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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for custom lateral unloader knee orthosis for the left knee for treatment of the enrollee who has a history of sarcoma soft tissue and bilateral knee pain. Findings:  The physician reviewer found that evidence based medical guidelines and peer reviewed literature supports the requested device in this clinical setting. This patient is currently not an appropriate candidate for knee surgery to address her knee pain. The use of orthotics as a method of providing pain relief for this patients left knee is medically indicated and appropriate. Custom fabricated orthotic is a reasonable part of nonsurgical management of degenerative osteoarthritis of the knee. The patient has general health considerations which does not allow her to undergo knee surgery at this time, make temporizing measures appropriate and necessary. Orthotics may be combined with the use of a cane, walker and external support. The device will also allow the patient to have appropriate physical and occupational therapies to provide pain relief and to temporize before any surgical interventions. For these reasons, coverage for custom lateral unloader knee orthosis for the left knee is medically necessary for treatment of this patients medical condition. Final Result: The reviewer determined that the requested device is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in 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 genomic sequencing (CPT 81422). This patients records document a history of hypoglycemia, threatened early pregnancy, and urinary tract infection during pregnancy. The patient underwent evaluation with genomic sequencing with the Panorama Prenatal Panel Plus and Panorama Extended Panel. Expanded carrier screening panels with microdeletion testing are not supported for routine work-up of all pregnancies. Given the multitude of conditions that can be included in expanded carrier screening panels, the disorders selected for inclusion should have a carrier frequency of 1 in 100 or greater, a well-defined phenotype, a detrimental effect on quality of life, cause cognitive or physical impairment, require surgical or medical intervention, or have an onset early in life. Additionally, screened conditions should be able to be diagnosed prenatally and may afford opportunities for antenatal intervention to improve perinatal outcomes, changes to delivery management to optimize newborn and infant outcomes, and education of the parents about special care needs after birth. Fetal aneuploidy testing consisting of Trisomy 21, 18, 13 analysis is considered the standard of care. However, carrier screening panels should not include conditions primarily associated with a disease of adult onset. Per the American College of Obstetricians and Gynecologists (ACOG), testing for microdeletions have not been clinically validated. Furthermore, expanded carrier screening panels do not replace previous risk-based screening recommendations. All told, the genomic sequencing (CPT 81422) 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 genomic sequencing (CPT 81422) 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 obstetrics and gynecology and is actively practicing. Physician reviewer 2 is board certified in obstetrics and gynecology with subspecialty certification in reproductive endocrinology and is actively practicing. Physician reviewer 3 is board certified in obstetrics and gynecology 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 proton beam radiation therapy for treatment of her acoustic neuroma.  Findings:  Three physician reviewers found that currently, there is inadequate clinical data to support treatment with proton beam radiation as superior to conventional radiation therapy techniques in the treatment of this patients benign tumor. The data regarding central nervous system tumors treated with proton therapy is limited. There is a lack of evidence in this setting that proton beam therapy is associated with improved control rates, a decrease in toxicity or a decrease in secondary malignancies compared to conventional fractionated radiation therapy or radiosurgery techniques. One review noted concern that proton therapy may be associated with higher rates of hearing loss than standard photon techniques. Standard treatment is with photon techniques which are already associated with very high rates of local control and minimal toxicity. All told, the requested proton beam radiation therapy is not likely to provide this patient with greater health benefits than standard radiation therapy. Final Result: 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:  All three reviewers are board certified in radiation oncology 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

The patient is a 39-year-old woman with chronic migraine headaches and comorbid stress and depression. The patient experiences approximately three headaches per week. She reports her headaches are fairly well controlled by taking Neurontin and Imitrex nasal spray. The patient has requested authorization and coverage for 18 Imitrex 20mg nasal spray units per month. The Health Plan has denied her request on the basis the requested prescription is not medically necessary for treatment of the patients migraine headaches. Review of the submitted medical records indicates the patient requires vigorous prophylactic treatment for her headaches. In addition, the patient requires treatment for her comorbid depression in the form of a mild antidepressant. The requested dosage of Imitrex nasal spray will likely result in rebound headaches. This condition is frequently noted in patients who take large quantities of medications aimed at the acute treatment of migraine headaches. Further attempts at prophylactic headache treatment are medically indicated and likely to be more effective than the requested regimen. Therefore, I have determined the requested prescription is not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/ Case Summary:  The enrollee is requesting authorization and coverage for MRI of the right knee. The patient has chronic pain due to bilateral osteoarthritis of the knees; right more painful than the left. During an office visit the provider noted a probable sprain. Progress notes from the visit indicate the patient believes she has a meniscal tear. She consulted with a sports medicine physician, on who diagnosed left knee degenerative joint disease. Previous treatments, including medications, cold therapy, and stem cell injections were ineffective. Her physician  explained a magnetic resonance imaging (MRI) scan was not needed at the time to help with diagnosis or to make treatment recommendations. She then presented to anotherorthopedic physician, who diagnosed her with a meniscal tear and ordered an MRI. The medical literature indicates the use of MRI to diagnose a possible meniscus tear is not supported without a trial of six to ten weeks of physical therapy as a majority of patients with osteoarthritis and meniscus tears do get better without surgery. Furthermore, an analysis of randomized trials of surgery for patients with osteoarthritis and a meniscal tear found the benefit was limited to three to six months duration and not present beyond that time period. There is insufficient evidence in the record of the patients trial of physical therapy. In sum, there was no indication for the use of MRI to guide therapy. 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 orthopedic surgery and sports 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: Experimental/Investigational
Decision: Overturned

