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

Nature of Statutory Criteria/Case Summary: The patient has been diagnosed with major depressive disorder. The patient reported feeling as if her depression was in remission. The patient was noted to have begun transcranial magnetic stimulation (TMS) treatment for maintenance in January 2020 after completing acute phase treatment. In a letter, the provider noted that the patient received TMS treatments in 2017 with a remarkable change in the patients condition, although the improvement was not sustained. The provider noted that the patient had rapid decompensation and was treated with additional TMS treatments 2018 and 2019. Per the records, the Patient Health Questionnaire (PHQ-9) scores were noted to have increased from zero in February 2020 to 10 in April 2020. The patients Beck Depression Inventory (BDI) scores had increased from eight in March 2020 to 20 in April 2020, indicating worsening depressive symptoms. The patient has requested reimbursement and prospective coverage for repetitive transcranial magnetic stimulation (rTMS) services provided  forward. The Health Plan denied the request and reported the services at issue were not and are not medically necessary for the treatment of this patient. At issue in this case is whether rTMS services provided forward were and/or are medically necessary for the treatment of the patients medical condition. Authors reported, Repetitive TMS could represent a novel strategy for preventing relapse in treatment resistant depression patients who respond to rTMS treatment. These results should be confirmed in a larger sample. Researchers reported, Once a determination of maximum benefit is made, the TMS treatments should be tapered and a continuation and then maintenance regimen developed for the patient. In this case, the provider noted that the patient had rapid decompensation and required additional TMS treatments in 2018 and 2019 after initial rTMS treatment in 2017. The medical evidence supports the services at issue in this clinical setting. Therefore, repetitive transcranial magnetic stimulation (rTMS) services provided forward were and are medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested services were and 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: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for occipital nerve block injection. Findings:  Two of the three physician reviewers found that the current medical evidence supports the service at issue in this clinical setting. This patient presented with signs and symptoms consistent with severe, intractable occipital neuralgia. The records indicate that the patients symptoms did not improve with standard conventional treatments, including medications and activity modification. She continued to experience pain despite these measures. A right occipital nerve block was appropriate in this setting. In sum, occipital nerve block injection was likely to have been of greater benefit than other treatment options. Final Result: The reviewers determined that the requested services are 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 anesthesiology with sub-specialty certification in pain medicine 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 female enrollee has requested coverage for Lyrica 25mg for treatment of her burning mouth syndrome.  Findings:  The physician reviewer found that the current medical evidence does not support the requested medication in this clinical situation.  The article by Schatton and Riechelmann noted that Lyrica is a potential treatment for burning mouth syndrome.  However, the authors noted that its value remains unproven at this time, and further study is required.  Patton and colleagues and Maltsman-Tseikhin and colleagues emphasized the need to investigate the underlying cause of burning mouth syndrome in each patient.  However, the authors noted that there is a lack of treatments that have proven to be effective for this condition.  There is a lack of support in the current medical literature for the requested medication in this patients case.
Appeal type: Medical Necessity
Decision: Upheld

A 51-year-old female enrollee requested authorization and coverage of continued Orthopedic Spine Treatment (OST) for treatment of back pain.  The health plan denied the enrollees request indicating that the requested treatment is not medically necessary.One physician reviewer performed a medical necessity Independent Medical Review.  The physician reviewer upheld the health plans denial on the basis that the requested therapy is not medically necessary.
