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

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for (1) a quantitative electroencephalography (qEEG), (2) a neurofeedback of a qEEG, (3) a neurotransmitter test, and (4) an adrenal stress test. A qEEG is a modern type of electroencephalography (EEG) analysis that involves recording digital EEG signals which are processed, transformed, and analyzed using complex mathematical algorithms. While studies have shown some distinctive forms of electrical activity in various conditions such as ADHD, schizophrenia, depression, and obsessive-compulsive disorder, the clinical conclusion of such distinctive patterns is unclear and do not as of yet render durable recommendations in changes of management and/or outcome. Neurofeedback of a qEEG is a treatment including components such as reinforcement, coaching, and direct feedback on brain activity, in particular electrical brain activity. Krepel and colleagues report that in a sample of 114 patients with ADHD, response rates were 85% with greater or equal to 25% reduction, 70% with greater or equal to 50% reduction, and 55% with remission. While Coben and colleagues note that the use of qEEG guided neurofeedback shows promise as an emerging treatment for various diagnoses including ADHD, seizure disorders, learning disabilities, and symptoms associated with autism spectrum disorder, there is a lack of evidence supporting a benefit of qEEG for this patients conditions. Regarding neurotransmitter testing, while differences may be detected from person to person, its clinical application is limited at best, and there is a lack of data in current medical literature supporting the use and/or the association of improved outcomes of neurotransmitter testing in evaluating patients with gastrointestinal complaints. Adrenal states may also vary from individual to individual. From a neurological perspective, such variations identified by testing are of limited clinical neurological benefit. There is a lack of data that such information would alter outcomes and/or management of a patient. Therefore, (1) a qEEG, (2) a neurofeedback of a qEEG, (3) a neurotransmitter test, and (4) an adrenal stress test are not medically necessary for the evaluation of this patient..Final Result: The reviewer determined that the requested/at issue services are not medically necessary for evaluation of the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is board certified in 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.
Appeal type: Medical Necessity
Decision: Upheld

A 49-year-old female enrollee has requested for a panniculectomy for treatment of her excessive abdominal skin. Findings:  The physician reviewer found that weight loss and dermatology consultation are the safest initial treatments for this patient. In the absence of such interventions, however, a panniculectomy is not a medically necessary procedure.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for replacement hearing aids for treatment of the enrollees mild to moderate bilateral sensorineural hearing loss. Findings:  The physician reviewer found that hearing loss is the most common form of sensory impairment in patients and hearing aids are a first-line of audiologic intervention for many patients. Untreated hearing loss can interfere with a patients cognitive abilities and intellectual function. This patient has been able to use hearing aids, however, her current hearing aids do not provide adequate amplification. This patient has mild to moderate sensorineural hearing loss bilaterally. Her current hearing aids do not support her activities of daily living. She would benefit from amplification which would allow her to hear in her work environment. Thus, the patient requires replacement hearing aids with enhanced technology to improve her hearing quality. All told, the requested replacement hearing aids are medically necessary for treatment of this patients medical condition. Final Result: The reviewer determined that the requested equipment 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 otolaryngology 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: Overturned

A 54-year-old female has requested an epidural lysis for treatment of her L3-4 arachnoiditis.  Findings:  Three physician reviewers found that the patient has a history of decompressive laminectomy from L3 to S1 and posterior lumbar fusion. The patient reported right hip and low back pain starting a year ago. She reported symptoms of radiating pain to the right lower extremity, down to her foot. Past therapies were noted to include: Motrin, soma injections, massage therapy, ice, surgery, Vicodin and Neurontin. The patients physical examination was positive for tenderness of the lumbar sacral junction and right sacroiliac joint junction, gait with right sided limp and reduced twisting ability with reported pain. A MRI of the patients lumbar spine evidenced thickening and tethering of the right-sided nerve roots at the L3-4 levels, which was noted to be compatible with arachnoiditis. The patient underwent an epidural lysis on 4/13/12 with noted pain relief. The provider has recommended a second epidural lysis procedure to target the patients residual low back and buttock pain. Percutaneous adhesiolysis is a technique whereby scarring or fibrosis is removed or modified using not only mechanical instrumentation, but chemical injections as well and is generally used postoperatively for continued back and leg pain.  Epidural scarring can develop after surgery, infection, bleeding, and leakage of nuclear material.  Use of a wire bound steerable catheter is used to direct medication, generally saline, local anesthetic, and commonly hypertonic saline. Helm and colleagues reviewed several studies involving individuals with spinal stenosis and post lumbar surgery syndrome and found that there was a fair amount of evidence supporting use of epidural lysis in the reduction of back and/or leg pain. Evidence based guidelines in the management of chronic spinal pain found that there is strong evidence supporting the efficacy of epidural lysis in the treatment of chronic low back and lower extremity pain in post surgery syndrome (Boswell, et al.). A review by Epter, et al. identified percutaneous adhesiolysis as being clearly superior to fluoroscopically directed epidural steroid injections, especially in those patients with chronic, refractory low back and lower extremity pain. Thus, the peer reviewed medical literature and the documentation submitted for review in this case, support the use of epidural lysis for treatment of the patients medical condition.
Appeal type: Urgent Care
Decision: Upheld

