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

The patient is a 42-year-old female who was seen by a podiatrist in February 2005 for thickening of the right hallux nail. The patient states the toenail is painful and cracked. She also reports the toe is red and swollen with resultant pain and difficulty with walking and wearing shoes. Chart notes indicate severe thickening and yellow discoloration of the toenail. Lamisil has been recommended. The Health Plan has denied authorization because the diagnosis of onychomycosis has not been confirmed through appropriate testing.The Health Plans denial is correct. Although the patients clinical presentation is strongly suggestive of onychomycosis, further testing (KOH, fungal culture or nail biopsy) is necessary to confirm the diagnosis and establish the need for Lamisil. If appropriate testing confirms a diagnosis of onychomycosis, Lamisil should be authorized. However, at this time Lamisil cannot be authorized because of the lack of a confirmed diagnosis.Based upon the information set forth above, I have determined the requested medication is not medically necessary at this time. Therefore, the Health Plans denial should be upheld at this time. If a diagnosis of onychomycosis is confirmed through appropriate testing, Lamisil should be authorized.
Appeal type: Medical Necessity
Decision: Upheld

A female enrollee requested Norco for medical treatment of her pelvic bone replacement.  Findings:  The physician reviewer found that in this case, there is a lack of evidence of objective functional improvement following the initial use of Norco. It is noted that the patient reported a significant improvement in symptoms. There is no documentation of an attempt at psychological modalities or non-opioid analgesic medication prior to the initiation of Norco. Only after all other treatment modalities have been exhausted should opioid therapy be considered. Based on the clinical documentation provided and the peer-reviewed literature, the request for coverage of Norco is not medically necessary for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned

A 56-year-old female enrollee has requested Provigil for the treatment of her chronic inflammatory demyelinating polyneuropathy (CIDP). Findings:  The physician reviewer found that there have been no large scale studies evaluating the use of Provigil in CIDP. However, it has been shown to have a positive effect in patients with Charcot-Marie-Tooth neuropathies and fatigue in other subsets of patients. Provigil is a medically reasonable treatment option for this patients overall symptoms given her current medical conditions. This patient has responded well to this medication in the past, and it is medically appropriate to continue her with this medication.
Appeal type: Medical Necessity
Decision: Upheld

A 25-year-old female enrollee has requested Suboxone for treatment of her back pain.    Findings:  The physician reviewer found that review of the submitted documentation and relevant literature fails to demonstrate the medical necessity of the requested medication. Buprenorphine is a long-acting semisynthetic opioid that has partial mu receptor agonist and kappa receptor antagonist activities. Its clinical effects at low doses are similar to morphine. At higher doses, its effects are less than those of full opiate receptor agonists (Wesson). Buprenorphine, nonetheless, is a widely-abused drug (Yokell, et al). Suboxone is a combination drug that contains buprenorphine and naloxone, an opioid antagonist. Naloxone primarily serves as a deterrent against intravenous abuse since its bioavailability is significantly increased when intravenously injected (versus the sublingual route, where bioavailability is low). Intravenously injected naloxone blocks the analgesic/euphoric effects of the buprenorphine and can precipitate withdrawal symptoms (Helm, et al). This combination of pharmacological properties and activities makes Suboxone useful in the treatment of opioid dependence (i.e., detoxification). It has some favorable clinical and non-clinical features in comparison to methadone when used for detoxification. However, there is no clear pharmacological or clinical rationale for the use of this combination (i.e., buprenorphine plus naloxone) in the treatment of a chronic pain condition. There is no proven marginally significant analgesic benefit of using Suboxone in comparison to conventional analgesics for any pain condition. Daitch and colleagues investigation into the use of sublingual buprenorphine in certain subsets of patients with conditions such as opioid-induced hyperalgesia is only in the early stages. Overall, there are no well-accepted indications for the use of Suboxone in the treatment of any clinical condition other than for opioid detoxification at this time. In this patients case, the basis for the request for continued Suboxone is for the treatment of a chronic low back pain complaint and not for opioid detoxification. Thus, this is not an appropriate use of this medication combination. For the reasons set forth above, Suboxone is not medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld

