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 left atrial appendage occlude implant procedure for treatment of the enrollees atrial fibrillation. Findings:  The physician reviewers found that this patient has a very high risk for bleeding on long-term anticoagulation. She has also had significant bleeding episodes in the past requiring transfusion and fistula surgery while on anticoagulation and needs to also be maintained on aspirin for coronary artery disease and prior drug eluting stents. She also has a high risk of embolic stroke. Given these competing issues, an alternative to long-term anticoagulation is reasonable to consider in this specific high risk clinical circumstance. The requested services have been shown to be efficacious in decreasing the risk of embolic stroke in patients with chronic atrial fibrillation. In this specific clinical scenario, in a patient with both high embolic stroke and high bleeding risk, the requested left atrial appendage occlude implant procedure is likely to be more effective than other treatment options. Final Result: Two of three 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 number one, two, and three are board certified in internal medicine with sub-specialty certification in cardiovascular disease and 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

Nature of Statutory Criteria/Case Summary: A female enrollee has requested authorization and coverage for sclerotherapy for treatment of the enrollees peripheral venous insufficiency.  Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested services. The current medical evidence suggests that the current place of sclerotherapy in modern clinical practice is limited to the treatment of accessory recurrent varicose veins following surgery and thread veins. Intervention for CEAP 1-2 disease without evidence of axial reflux, complications of chronic venous insufficiency and failure of conservative measures is not standard of care. The medical evidence does not support the requested services in this clinical setting. Therefore, the requested sclerotherapy is not medically necessary for the treatment of this patient.  Final Result: The reviewer determined that the requested services are not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in vascular 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: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for percutaneous implantation of a neurostimulator electrode with anesthesia. The records document that this patient has chronic low back pain with radiation into the legs. The patient has been treated with two back surgeries and multiple pain management procedures without adequate benefit. Medication management has been attempted with multiple drug classes including opioid therapy with diminishing benefit. Physical therapy yielded some benefit but without improvement in quality of life parameters. Additional treatment is being requested to include percutaneous implantation of a neurostimulator electrode with anesthesia. There is extensive evidence in the peer-reviewed medical literature demonstrating that spinal cord stimulation can be effective for the treatment of patients with failed back surgery syndrome. A review by Perez and colleagues found that spinal cord stimulation resulted in improved health related quality of life and functionality of patients with refractory pain due to failed back surgery syndrome compared to conventional medical management alone. Rojo and colleagues concluded that at two years, patients treated with spinal cord stimulation experienced greater improvements in their health related quality of life as compared to patients treated with conventional medical management. Given these findings, the requested percutaneous implantation of a neurostimulator electrode with anesthesia is medically necessary for 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 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: Medical Necessity
Decision: Upheld

A 61-year-old female enrollee has requested ketamine infusion for treatment of her thoracic spine pain. Findings:  The physician reviewer found the submitted documentation and peer-reviewed literature fails to establish the medical necessity of the requested therapy. Ketamine infusion is not in widespread use, it is only indicated for recalcitrant complex regional pain syndrome or neuropathic pain (Pickering et al; Azari et al). Ketamine infusion is associated with complications with multiple drug therapy, as well as co-morbid conditions (Patil and Anitescu; Noppers et al). The records document that the patients co-morbid medical conditions include chronic kidney disease, sleep apnea syndrome, atrial fibrillation and obesity, thus she is not a good candidate for ketamine infusion. Moreover, ketamine infusion is indicated only as a last resort therapy in recalcitrant neuropathic pain or complex regional pain syndrome after failure of all modalities of treatments, including topical ketamine (Poterucha et al). Thus, based on the medical literature cited above along with the submitted medical records, ketamine infusion is not medically necessary for treatment of the patients medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld

A 63-year-old male has requested transcranial magnetic stimulation for treatment of his major depressive disorder.   Findings:  Two physician reviewers found that the patient has a 10-year history of depression.  He has been diagnosed with major depressive disorder.  His symptom complex consists of depressed mood with suicidal ideation, feelings of guilt, poor motivation, decreased energy, and hypersomnia.  His prior medications included Wellbutrin, Cymbalta, Abilify, Paxil, Prozac, Zoloft, Effexor, Pristiq, and Zyprexa.  Psychopharmacotherapy has not resulted in remission.  Due to persistent affective symptomatologies, transcranial magnetic stimulation was recommended.  The American Psychiatric Association has endorsed transcranial magnetic stimulation for the acute phase treatment of major depressive disorder.  However, the requested services are not likely to be more efficacious than other treatment options in this patients case.  The documentation provided describes no psychotherapy pursuits, such as interpersonal therapy or cognitive behavioral therapy, which have been proven effective in the treatment of depression.  Further, there is no mention of intermediate treatment settings, such as intensive outpatient or partial hospitalization programming.  This patient has not exhausted augmentative strategies.  Electroconvulsive therapy remains the proven non-pharmacologic intervention to which other stimulatory techniques are measured, and the superior effectiveness of transcranial magnetic stimulation as compared to electroconvulsive therapy has not been established
Appeal type: Medical Necessity
Decision: Overturned