A 59-year-old male enrollee has requested Rituxan (rituximab) for the treatment of his cryoglobinemia. Findings:  Three physician reviewers found that cryoglobulinemia is relatively rare, and it is unlikely that a large, controlled clinical trial will be forthcoming anytime soon. For a patient such as this patient, treatment options include immunosuppressive therapy such as cyclophosphamide or cyclosporine, or rituximab. Rituximab is an attractive alternative as the potential risks are minimal and the results in small case series are promising. Treatment with rituximab may also improve renal function and abrogate the need for regular plasma exchanges.
Appeal type: Medical Necessity
Decision: Upheld

A 51-year-old male enrollee has requested Arimidex for the treatment of his hypogonadotropic hypogonadism. Findings:  The physician reviewer found that Arimidex is being used to block the excess production of estrogen seen in patients with a large excess of adiopose tissue. The advantage of Arimidex was not in the treatment of the hypogonadism (which can be treated with testosterone) but was to increase the sperm count (which may drop with testosterone treatment). As such, Arimidex was not medically necessary for treatment of the patients hypogonadism.
Appeal type: Medical Necessity
Decision: Upheld

This patient is a 60-year-old postmenopausal female with a diagnosis of osteoporosis confirmed by a bone density study. Past treatment and prevention has included estrogen, Miacalcin, Fosamax and IV pamidronate, which was first administered in August 2004.  The frequency of her pamidronate infusions is not specified in the record provided.  The patient has not tolerated oral bisphosphonate, Fosamax, which caused oral ulcers. The IV infusions of pamidronate have been well tolerated.  The patients request for continued authorization of IV pamidronate was denied based upon the Health Plans determination that the therapy is not medically necessary to treat her osteoporosis.Pamidronate is not FDA approved for the treatment of osteoporosis; its approval is limited to specific applications in the oncology setting or for the treatment of Pagets disease. This medication has been associated with renal toxicity, osteonecrosis and low white blood cell counts. The FDA recently approved IV Boniva (ibandronate) for the treatment of osteoporosis. Quarterly IV Boniva has been shown to be effective in the treatment of osteoporosis and the prevention of vertebral and non-vertebral fractures. There is currently an FDA approved intravenous alternative to pamidronate that has been shown to be safe, effective and generally well tolerated. Therefore, I have determined 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: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Humira injections 40 mg weekly. Humira has demonstrated efficacy for induction and maintenance of remission in patients with moderate to severe Crohns disease. However, more than one third of patients do not respond to induction therapy and many patients lose response over time, sometimes resulting in disease exacerbation. Optimization of therapies, or switch to other anti-TNF-a, are currently the best studied strategies in case of loss of response, and can be successful in 40-60% of patients who lose response (Danese, et al.). The ULTRA 2 trial showed that, escalation to weekly adalimumab dosing demonstrated clinical benefits for patients who lost response to therapy and may be beneficial for patients not initially responding to induction therapy (Wolf, et al.). The authors noted that no new safety risks were identified with weekly dosing. This patient has inflammation on colonoscopy despite treatment with Humira 40 mg every other week. Her provider has recommended a more frequent dosing schedule to every week, which is consistent with the current medical literature and guidelines. Accordingly, the Humira injections 40 mg weekly are likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Findings:  Three physician reviewers found Humira injections 40 mg weekly are 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 dosage 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 reviewers 1, 2 and 3 are board certified in internal medicine with subspecialty 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 51-year-old female enrollee has requested for Oxycontin 80mg SR and Oxycodone-Acetaminophen 10/325 (Percocet) for treatment of her chronic pain.  Findings:  The physician reviewer found that there is no medical indication for the patients present dose requirements for Oxycontin. Current standard of care for chronic pain is treatment in a multidisciplinary practice to include physical therapy, massage therapy, behavioral therapy, and injections to help reduce pain. Opioids are considered adjunctive to this therapy and at that point controlled release narcotics with close monitoring by a certified physician is recommended. Presently the maximum recommended dose for Oxycontin is 80mg twice per day as indicated for cancer pain. Ballantyne and colleagues noted that prolonged use of high dose opioids may induce tolerance, abnormal pain sensitivity, and hormonal effects. The aim of current guidelines is to protect patients from the adverse effects of opioid therapy. Oxycontin as requested by the patient is contradictory to providing safe and effective healthcare. Oxycontin and Percocet are therefore, not medically necessary.
Appeal type: Medical Necessity
Decision: Upheld