The enrollee is requesting authorization and coverage for prostatic urethral lift. The enrollee has benign prostatic hypertrophy. His medical history includes diabetes mellitus and high body mass index. He reports symptoms of difficulty urinating, urine leakage, straining, frequent urination during the night, and weak urine flow. Progress notes from urology reported diagnoses of acute prostatitis and urinary retention. The plan included discussion of the medication finasteride and potential surgical interventions, including the Urolift procedure. Governmental organization guidelines indicate the requested procedure is approved for those with prostates whose weight is less than 80 grams. Records show the enrollee has been recently treated for prostatitis and urinary tract infections, but these diagnoses have not been corroborated by a urologist. The medical records for this enrollee report a history of recent prostatitis and urinary infection, but records do not provide evidence of a urinalysis or of a prostate examination. Professional society guidelines for evaluation and preoperative testing report criteria such as medical history and urinalysis as data to be included in the assessment. Also mentioned is assessment of prostate size and shape with the use of diagnostic procedures. Records provide insufficient evidence of the measurement of these parameters.Final Result: The reviewer determined that the requested service is not medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The physician reviewer is board certified in urology 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

The patient is an 11-year-old male who was born prematurely with an appropriate gestational growth for age. He received a workup for gastrointestinal causes of poor growth at the age of three. He had experienced learning and behavioral problems for which he was diagnosed with attention deficit hyperactivity disorder (ADHD) at eight years of age. The patients father indicates the patients ADHD was successfully treated with Strattera. The patient has been followed by an endocrinologist who found no evidence of growth hormone (GH) deficiency upon provocative testing. No other cause for the patients short stature has been revealed, though the patient was thought to express elements of the Russell-Silver phenotype and was reported to have a growth of 3.5cm extrapolated from a recent eight-month interval.The patients provider has recommended the patient be started on growth hormone therapy. The Health Plan has denied authorization for growth hormone therapy on the basis that it is not medically necessary for treatment of the patients medical condition.Analysis and Findings:Given the patients growth near the third percentile, his delayed bone age, and height attained to date, the patients projected adult height should place him in the normal range of at least 55. Thus, the patients most likely diagnosis would include constitutional delay. Low-normal IGF-1 levels are common in the immediate pre-pubertal period. In 2003, the Food and Drug Administration (FDA) approved the use of therapeutic GH for children who do not have GH deficiency, but are unusually short; however, the FDA approval indicated GH therapy should be reserved for boys with an adult height prediction less than 53. Since in this case the patients height prediction exceeds 53 he does not fall within FDA recommended guidelines. Thus, growth hormone therapy is not medically indicated for treatment of this patients short stature.Based upon the information set forth above, I have determined that the requested therapy is not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for advanced lipoprotein testing for evaluation of the enrollees risk for heart disease. Findings: Three physician reviewers found that in this circumstance, guidelines for the management of cardiac risk have been established, are periodically updated by expert committees and are endorsed by several national organizations. These guidelines currently do not recommend routine performance of specialized tests in the context of assessing coronary risk including lipoprotein associated phospholipase A2 (Lp-PLA2), myeloperoxidase, Apo-B, sub-classifications of low density lipoprotein, high density lipoprotein, subclasses, lipoprotein(a), C-reactive protein, insulin, fibrinogen, genetic testing and homocysteine. Treatment change or addition based on the results of screening with these specialized tests has not been shown to improve cardiac outcome incremental to that achievable by treatment based on standard risk factor profiling and basic lipid analysis.  For example, randomized trials testing treatment with therapy available to reduce homocysteine levels have not shown significant outcomes benefits. Likewise, even though results of some of these specialized tests may be abnormal and considered independent risk markers for coronary disease, controlled trials that demonstrate outcome benefits by treating routinely obtained abnormal results are lacking. As such, the advanced lipoprotein testing was not likely to have been more effective than the standard methods for the evaluation this patients medical condition.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: All three physician reviewers are board certified in internal medicine with sub-specialty certification in cardiovascular disease and are actively practicing. The reviewer 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 parent of a five-year-old male enrollee has requested for speech therapy for treatment of the enrollees autism. Findings:  The physician reviewer found that speech and language delay must be taken very seriously in young children, as the long-term consequences may be substantial. According to a Cochrane Database meta-analysis of 25 studies, children whose difficulties persist into primary school may have long-term problems concerning literacy, socialization, behavior and school attainment. Studies have shown that speech and language therapy can result in significant improvement in children with speech and language deficits. Improved play skills, social skills and self-esteem have also been demonstrated.
Appeal type: Medical Necessity
Decision: Upheld

