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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for pudendal nerve stimulation with StimWave neuromodulation (Phase 1  percutaneous implantation of neurostimulator electrode, peripheral nerve and Phase 2  insertion/replacement of peripheral neurostimulator pulse generator or receiver. In the medical literature, Murer and colleagues evaluated current studies on the treatment options available for patients with pudendal neuralgia (PN). The authors concluded that, Although there are a number of modalities utilized for the treatment of PN, there are no current recommendations based on treatment efficacies. Fang and colleagues reported on 80 patients with pudendal neuralgia who were treated with pulsed radiofrequency and pudendal nerve block or nerve block alone. The authors found that, Compared with the single nerve block treatment, pudendal nerve pulsed radiofrequency combined with nerve block could provide more long-lasting relief from pain symptoms of pudendal neuralgia. Furthermore, Roberts and colleagues reported on 13 patients treated with StimWave lead placed at the pudendal nerve who reported that nine underwent permanent lead placement given greater than 50% improvement in pain. The records provided for review document that this patient has failed reasonable conservative care measures and is a candidate for pudendal nerve stimulation with StimWave. Neuromodulation is less invasive than surgery, is accompanied with fewer risks, and is supported for use in patients with pudendal neuralgia who have failed conservative treatment. For these reasons, the requested pudendal nerve stimulation with StimWave neuromodulation (Phase 1  percutaneous implantation of neurostimulator electrode, peripheral nerve and Phase 2  insertion/replacement of peripheral neurostimulator pulse generator or receiver 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 services 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 services are 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 reviewer 1 is board certified in anesthesiology with subspecialty certification in pain medicine and is actively practicing. Physician reviewer 2 is board certified in physical medicine and rehabilitation with subspecialty certification in pain medicine and is actively practicing. Physician reviewer 3 is board certified in anesthesiology with subspecialty certification in pain medicine and is actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld

A 39-year-old female enrollee has requested a Saunders lumbar traction unit for the treatment of her lumbar disc herniation. Findings:  Three physician reviewers found that traction has no proven therapeutic efficacy. The American College of Occupational and Environmental Medicine (ACOEM) guidelines do not recommend traction, for treatment of acute, subacute or chronic low-back pain or radicular pain symptoms. Nor is there any scientific data to support the use of lumbar traction for back pain, and therefore, its efficacy in this setting remains unproven.
Appeal type: Medical Necessity
Decision: Upheld

The patient is a 62-year-old male who has requested continued chiropractic care for neck and back complaints. An MRI revealed degenerative disc and degenerative joint disease of his cervical spine. The patient sustained an injury from a motor vehicle accident approximately one year ago and found chiropractic care to be more beneficial than his experience with physical therapy and medications. The Health Plan has determined continued chiropractic care is not medically necessary for treatment of the patients medical condition.This patient wishes to receive chiropractic care beyond the eight sessions received over approximately 60 days. Chiropractic care can improve spinal degenerative complaints and is an effective alternative to medications and other physical treatment options. However, in this case the submitted documentation does not demonstrate continued chiropractic care is medically necessary. The notes provided do not adequately document symptoms intake, objective findings, and patient response to care (S.O.A.P.) and fail to justify the need for continued chiropractic care. Therefore, 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: Medical Necessity
Decision: Upheld

The parent of a two-year-old male enrollee has requested speech therapy for treatment of the enrollees mixed receptive-expressive language disorder. Findings:  The physician reviewer found that this nearly 3-year-old patients receptive and expressive language tests place him in the lowest quartile of normalcy for his age. However, both the 17th and 24th percentiles fall well within the normal range for his age. Since the patients scores are in the normal range, the medical necessity of speech therapy is not established. In order to meet clinical indications for speech therapy, test scores should be below the 10th percentile for the individuals age. Review of the literature demonstrates that two-year-olds who tested below the 10th percentile did require and benefit from speech therapy (Emmanues, et al. and Buschman, et al.). At this time, the available evidence demonstrates that speech therapy has been proven to be an effective tool for improving speech outcomes in children who demonstrate a significant delay in language development, as defined by test scores below the 10th percentile. If future evaluations result in receptive and expressive language test scores below the 10th percentile, the request for speech therapy should be reconsidered.
Appeal type: Medical Necessity
Decision: Overturned