Appeal type: Experimental/Investigational
Decision: Upheld

A 51-year-old male enrollee has requested  for the use of computer-assisted navigation used in conjunction with a hip arthroplasty surgery for treatment of his hip arthritis.   Findings:  Two physician reviewers found that computer-assisted navigation of total joint arthroplasty has been shown to increase the precision of component positioning, but it has not been proven to improve the results of total joint arthroplasty with respect to relief of pain, improved function, or longevity of the arthroplasty when compared to arthroplasty performed without computer-assisted navigation (see Parratte and Argenson). At present, there is insufficient evidence to allow scientific conclusions regarding the superiority or added value of computer-assisted technologies for orthopedic surgery compared to conventional methods. Authors have assessed only short-term outcomes; long-term effectiveness has not been demonstrated. Until additional studies are available involving longer followup periods, there is inadequate data to support the contention that computed-assisted navigation is superior to freehand positioning.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary:  An enrollee has requested Sovaldi in combination with Daklinza for treatment of his hepatitis C. Findings:  The physician reviewer found that according to joint guidelines issued by the American Association for the Study of Liver Diseases and the Infectious Diseases Society of America, all patients with chronic hepatitis C should be treated except those with life expectancy less than 12 months due to non-liver-related conditions. In treatment-naive genotype 3 patients, therapy is recommended with Sovaldi and Daklinza for 12 weeks, regardless of interferon eligibility. The medical evidence indicates that a delay in treatment may result in decreased survival.  No alternative regimen has been approved for treatment of hepatitis C in this case.  For these reasons, the requested Sovaldi in combination with Daklinza is medically indicated for the treatment of this patient.  Final Result: The reviewer determined that the requested medications 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 internal medicine with sub-specialty certification in gastroenterology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for oxycodone 5 mg. Findings:  The physician reviewer found that Centers for Disease Control and Prevention (CDC) guidelines state that when opioid therapy is used, a patients regimen should include nonpharmacologic therapy and non-opioid pharmacologic interventions. Additionally, the CDC noted that, Clinicians should continue opioid therapy only if there is clinically meaningful improvement in pain and function that outweighs risks to patient safety. The Washington Agency Medical Directors Group Interagency guidelines state that providers should reserve opioids for acute pain resulting from severe injuries or medical conditions, surgical procedures, or when alternatives (non-opioid options) are ineffective or contraindicated. If opioids are prescribed, it should be at the lowest necessary dose and for the shortest duration (usually less than 14 days). The records document that this patient underwent a hip abscess drainage with uncomplicated post-operative course and was successfully transitioned from IV analgesics to oral oxycodone at discharge. The provider recommended an appropriate amount of oral opioid medication to managed expected course of post-operative pain at discharge. After contacting the provider requesting additional refills, the provider recommended discontinuation of opioid therapy is not indicated based on his post-operative course and that transition to non-opioid analgesics is the best course of action. For these reasons, the requested oxycodone 5 mg 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 anesthesiology with subspecialty certification in pain medicine and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: At issue is whether a DaT scan is likely to be more beneficial for evaluation of the enrollees condition than any available standard therapy. The enrollee presented for a sudden onset of hand tremors. The enrollee reported symptoms to be most noticeable when performing activities requiring fine motor skills, and are lessened with drinking alcohol. Two out of three physician reviewers determined that while dopamine transporter (DaT) scans are not indicated for all patients with features of suspected parkinsonism, it has been shown to be useful in cases where the diagnosis of idiopathic Parkinson disease versus essential tremor is being considered. In some patients with suspected parkinsonian syndromes, SPECT imaging is useful to assist in the diagnosis and to help guide prognosis and treatment decisions, including avoiding medications that are unlikely to provide a benefit.  A review addresses the value of DAT-SPECT and its impact on diagnostic accuracy in movement disorders presenting with tremor and/or Parkinson disease. The authors concluded that DaT scans are helpful and sensitive to differentiate further the exact diagnosis. For this patient, the exact diagnosis is not clear. The patient does not have definitive features of either disease.  It is imperative to provide a definitive diagnosis, as a treatment for Parkinsons disease versus essential tremor are different, and placing the patient on a continued trial of dopamine therapy would place the patient at risk of significant short or long term side effects.  In this particular case, the patients care will be assisted by this study as it will help aid in the selection of future managementFinal Result: The reviewers determined that the requested diagnostic test is likely to be more beneficial for evaluation 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 board certified in neurology 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