The parent of a 2-year-11-month old female has requested 5 hours of applied behavioral analysis (ABA) therapy per week and 1 hour of speech therapy per week for treatment of delayed language development.  Findings:  The physician reviewer found that this patient has an identified delay in receptive and expressive speech of approximately 35%. Speech therapy is indicated with any delay greater than 25% (Feldman and Messick). Extensive review of the literature including a meta-analysis by Law and colleagues notes the positive effect of speech and language therapy interventions for children with expressive phonological and expressive vocabulary difficulty. Feldman and Messick note that treatment for language disorders is predicated primarily on the childs language profile and level of communication skills. Children with mild to moderate disorders are more likely to resolve their delay compared to those with severe disorders. According to the authors, children who participate in speech-language therapy show better improvement than those children who receive no treatment. All told, review of the submitted documentation demonstrates that the patient is an appropriate candidate for speech therapy services and speech therapy at a frequency of one hour per week is medically necessary.With regard to the request for ABA therapy, the submitted documentation does not establish the medical necessity of ABA services. ABA is a medically necessary modality for individuals with an autism spectrum disorder who have behavioral problems. Based upon the documentation provided, this patient has not been diagnosed with autism spectrum disorder. Nor do the submitted medical records document any other significant underlying behavior disorder. As such, the patient does not meet clinical indications for ABA therapy. The Health Plans recommendation of evaluation by a psychiatrist is medically reasonable and appropriate in this setting. Accordingly, the requested ABA therapy is not medically necessary for treatment of this patients condition.
Appeal type: Medical Necessity
Decision: Upheld

A 31-year-old male enrollee has requested inpatient psychiatric hospitalization for treatment of her behavioral health condition. Findings:  The physician reviewer found that the inpatient psychiatric hospitalization provided on the date indicated was not medically necessary for treatment of the patients behavioral health condition. According to the medical records submitted for review, the patient was described as paranoid, but was not evincing suicidal or homicidal ideation. He was not demonstrating violent behavior and did not show himself to be a danger to others.  He was able to attend to his basic activities of daily living.  He showed impaired judgment and lacked insight in that he believed that he did not have an illness and did not require medication. Overall he was noncompliant with his treatment plan and indicated that he would not take medications when discharged home. There did not appear to have been any new or novel treatments implemented that this patient would have benefited from during the additional inpatient day. There was also no significant improvement in the patients overall condition. Overall, the services at issue did not the meet medical necessity for inpatient level of care treatment and could have been rendered at a lower level of care.
Appeal type: Medical Necessity
Decision: Upheld

The parent of a 17-year-old male enrollee has requested in home applied behavioral analysis (ABA) therapy for 30 hours per week for treatment of the enrollees autism. Findings:  The physician reviewer found that there is medical research supporting the effectiveness of intensive, early behavioral treatment resulting in some young patients testing within normal range in IQ, adaptive skills, and social skills. Many of these studies are instituted in patients between the ages of two and four, although there is data documenting the use of ABA principles to teach new skills to children with autism who were older than five years of age. However, most of these studies were not comprehensive programs; rather, they focused on one skill to develop or a behavior to change. With regard to this patient, he has a diagnosis of autism and is nonverbal or has very limited speech and language development; he is aggressive and violent; he has anger outbursts; and he is diagnosed with seizure disorder. Based on the evidence provided, there appears to be a correlation between his seizures and the occurrence of his aggressive behaviors. The severe outbursts and aggression could be symptoms of the seizure disorder, specifically of the temporal lobe. The likelihood that ABA therapy will be effective in this setting is quite low. ABA is an evidence-based treatment of autistic disorder that should be started as early as possible, preferably as early as two years of age, to have the greatest chance of efficacy. Its use in the case of a patient such as this patient who is 17 years of age and has a complicating diagnosis of seizure disorder is not consistent with the standard of care in this setting. As such, I find that ABA therapy is not medically necessary for this patient.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested greater occipital nerve block (facet blocks) for treatment of her medical condition.  Findings: The physician reviewer found that there is sufficient support for the requested services in this patients case.  This patient currently has chronic neck pain with radiculopathy and headache pain.  The records noted that her prior treatment has included physical therapy, injections and multiple medications.  The current medical evidence supports the requested services in this patients case.  In the article by Saracco and colleagues, the objective of this study was to determine whether adding triamcinolone to local anesthetics increased the efficacy of greater occipital nerve block and trigger point injections for chronic migraine.  In both groups, the procedure resulted in significant and rapid relief of headache, neck pain, photophobia and phonophobia.  There is a lack of treatment options in this patients case.  All told, the requested greater occipital nerve block (facet blocks) is 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 anesthesiology with sub-specialty 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: Medical Necessity
Decision: Overturned