Findings:  The physician reviewer found that Nature of Statutory Criteria/Case Summary:  An enrollee has requested authorization and coverage for gastric sleeve surgery (CPT 43775).Mechanick and colleagues state, Bariatric procedures remain a safe and effective intervention for higher-risk patients with obesity. Clinical decision-making should be evidence-based within the context of a chronic disease. A team approach to perioperative care is mandatory with special attention to nutritional and metabolic issues. Moreover, the medical literature indicates that bariatric surgery for treatment of morbid obesity requires a multidisciplinary evaluation to determine eligibility. In this case, the patient has been diagnosed with morbid obesity. The patient has completed a multidisciplinary evaluation, including a behavioral evaluation and a dietary evaluation. Therefore, the requested gastric sleeve surgery (CPT 43775) is medically necessary for treatment of the patients medical condition.Final Result: The reviewer determined that the requested service 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 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: Overturned

The parent of a ten-year-old male enrollee has requested  Femara 2.5mg for treatment of the enrollees Russell-Silver syndrome.  Findings:  Three physician reviewers found that Russell-Silver syndrome is characterized by intrauterine growth restriction, poor postnatal growth, relative macrocephaly, asymmetry and feeding difficulties.  Because of accelerated bone maturation due to atypical puberty in individuals with this condition, often height growth is terminated at a far younger than normal age.  Unfortunately, there are limited treatments available to help promote growth velocity in affected individuals, and there can be shortcomings with use of growth hormone, including lower limb asymmetry.  Aromatase inhibitors are a class of drugs that block the synthesis of estrogen. Recent data suggests that aromatase inhibitors may be a very promising treatment for boys with short stature due to precocious puberty.   Aromatase inhibitors hold promise of delaying the acceleration of bone age and increasing predicted adult height in adolescent boys with growth hormone deficiency. Femara, a potent third-generation aromatase inhibitor, has shown significant efficacy with a good safety profile.  In this patients case, Femara 2.5mg is likely to be superior over other available treatments.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a 3 year old female enrollee has requested for speech therapy for treatment of the enrollees speech delay.  Findings:  The physician reviewer found that the standard and customary practice in the medical community would be to arrange speech therapy for this patient whose expressive language is markedly delayed as there is a compelling medical literature that supports speech therapy in this young population. Law and colleagues reported that children with speech delay can be readily treated, as confirmed in a meta-analysis of multiple medical journal articles. Similarly, Goorhuis-Brouwer and Kniff concluded that normal and developmentally delayed children with speech delay are candidates for successful speech therapy. In addition, Emanuel and colleagues noted that in prospective studies on patients in the 2-year-old population, who tested below the 10th percentile for age, benefit from speech therapy. Therefore, the recommendation is that this patient receives individual speech therapy sessions.
Appeal type: Medical Necessity
Decision: Upheld

The patient is a 14-year-old female diagnosed with a metastatic mixed ependymoma. The patients pediatric oncologist recommended radiation therapy and chemotherapy. The patients family declined radiation and chemotherapy and the patient began receiving antineoplaston therapy with Dr. Burzynski. A recent MRI showed marked progression of the patients tumor. The Health Plan has denied coverage for treatment with Dr. Burzynski on the basis the therapy is not medically necessary for treatment of the patients medical condition.The Health Plans denial should be upheld. Conventional therapy for this situation would involve radiation therapy with chemotherapy agents that have shown some response (i.e., carboplatin, etoposide). Antineoplaston therapy is experimental with no evidence of better success compared to conventional therapy. Furthermore, the results of a recent MRI show antineoplaston therapy has not been effective for this patient. Accordingly, 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: Upheld