A 21-year-old female enrollee has requested for emergency services for treatment of her thumb abscess.  Findings:  The physician reviewer found that the prudent layperson standard for an emergency requires that the patients condition be of acute onset and of such severity that a prudent layperson would believe her health to be in jeopardy without immediate medical attention. This patients symptoms commenced gradually over at least three days. She was not experiencing severe pain, nor did she require any medication in the emergency department. She had already been evaluated for her thumb lesion.
Appeal type: Medical Necessity
Decision: Overturned

A 53-year-old female enrollee has requested for the Flexitouch Lymphedema System for treatment of her lymphedema (secondary to breast cancer). Findings:  The physician reviewer found that Bio-compression devices usually only offer a one size fits all jacket for truncal edema where the Flexitouch system is adjustable. In addition, the Flexitouch system offers variability in pressure settings making it safe and more effective.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for two (2) additional acupuncture treatments.Peer reviewed literature recommends an initial trial of five to six acupuncture appointments in combination with a conditioning program of aerobic and strengthening exercises to stimulate self-reliance. Future acupuncture appointments should be tied to improvements in objective measures to justify an additional 6 sessions, for a total of 12 sessions. Additional treatments should only occur based on progressively greater, incremental objective gains. In addition, passive care (acupuncture) should be combined with active care (conditioning-aerobic-stretching exercise program) to stimulate self-care and avoid medical dependency. Indications for care discontinuation would include resolution, intolerance, lack of measurable improvements, or non-compliance including non-compliance with aerobic and strengthening exercises.In this case, the patient suffers from chronic, bilateral foot pain that has been treated with acupuncture. While the patient has reported that prior acupuncture care has been beneficial, no pre-acupuncture and post-acupuncture baselines were documented for comparison purposes. After an extensive number of prior acupuncture sessions were completed, the provider failed to document any measurable, progressive, significant, objective functional improvement (quantifiable response to treatment) obtained with previous acupuncture to support the reasonableness and necessity of the additional acupuncture requested. Because no recent physical examination has been documented, the patients deficits (motor-sensory-functional) are unknown, and the patients goals with the requested acupuncture are unclear. In addition, there is no clear documentation that indicates whether the patient is currently undergoing an independent exercise program (conditioning-aerobic-stretching exercise program based on patient's tolerance), which is essential to stimulate self-reliance and avoid acupuncture co-dependence. Therefore, the submitted documentation does not demonstrate a reduced need for medication or a measurable improvement in function or activities of daily living that is directly attributable to prior acupuncture. Under these circumstances, the requested two (2) additional acupuncture treatments are not medically necessary for the patients medical condition.Final Result: The reviewer determined that the requested services are not medically necessary for the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is a licensed acupuncturist, board certified in oriental 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

A female enrollee requested the brand name medication Vicodin and the brand name medication CellCept for medical treatment of her optic neuritis and chronic pain.  Findings:  The physician reviewer found that the medical records do not demonstrate any ongoing history of reaction to generic versions of CellCept or Vicodin medication that supports the medical necessity of brand name CellCept or Vicodin.  Further, the medical records do not provide rationale from the patients provider as to the medical necessity for brand name CellCept or Vicodin.   All told, the request for the brand name medication Vicodin and CellCept is not supported as medically necessary.
Appeal type: Medical Necessity
Decision: Overturned

A 61-year-old male enrollee has requested for Oxycontin and Dilaudid 4mg for treatment of his chronic lung cancer pain.  Findings:  The physician reviewer found that pain related to cancer is severe and patients often have multiple episodes of breakthrough pain daily. In pain management practice, as well as in the literature, it is noted that higher opioid doses should be permitted for cancer pain control than in management of non-cancer pain conditions. Cancer pain is multifaceted and is often severe and disabling.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested a computed tomography (CT) angiogram for evaluation of his medical condition. Findings: Two physician reviewers found that the results of a stress echocardiogram was essentially negative for ischemia.  In this circumstance, the post-test likelihood of significant coronary ischemia is very low such that additional testing is not standard accepted practice in the medical community in the absence of documented ongoing symptoms.  Moreover, if an assessment of coronary anatomy is thought to be medically indicated, then conventional coronary angiography is preferred due to its improved accuracy related to coronary CT angiography and the ability to intervene with coronary revascularization during the same procedure if clinically indicated.  Therefore, CT angiogram was not likely to have been superior over other modalities.  Final Result: Two 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.  All three reviewers are experts in the treatments 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 Euflexxa injection series in the left knee. The records provided for review document that this patients pain source is likely due to chondromalacia of patellofemoral joint based on the reported symptoms of anterior knee pain, popping, catching, and clicking, and difficulty getting up from a sitting position, with physical findings of patellar tenderness. The provider noted that the patients conservative treatment has included non-steroidal anti-inflammatory drugs (NSAIDs), an intra-articular corticosteroid injection, and physical therapy. The provider has recommended treatment with Euflexxa. Viscosupplementation with Euflexxa hyaluronic acid has been demonstrated to improve the shock absorption and lubrication properties of the synovial fluid in patients with chondropathy and osteoarthritis. Viscosupplementation has anti-inflammatory, analgesic, and chondroprotective properties that can be beneficial in patients with chondromalacia and osteoarthritis. Hyaluronic acid is known to be effective in the treatment of pain related to patellar chondropathy, as in this patients case. Given this support, the requested Euflexxa injections are appropriate for management of this patients chronic left knee pain due to chondromalacia. Therefore, the requested Euflexxa injection series in the left knee is medically necessary for 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 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: Upheld