A 26-year-old male enrollee has requested a left knee magnetic resonance imaging (MRI) scan for an evaluation of his left knee pain. Findings:  The physician reviewer found that the indications for obtaining an MRI of the knee include the diagnosis, grading or exclusion of suspected disorders, and also the evaluation of various symptoms, such as mechanical symptoms or the presence of prolonged, refractory or unexplained pain (American College of Radiology). MRI is also of value in the evaluation of acute pain when the history and physical examination point to damage which may require surgery (Koplas and colleagues). Clinical examination by a skilled orthopedic surgeon is at least as accurate as MRI which should be reserved for the more complicated situation, and the routine ordering of an MRI prior to orthopedic evaluation is not recommended (Kocabey and colleagues). In this case, there is a lack of documentation of recent left knee complaints or positive physical findings in the left knee prior to the MRI performed on the date of service at issue. The documentation provided indicates that a bilateral MRI was requested prior to the orthopedic evaluation that had been scheduled for complaints of right knee pain. Although left knee pathology was identified as a result of the MRI, there is no evidence that the patient met clinical indications for an MRI of the left knee at the time the study was ordered and performed. As such, the left knee MRI was not consistent with American College of Radiology practice guidelines for performance of an MRI of the knee. In this case, because the medical records do not document any indications for an MRI of the left knee prior to the study, the Health Plans denial was appropriate.
Appeal type: Medical Necessity
Decision: Overturned

A 38-year-old female enrollee has requested acupuncture for treatment of her hemifacial spasm.  Findings:  The physician reviewer found that in this patients case, acupuncture for the treatment of hemifacial spasm is medically necessary.  The recommended surgical treatment involves significant risk. The medical literature supports acupuncture treatment in this clinical situation.  Huajun conducted a study to search for a convenient, safe and effective method for treatment of facial spasms. Following the study, it was determined that acupuncture plus cupping is a convenient, safe and effective method for the treatment of facial spasms.  Candong and colleagues performed a study to observe the therapeutic effect of acupuncture on facial neuritis at acute stage. The authors observed superiority of the therapeutic course in the acupuncture group when compared to the control group. They concluded that acupuncture can shorten the therapeutic course and increase the therapeutic effect for facial neuritis at the acute stage.  In this patients case, the current medical evidence support acupuncture treatment, and prior acupuncture treatment has been of benefit. All told, the requested acupuncture treatment is medically indicated in this patients case.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has been diagnosed with osteoarthritis of the right knee.  The patient reported right knee pain associated with crepitation and stiffness. The provider noted the patient had moderately responded to a corticosteroid injection in the past with a limited duration. Physical examination findings included mild right knee valgus alignment. Tenderness to palpation was noted over the right knee lateral and patellofemoral compartments. There is no documentation of past relief from viscosupplementation injections. The patient has requested authorization and coverage for Euflexxa injections in the right knee only. The Health Plan denied the request and reported the requested services are not medically necessary for the treatment of this patient. At issue in this case is whether Euflexxa injections in the right knee only are medically necessary for the treatment of the patients medical condition. Review of the current medical literature pertaining to viscosupplementation reveals mixed results.  Although viscosupplementation may relieve knee pain in some patients with osteoarthritis, it is unknown which individuals will benefit. Viscosupplementation can only be recommended in patients with a history of lasting benefit from prior injections and in carefully selected cases where the options are limited. A clinical trial by Campos and colleagues found that viscosupplementation increased functional scores in patients with severe osteoarthritis of the knee, especially within three months of injection. In this case, the patient had limited benefit from a corticosteroid injection. The provider has therefore recommended viscosupplementation with Euflexxa injections. The patients options are limited. He has tried and failed other conservative treatments, including a corticosteroid injection, with the alternative being a total knee arthroplasty. The medical evidence supports the requested services in this clinical setting. Therefore, Euflexxa injections in the right knee only are 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 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.