A 59-year-old female enrollee has requested a PET scan for the treatment of her progressive neurologic weakness and dysfunction. Findings:  Three physician reviewers found that the patient has a progressive neurologic disorder with limb weakness and has been diagnosed as having multifocal motor neuropathy, which is an autoimmune disorder. She has had MRI scans of the brain that show non-specific subcortical lesions. Tumor is not within the listed differential. PET scan has value in diagnosing suspected tumor, but no evidence has been submitted showing benefit in the evaluation of subcortical white matter lesions. A PET scan is not indicated in this case, as it is not likely to be superior to other assessments in clarifying the diagnosis.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a 17-year-old male enrollee has requested  residential level of care services for treatment of the enrollees behavioral health issues.  Findings:  The physician reviewer found that based on review of the available records, this patient meets the Texas Commission on Alcohol and Drug Abuse (TCADA) treatment criteria for substance abuse RTC level of care from the said date and forward. He was not in withdrawal at the time of admission but he exhibited significant family, social, and academic dysfunction. His interpersonal environment, as documented by his mother, was one in which his treatment was unlikely to succeed. Although the least restrictive treatment environment is desirable, the records indicate the patient had already received several years of structured outpatient treatment, with a combination of special educational support, psychiatric support, group therapy, individual therapy and family therapy without substantial improvement. Further, the patient continued to sabotage his treatment, with ongoing or escalating usage during therapy. Overall, the records indicate the patient had deteriorated to the degree that he was no longer able to function in society as an independent person and requires the intensity of care with the monitoring and supervision provided at the RTC level of care. Thus, the RTC services provided from the date in question and forward are supported as medically necessary for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An 18-year-old female enrollee has requested authorization and coverage for septoplasty (CPT code 30520), inferior turbinate reduction (CPT code 30140), and open nasal reconstruction (CPT code 30410). Findings:  The physician reviewer found that According to the American Academy of Otolaryngology-Head and Neck Surgery Foundation (AAOHNSF), indications for septoplasty and turbinate reduction surgery include nasal obstruction secondary to septal deviation, refractory to medical management or for surgical access. Although this patients records include documentation of septal deviation, turbinate hypertrophy and nasal obstruction, there is no record that adequate medical management has failed to improve this patients symptoms. Thus, the requested surgery is not supported as medically necessary for treatment of this patients medical condition. This patient has a remote history of nasal trauma and previous surgery to correct the nasal fracture. While the bony dorsum was described as deviated to the left, there were no descriptions of the nasal bones or any other anatomical structures beside the septum and turbinates to demonstrate the presence of an abnormal condition. There were no photographs to document the deformity. Further, the records do not demonstrate that the requested rhinoplasty is functional in nature. The patient reported she did not like the appearance and it was noted that the surgery was to address cosmetic issues. For these reasons, the requested surgery is not reconstructive in nature. Final Result: The reviewer determined that the requested surgery is not reconstructive in nature or 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 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: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for a surgical implant of a leadless pacemaker (CPT 33274). In this case, there is no reported contraindication to placement of a standard leaded pacemaker system such as lack of venous access, young age with anticipated multiple subsequent procedures, or need for venous catheters. In addition, leadless pacemakers lack adequate long-term follow-up data to support a clinical role for patients in this clinical setting (Reddt, et al.; Miller, et al.; Kusamoto, et al.). This patient has an intermittent Mobitz II atrioventricular (AV) block that cannot be effectively treated with a leadless ventricular pacemaker and requires a standard leaded dual chamber system to maintain AV synchrony. For these reasons, the requested surgical implant of a leadless pacemaker (CPT 33274) is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Findings:  Three of the three physician reviewers found the requested surgical implant of a leadless pacemaker (CPT 33274) is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the requested services are not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: Physician reviewer 1 is board certified in internal medicine with subspecialty certification in cardiovascular disease and is actively practicing. Physician reviewer 2 is board certified in internal medicine with subspecialty certification in cardiovascular disease and is actively practicing. Physician reviewer 3 is board certified in internal medicine with subspecialty certifications in cardiovascular disease and cardiac electrophysiology and is actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for OxyContin ER 15 mg tablets every 12 hours. The Centers for Disease Control and Prevention (CDC) guidelines state that, non-pharmacologic therapy and non-opioid pharmacologic therapy are preferred for chronic pain. Clinicians should consider opioid therapy only if expected benefits for both pain and function are anticipated to outweigh risks to the patient. If opioids are used, they should be combined with non-pharmacologic therapy and non-opioid pharmacologic therapy, as appropriate. The Federation of State Medical Boards (FSMB) recommends opioid therapy for chronic pain that is not cancer-related, or part of palliative care or end-of-life care, only when non-opioid and non-pharmacological options have not been effective and maintain opioid dosage as low as possible and continue only if clear and objective outcomes are being met. This patients records document chronic pain related to cervical radiculopathy, cervicalgia, and migraines. She has attempted several forms of conservative non-opioid therapy including epidural steroid injections, trigger point injections and physical therapy with marginal results. Her urine toxicology screens and CURES reports have been consistent with her therapeutic regimen. The provider documented that the patients pain control has been satisfactory with OxyContin and that there is no evidence of adverse drug reactions or aberrant behavior identified. Given these findings, the requested OxyContin ER 15 mg tablets every 12 hours is medically necessary for this patient.Final Result: The reviewer determined that the requested medication is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in anesthesiology with subspecialty certification in pain management 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 and prospective authorization and coverage for biofeedback services. Pelvic pain is a complex problem that is typically difficult to treat as the disease process is multifactorial without one specific etiology. Some common diagnoses include infection, endometriosis, adhesions, irritable bowel syndrome, and interstitial cystitis. Given the lack of work-up for this patients symptoms, it is difficult to ascertain if physical therapy is the best therapy for her symptoms. Depending on the patients ultimate diagnosis, different management options can be helpful.  The enrollee would likely benefit from counseling for PTSD and possibly sexual counseling for longstanding anorgasmia. In the absence of a thorough work-up of bladder/pelvic floor issues, the biofeedback services were not and are not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: Two of the three reviewers determined that the services at issue were not and are 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:  One reviewer is board certified in obstetrics and gynecology and is actively practicing. One Reviewer is board certified in obstetrics and gynecology and is actively practicing.  One Reviewer is board certified in obstetrics and gynecology and is actively practicing.  All three reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