A 54-year-old female enrollee has requested for Celebrex and Lidoderm patches for treatment of her lower back pain.  Findings:  The physician reviewer found that although the has only FDA approved the Lidoderm patch for the treatment of post-herpetic neuralgia, Lidoderm is prescribed by many practitioners for the management of regional pain such as back pain and osteoarthritis of the knee and shoulder. The medication has a good safety profile and two open-label studies support its beneficial effects in the treatment of low back pain. The patient has already tried this medication with good results and continued treatment is medically appropriate. Celebrex is a selective Cox-2 inhibitor used primarily in the management of chronic pain due to osteoarthritis. Its efficacy is comparable to other NSAIDs, but its safety profile is better due to the lack of gastrointestinal side effects. Cardiovascular side effects have been noted in the product literature, however that is likely a class effect found with all NSAIDs. With regard to this particular patient, her MRI is consistent with a diagnosis of lumbar spondylosis, which is a form of osteoarthritis with a degenerative course.
Appeal type: Medical Necessity
Decision: Overturned

The patient is a 55-year-old male with hepatitis C, genotype 1.  He received four months of treatment with pegylated formula interferon and ribavirin, and subsequently relapsed after the treatment was completed. The patients provider has requested authorization for further treatment with Infergen. The Health Plan denied authorization based upon a determination that the therapy is not medically necessary.Infergen has been approved by the FDA and is specifically indicated for the treatment of patients who have not responded to pegylated interferon therapy. This patient received the pegylated formulation treatment for four months, and has now relapsed as demonstrated by a viral load of 1,370,000 IU/ml. At this point, it is reasonable to proceed with Infergen therapy.  Therefore, I have determined the requested therapy is medically necessary for treatment of the patients medical condition. The Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a 13-year-old male enrollee requested Humira for medical treatment of the enrollees psoriatic arthritis.  Findings:  The physician reviewer found that review of the submitted documentation and relevant literature demonstrates the medical necessity of the requested medication. This patient should be treated with a tumor necrosis factor (TNF) antagonist as initial therapy based upon the severity of his disease. In this clinical setting, a TNF antagonist is clinically indicated to prevent any additional long-term damage.  As such, the request for Humira is appropriate and clinically indicated for treatment of the patients psoriatic arthritis. Based on the documentation submitted for review and the peer-reviewed literature cited above, the requested medication is medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary:   An enrollee has requested incontinence supplies (disposable liners, reusable underpants and large disposable under pads) for treatment of her urinary incontinence.  The physician reviewer found that the submitted documentation fails to establish the medical necessity of the requested services. According to the documentation submitted for review, the patient presents with a symptom-based diagnosis of stress incontinence. The documentation submitted does not include a detailed work-up or evaluation of urinary incontinence. In addition, there is no documentation to support the cause of incontinence. Thus, the request for incontinence supplies (disposable liners, reusable underpants and large disposable under pads) is not medically necessary for treatment of the patients medical condition. Final Result: The reviewer determined that the requested services are not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.  Credentials/Qualifications: The reviewer is board certified in urology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: an enrollee has requested reimbursement for the eight transcranial magnetic stimulation (TMS) sessions provided.  Findings:  The physician reviewer found that TMS is non-invasive, neuro-stimulatory intervention endorsed by the American Psychiatric Association (APA) for the treatment of acute phase depression in the adult population. A typical treatment course of TMS consists of 30-40 sessions spanning four to six weeks. According to the summary of TMS treatment recommendations authored by Perera and colleagues The standard parameter setprovided clinical benefit in treatment courses up to six weeks in duration. Controlled studies of longer duration, acute treatment courses or using alternative treatment parameters are not established. The article did suggest that an extended treatment course of one to two weeks may be appropriate for patients who experience only partial improvement and the clinician believes that a clear plateau of benefit has not been obtained. At this time, there are a lack of adequate controlled studies showing the benefit of longer courses of TMS therapy. Thus, the medical literature does not support a reasonable expectation that additional TMS therapy at the time would have improved the patients condition or prevented a more serious episode of illness. Further, there is no evidence in the medical literature to suggest that the patients improvement was more than likely due to the additional TMS sessions. The timing of the remission in this case may have been the natural course of the episode. In sum, based the documentation provided in context of the relevant literature and practice standards, the TMS services in dispute were not medically necessary for treatment of the patients medical condition. Final Result: The reviewer determined that the services at issue were not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: the physician 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: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for D cup breast implants as part of mastopexy. Findings:  The physician reviewer found that This patient has lost a significant amount of weight following bariatric surgery.  She is noted to have significant rashes associated with her ptotic breasts from skin-to-skin contact. A mastopexy is indicated for functional improvement, and this procedure was approved by the Health Plan. However, per the submitted documentation, breast augmentation for this patient is a cosmetic intervention and is not medically necessary.  The records document that the patient has ptotic breasts of moderate size, which is confirmed by the photographs.  Other than the ptosis of the breasts, the patient has a normal breast appearance for her current body size and weight. The ptotic aspect of the breasts will be addressed with the mastopexy, which has been approved. Thus, as the patient has a normal appearance with respect to breast volume, the requested services with not be performed to create a normal appearance. Additionally, the records do not document that the requested services will improve function. Therefore, the requested D cup breast implants as part of mastopexy are not medically necessary for the treatment of this patient and are not reconstructive in nature.Final Result: The reviewer determined that the requested services are not medically necessary for treatment of the patients medical condition and are not reconstructive in nature. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is board certified in plastic 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.