A 55-year-old male has requested coverage for past services received over a 3-day period, future skilled rehabilitation services, skilled nursing care provided at a skilled nursing facility (SNF), future skilled rehabilitation services (physical therapy and occupational therapy), and skilled nursing care for treatment of his bone cancer and history of fall with closed fracture at C5-7.  Findings:  The physician reviewer found that review of the submitted clinical documentation does not support the medical necessity of continued SNF services as of the first date in question. As the last authorized date of service, the patient was established with activities of daily living with the exception of bathing and dressing. He was at contact guard to stand by assist level for transfers and ambulation. He was ambulating 150 feet. The patient had reached a level of function that did not require daily skilled therapy to restore or maintain function (Ward, et al. and Stolee, et al.). As the above referenced literature demonstrates, continued improvement in function can be achieved with continued exercise without daily supervision from a skilled therapist. Further, the patient did not have daily skilled nursing needs as of the first date in question. By the last authorized date of service, the patient reached the level of function routinely addressed with outpatient or home rehabilitation (Medicare guidelines). All told, the medical necessity of continued SNF services is not established in this patients case.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a five-year-old male has requested applied behavioral analysis (ABA) therapy for treatment of his medical condition.  Findings:  The physician reviewer found that  review of the submitted documentation demonstrates that the patient has had three evaluations along with a developmental history that support a diagnosis of autism spectrum disorder. The behaviors in this patient that need to be addressed include maladaptive behaviors of communication, nonfunctional rituals, complying with requests, as well as social and language skills. As the above cited literature demonstrates, applied behavioral analysis (ABA) has been shown to be effective in treating maladaptive behaviors associated with autism spectrum disorder. As such, ABA therapy is medically necessary for this patient with autism.
Appeal type: Experimental/Investigational
Decision: Overturned

A 61-year-old female enrollee has requested breast tomosynthesis for evaluation of her medical condition.   Findings:  Three physician reviewers found that in this case, the services at issue were likely to have been more effective than other modalities for evaluating this patient.  The current medical literature supports the addition of digital breast tomosynthesis to screening mammography since there is a reduction in recall rates for non-cancer cases and increased diagnostic accuracy in early breast cancer cases.  There is sufficient support for breast tomosynthesis in this case.  All told, breast tomosynthesis (CPT 76499) performed on the date indicated was likely to have been more efficacious than other methods of evaluation.
Appeal type: Experimental/Investigational
Decision: Upheld

A 26-year-old male enrollee has requested vertebral axial decompression (VAX-D) therapy for treatment of his herniated disc at L5-S1. Findings:  Three physician reviewers found that there is a paucity of quality medical literature on VAX-D. While there is a study published by Clarke and colleagues in 2007 that demonstrated positive outcomes with the use of VAX-D, methodological flaws were an issue. There are numerous articles of better quality in support of other treatments, both non-surgical and surgical, for management of a patient with a herniated disc than VAX-D. Therefore, the therapy at issue continues to be classified as investigational.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for platelet-rich plasma injections (CPT Code 0232T). Findings:  The physician reviewer found that platelet-rich plasma is a promising treatment modality with substantial evidence of safety. Houck and colleagues reported that the results of their systematic review of overlapping meta-analyses suggest that corticosteroid injection improves functional outcomes and pain relief for lateral epicondylitis in the short-term, while autologous blood and platelet-rich plasma are the most effective treatment options in the intermediate-term. Arirachakaran and colleagues provided additional results indicating that platelet-rich plasma injections can be effective in the management of chronic lateral epicondylitis. This patient presented with persistent left lateral elbow pain. Clinical examination findings were consistent with left lateral epicondylitis. There was also imaging evidence of extensor tendinosis with partial extensor tendon tear and edema in the capitellum. The patient failed long-term reasonable and comprehensive conservative treatment, including bracing, Voltaren gel, therapeutic exercises, and cortisone injections. Current evidence based medical literature supports the use of platelet-rich plasma for recalcitrant lateral epicondylitis. Therefore, the platelet-rich plasma injections (CPT Code 0232T) were likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Findings:  Two of the three physician reviewers found the platelet-rich plasma injections (CPT Code 0232T) were 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 likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: 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: Experimental/Investigational
Decision: Upheld

