patient is requesting coverage for Otezla for treatment of chronic plaque psoriasis. Otezla is Food and Drug Administration approved for the treatment of psoriasis and psoriatic arthritis. The Health Plan requires failure of two preferred injectable biologic agents prior to covering Otezla. As the patient has shown improvement with psoriasis since taking Otezla, the request for coverage of Otezla should be approved and is considered medically necessary for this patient. Accordingly, Otezla 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: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for eye movement desensitization and reprocessing (EMDR) therapy. The submitted documentation supports the medical necessity of the requested services. Current medical literature supports the use of EMDR psychotherapy as a well-established psychotherapy modality to manage symptoms related to past trauma. Bisson and colleagues report that there is evidence that EMDR is effective immediately post-treatment in the treatment of PTSD. In this case, the patient has a history of significant trauma through childhood with mood and anxiety symptoms and suicidality progressing from that trauma. Although her anxiety and depression are improved with psychiatric medications, the patient continues to struggle significantly with symptoms that are based in that early childhood trauma. The patients psychiatric team has referred the patient for EMDR. While the records do not note a formal diagnosis of PTSD, given that the patient continues to report various issues in relationships and a lack of feeling safe in connections with others that is directly related to the childhood trauma, the requested services are medically indicated. Therefore, EMDR therapy is medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested services are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in psychiatry and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld

Credentials/Qualifications: An enrollee has requested radiofrequency neurolysis for treatment of her medical condition.  All three reviewers are board certified in anesthesiology with sub-specialty certification in pain medicine 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.  Nature of Statutory Criteria/Case Summary: In the documentation available for review, there is no documentation of a diagnostic block prior to radiofrequency neurolysis.  In addition, the medical literature suggests that radiofrequency ablation only be performed after a diagnostic block with local anesthetic alone and a pain diary with notations of medication usage (Ferrante, et al; Cohen, et al). In the absence of this information, the requested radiofrequency neurolysis was not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Final Result: Three 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: All three reviewers are board certified in anesthesiology with sub-specialty certification in pain medicine 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: Upheld

A 59-year-old male enrollee requested methadone 50 mg daily for medical treatment of the enrollees spinal stenosis and cancer pain.  Findings:  The physician reviewer found that the requested methadone 50 mg per day is not medically necessary for treatment of this patients medical condition. The records indicate that this patient has non-malignant chronic pain, which will often worsen or recur as a result of opioid rebound. The standard of care for chronic pain is treatment in a multidisciplinary practice to include physical therapy, massage therapy, cognitive behavioral therapy, and injections to help reduce pain.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for peripheral nerve stimulation (PNS) trial and implantation with Stimwave (CPT 64555). In this case, the patient has chronic occipital migraines, which have been diagnosed as occipital neuralgia. The records document that the patients symptoms have been refractory to medication management, physical therapy, Botox injections, and occipital nerve blocks. The provider has recommended treatment with peripheral nerve stimulation (PNS). However, there are insufficient data in the current peer-reviewed medical literature to support use of PNS in lieu of standard of care modalities. Cadalso and colleagues assessed the safety and efficacy of occipital nerve stimulation in the treatment of patients with refractory headaches. The authors noted that this therapy may be effective when compared to placebo, but additional prospective randomized controlled clinical trials are needed to determine whether PNS yields improved patient health outcomes when compared to current treatment options. A systematic review published by Yang and colleagues reported that, the evidence of occipital nerve stimulation efficacy established by randomized controlled trials was limited. All told, the requested PNS trial and implantation with Stimwave (CPT 64555) is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Findings:  Three of the three physician reviewers found the requested PNS trial and implantation with Stimwave (CPT 64555) is 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 requested services are 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 1 is board certified in anesthesiology with subspecialty certification in pain medicine and is actively practicing. Physician reviewer 2 is board certified in anesthesiology with subspecialty certification in pain medicine and is actively practicing. Physician reviewer 3 is board certified in anesthesiology with subspecialty certification in pain medicine and is actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

The patient is a 57-year-old female with a history of depression with associated vegetative symptoms including daytime fatigue. Her daytime fatigue apparently did not respond well while being treated with methylphenidate and Wellbutrin. Thereafter, the patient was tried on Provigil and fluoxetine. This combination of medications has improved the patients condition markedly. The Health Plan has denied coverage for Provigil.Prior to Provigil, the patient was tried on stimulant medication and SSRI agents without significant benefit. The patient is benefiting from her current medication regimen. There is sufficient evidence in the medical literature to support Provigil as useful as an adjunct medication for the treatment of the vegetative symptoms associated with mood disorders. Based upon this evidence and the patients clinical response, I have determined Provigil is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested radiofrequency ablation of uterine fibroids for treatment of her medical condition. Findings: Two physician reviewers found that the submitted medical records do not demonstrate the superior effectiveness of the requested services.  Options for minimally invasive alternatives for the treatment of uterine fibroids include myomectomy and uterine artery embolization.  The Acessa device is a new minimally invasive treatment for uterine fibroids that uses radiofrequency energy to destroy fibroid tissue.  However, this treatment has not been thoroughly evaluated for long-term clinical efficacy in a randomized study. There is a lack of peer-reviewed studies in the medical literature that evaluate the fertility outcomes of patients undergoing this procedure. It is not considered standard of care in this clinical setting.  Thus, the requested radiofrequency ablation of uterine fibroids has not been established as more effective than other treatment alternatives.  Final Result: Two reviewers determined that the requested services are 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: All three physician reviewers are board certified in obstetrics and gynecology 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: Urgent Care
Decision: Upheld

A 36-year-old male enrollee requested ambulance services on an emergent or urgent in nature basis.  Findings:  The physician reviewer found that based on the patients clinical presentation, the symptoms would not cause a reasonable and prudent layperson to believe he or she required immediate medical attention. Thus, his symptoms on did not meet prudent layperson criteria for emergent care or urgently needed services.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Signifor. Researchers describe tumor-induced hypoglycemia as a serious disorder most commonly caused by insulinoma or non-islet cell tumor hypoglycemia. The authors further report that in a case series, three patients with tumor-induced hypoglycemia refractory to guideline-recommended medical therapy, such as diazoxide, nonpasireotide somatostatin analogues, and glucocorticoids, the addition of pasireotide led to prompt improvement in the frequency and severity of hypoglycemic episodes. In this case, the patients hypoglycemia is likely related to a non-islet cell tumor.  The patients hypoglycemia persisted despite a trial of glucocorticoids, and somatostatin analogues and diazoxide may not be advisable as they may contribute to tumor progression. In this clinical setting, given that current medical literature supports the use of pasireotide for the treatment of hypoglycemia, the requested medication is medically indicated. Therefore, Signifor is 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 medical oncology 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.