A 55-year-old female enrollee has requested Chantix for treatment of her chronic obstructive pulmonary disease. Findings:  The physician reviewer found that the Food and Drug Administration (FDA) has approved the use of Chantix for the cessation of smoking, however the current recommended maximum amount of continuous use is 24 weeks. In the medical literature, Williams and colleagues studied the long-term use of 251 patients treated with Chantix and found that at 52-week follow-up, 36.7% of patients treated with Chantix remained abstinent compared to 7.9% who received placebo. Despite this outcome, the safety and efficacy of long-term use has not been evaluated with sufficient studies and adequate follow-up to endorse its use after 24 weeks. It should be noted that serious and important side effects, including depression, suicidal thoughts, sub-capsular cataracts, and cardiovascular events have been reported with both short- and long-term use. Indeed, serious adverse events were found to be 2.5 times more likely to occur in the Chantix group compared to the placebo group in Williams and colleagues study. Thus, the extended use of Chantix is not clinically indicated beyond 24 weeks.
Appeal type: Experimental/Investigational
Decision: Upheld

A 45-year-old female enrollee has requested Botox injections for the treatment of her migraine headaches. Findings:  Three physician reviewers found that although Botox is not a first-line therapy for migraine headache there is literature supporting its use for patients with refractory headaches.  In this particular case, the patient has showed a documented response to occipital blocks and Verapamil. The available evidence does not demonstrate that Botox is likely to confer additional benefit over the response the patient has had to occipital blocks and Verapamil.