A 44-year-old female enrollee has requested bilateral pulsed radiofrequency ablation of the occipital nerves for treatment of her headache and neck pain.  Findings:  Three physician reviewers found that the proposed procedure is experimental without established long-term safety and efficacy. Available data is sparse and current outcomes do not support the superior efficacy or the lasting benefit of occipital nerve RFA. One of the few, randomized, controlled trials noted initial improvement, however there was no indication it was a better treatment than infiltration of the greater occipital nerve followed by the application of TENS.
Appeal type: Medical Necessity
Decision: Upheld

The patient is a 49-year-old female who, after having a biopsy of a lesion on her right cheek in October 2003, was diagnosed as having pseudocarcinomatous hyperplasia versus well-differentiated squamous cell carcinoma. The excised specimen, which measured 0.5cm at its greatest dimension, was noted to have a positive deep margin. Further excision is needed in order to obtain clear margins. The patient states she is an actress and is quite concerned about facial scarring. In addition, the patient indicates the skin lesion overlies an implant that was placed in 1998. Because of these issues, the patient is requesting a referral to a plastic surgeon for further excision of the lesion on her right cheek. The Health Plan has referred the patient to an in-network otolaryngologist with specialty training in cosmetic and facial reconstructive surgery. The submitted evidence does not demonstrate that a referral to a plastic surgeon is medically indicated. The patient will have a scar at the excision site whether the procedure is performed by a plastic surgeon or otolaryngologist/facial plastic surgeon. Cutting the skin leaves a scar. Review of the submitted records indicates this is a small lesion that appears to be located at or near the nasolabial fold so that the scar may be camouflaged, but it will still be present. How well a scar heals generally depends more on a patients skin quality, age, and health status (e.g., smoker versus non-smoker) than on how the excision and repair is done. Furthermore, an otolaryngologist/facial plastic surgeon is qualified to excise a lesion such as the patients lesion. With some variation depending upon institution, training in general plastic surgery involves the completion of a general surgery residency (approximately five years of non-plastic training) followed by two years of general plastics. This latter segment covers training in plastic surgery of the body and face. This is different from the training of an otolaryngologist/facial plastic surgeon. Training of an otolaryngologist/facial plastic surgeon currently involves one to two years of general surgery training, followed by four years of study regarding diseases and surgery of the head and neck (including the face), and is sometimes followed by another year of fellowship emphasizing plastic and reconstructive surgery of the face and neck only. As such, an otolaryngologist/facial plastic surgeon generally has had at least as much experience and often more training in the care (both medical and surgical) of lesions involving the face than a general plastic surgeon. Having undergone this training, an otolaryngologist/facial plastic surgeon is fully qualified to perform excision of facial lesions such as this patients cheek lesion. Based upon the information set forth above, I have determined that the requested referral is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Vyepti infusions. Current medical literature does not support the safe and effective  treatment of migraines with a combination of Vyepti and Botox. In this case, the patient has tried and failed medical and surgical interventions in the management of her condition. While Vyepti monotherapy may be considered to manage her condition, given the lack of data supporting combination therapy with Botox, the requested service is not medically indicated. Therefore, Vyepti infusions are not medically necessary for the treatment of this patient.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 neurology with sub-specialty certification in vascular neurology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.