A 47-year-old female enrollee has requested  neuropsychological testing for evaluation of her memory issues, dexterity problems, trembling and clumsiness.  Findings:  The physician reviewer found that this patient presented to her provider with reported memory problems.  The records indicate that the provider took a very brief history of the problem, did not perform neurologic testing or simple memory testing, and subsequently ordered an MRI and neuropsychological testing.  Memory complaints in the peri-menopausal period are very common and typically improve once menopause has started.  While hormonal changes may be one cause, anxiety, sleep disorder and depression are also common causes of memory issues in midlife.  There is a lack of support for the services at issue in this clinical setting.  The usual work-up would include a much more detailed history, a complete neurologic examination, and screening memory testing.  The medical records do not document objective findings to suggest early onset dementia or encephalopathy.  All told, the neuropsychological testing performed was not medically indicated for the evaluation of this patient.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a two-year-old male enrollee has requested for speech therapy for treatment of the enrollees speech delay. Findings:  The physician reviewer found that Nelson and colleagues, speech and language development is considered by experts to be a useful indicator of a childs overall development and cognitive ability and is related to school success.  Speech and language delay must be taken seriously in young children because the long-term consequences may be substantial. According to Law and colleagues, approximately 6% of children have speech and language difficulties.  The authors noted that children whose difficulties persist into primary school may have long-term problems concerning literacy, socialization, behavior, and school attainment.  Per Bernhardt and Major, early phonological and metaphonological intervention can promote normalization of speech development and normal acquisition of literacy skills for some children with a history of severe phonological impairment.  This patient demonstrates significant expressive language delay, and this is negatively impacting his ability to communicate in a functional and age-appropriate manner.  Studies have shown that speech and language therapy can result in significant improvement in this clinical situation.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Xeljanz 5 mg twice daily. The current treatment options for alopecia areata are limited, especially for multifocal involvement where standard therapies such as topical steroids, intralesional Kenalog, contact immunotherapy, and conventional immunosuppressants are oftentimes inadequate to control symptoms and are associated with side effects. Although trials remain underway, there is substantial clinical evidence to support the use of oral Janus kinase (JAK) inhibitors such as Xeljanz for alopecia areata. In one open label pilot study 8 of 12 patients demonstrated approximately 50% hair regrowth as measured by Severity in Alopecia Tool (SALT) scoring. Another study included patients with at least 40% scalp hair loss due to alopecia areata treated with Xeljanz (Liu, et al.). The authors found that 77% of the patient treated achieved a clinical response with minimal adverse effects. Moreover, these results are superior to data on treatment with contact immunotherapy and systemic steroids. In conclusion, the requested Xeljanz 5 mg twice daily is 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 requested Xeljanz 5 mg twice daily is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the requested medication is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: Physician reviewer 1 is board certified in dermatology and is actively practicing. Physician reviewer 2 is board certified in dermatology and is actively practicing. Physician reviewer 3 is board certified in dermatology 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: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for DecisionDx-Melanoma genetic testing provided by Castle Biosciences. This patient presents with a history of invasive malignant melanoma. A pathology report indicates that SOX-10 and PRAME stains were positive. Analysis with DecisionDx-Melanoma gene expression profiling demonstrated Class 1B findings associated with an increased risk of recurrence/metastasis within five years. The DecisionDx-Melanoma gene expression profile test is an expression assay designed to predict distant metastasis in stage I and stage II melanoma patients. DecisionDx-Melanoma assesses the expression of 31 genes that have been associated with metastasis and classifies tumors as Class 1 consistent with low risk of metastasis or Class 2 suggestive of high risk of metastasis. The peer-reviewed medical literature indicates that there is a statistically significant association of a Class 1 signature by DecisionDx-Melanoma assay for primary dermal melanoma, whereas cutaneous metastatic melanoma was more frequently class 2 (Sidiropoulos, et al.). Overall, there is paucity of prospective randomized controlled studies reporting improved health outcomes with use of the DecisionDx-Melanoma assay in patient treatment planning. All told, the DecisionDx-Melanoma genetic testing provided by Castle Biosciences was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Findings: Three of the three physician reviewers found the DecisionDx-Melanoma genetic testing provided by Castle Biosciences 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 reviewer 1 is board certified in dermatology and is actively practicing. Physician reviewer 2 is board certified in dermatology and is actively practicing. Physician reviewer 3 is board certified in dermatology 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.