Nature of Statutory Criteria/Case Summary:  An enrollee has requested reimbursement for the Foundation One test provided for evaluation of the enrollees breast cancer with bone metastases. Findings:  2/3 of the physician reviewers found that Foundation One is a molecular assay that explores the mutations of an individual patients cancer cells. The goal of the assay is to identify a specific mutation or target which could guide the provider as to which chemotherapeutic agent would be useful. However, there is a paucity of evidence that the Foundation One assay adds to decision making ability, or yields a result that is reliably clinically beneficial. There are non-randomized studies exploring the value of molecular profiling, but the results have not been convincing as to the efficacy of such an approach to treatment. A randomized trial did not demonstrate a significant clinical benefit from choosing therapy based on molecular targets versus by the providers clinical judgment. Currently, the data suggests that finding a mutation does not support treatment directed at that target to produce a clinically meaningful response. All told, the Foundation One test provided was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Final Result: 2/3 of the reviewers determined that the testing at issue was 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 number one 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.Physician reviewer number two 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.Physician reviewer number three 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.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for durable medical equipment, RT300 functional electrical stimulation (FES) cycle therapy for treatment of the enrollees medical condition. Findings:  The physician reviewer found that yhe patient is approximately one year status post traumatic spinal cord injury as described above. In terms of recovery after spinal cord injury, most recovery occurs in the first six to 12 months. However, recovery can extend beyond one year, and neurologic recovery continues for perhaps up to two years. In this patients case, further neurological recovery may occur. The patient has an incomplete, mid-level cervical spinal cord injury. The patient has ongoing spasticity. There are no reported episodes of autonomic dysreflexia or active skin issues. However, use of the RT300 FES cycle therapy would carry potential risks of pressure ulcer formation, autonomic dysreflexia, post exercise hypotension, thermal dysregulation, as well as other musculoskeletal injuries.  In terms of functional abilities and at the patients neurological level of injury, the patient would be expected to be able to use conventional equipment for strengthening and an upper extremity or wheelchair ergometer for cardiovascular exercise. The patient is already using a standing frame and may progress to ambulating with bracing, likely on a limited basis for exercise. While this system may have benefits as a preventative measure and as a means of exercise, the RT300 FES Cycle Therapy would not treat the patients spinal cord injury. Although exercise is beneficial and highly recommended, the RT300 FES cycle therapy was not likely to have been more beneficial than the standard options available for treatment of this patients medical condition. Final Result: The reviewers determined that the equipment at issue was 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: Reviewers 1, 2 and 3 are board certified in physical medicine and rehabilitation 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: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for a magnetic resonance imaging (MRI) of the lower extremity for evaluation of the enrollees left hip pain. Findings:  Two physician reviewers found that the patient is currently a long distance runner, averaging up to 75 miles per week. As noted in the medical literature, runners experience a myriad of orthopedic problems including simple arthritis, acetabular labral tears, stress fractures, avascular necrosis, bursitis of the iliotibial band, tendinopathy/bursitis, piriformis syndromes, and hernias. The American College of Radiology (ACR) noted that in this clinical setting, a patient should have routine plain x-rays. Since the patients condition has been present for at least 18 months and plain x-rays have not been diagnostic, the second imaging modality recommended for chronic hip pain is an MRI. This is geared to detecting subchondral or stress fractures, osteonecrosis. In an extensive review of the various and likely causes of hip pain in an active individual, a research study concluded that MRI has proven to be a sensitive and efficient modality in the use of fracture imaging. The study found that MRI aids in streamlining patient care, can help guiding towards adequate treatment decision making, as well as detecting different causes of the patient symptoms. Given this support, the requested MRI of the lower extremity is likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Final Result: The reviewers determined that the requested diagnostic procedure is likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Credentials/Qualifications: All three reviewers are board certified in diagnostic radiology 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: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement and prospective authorization and coverage for residential treatment center (RTC) level of care services. Per the American Society of Addiction Medicine (ASAM) criteria, this patient meets Level 3 criteria for RTC services. Applying the ASAM framework, this patient has demonstrated significant protracted withdrawal symptoms and her treating providers have been trying to mitigate this with Sublocade, intensive psychosocial treatment and programming in a 24-hour monitored setting. The patient relapsed despite treatment with a Sublocade injection after she prematurely left the treatment facility. The patient has a diagnosis of type 1 diabetes mellitus with a history of ketoacidosis. Thus, continued substance use poses a significant risk to the patients health. The patients blood sugar levels were poorly controlled on admission. However, these appeared to stabilize as treatment progressed through close monitoring of her diet and frequent redirection. She also has extreme cravings for sugar due to withdrawal. The patients mental status is sufficient to permit participation. Her inability to control her impulsive behaviors has demonstrated that she has been unable to control her substance use without 24-hour support and redirection. The patient has significant impulse control problems and cognitive distortions due to her PTSD and lengthy history of substance use. She isolates and withdraws socially and has poor decision-making skills. These factors require a structured program offering a 24-hour milieu. The patient continues to have cravings and other psychiatric symptoms, which predispose her to self-medicate. She is at serious risk of relapse given her homeless state, her impulsivity and the COVID-19 restrictions. The patients recovery environment is too chaotic to support her recovery goals. She has been aggressive toward her family in the past. Due to relapse, she was removed from her sober living facility and she cannot return to her family home until she has been sober for one year. Given these findings, the subacute RTC level of care services provided were and are medically necessary for treatment of this patient. Final Result: The reviewer determined that the services at issue were and 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 with subspecialty certification in addiction 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.