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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage of naproxen and esomeprazole magnesium (Vimovo) DR. Findings: The physician reviewer found that the submitted documentation does not support that the requested medication is medically necessary. The American College of Physicians Best Practice Advice for Clinical Guidelines recommends prescribing generic medications. The long-term use of proton pump inhibitors has the potential for serious side effects. Current research indicates that chronic acid suppression can potentially lead to an increased occurrence of bone fractures. Medical literature does not demonstrate that the addition of esomeprazole in combination with naproxen, in the same pill, increases the effectiveness of naproxen. There is no documentation that the patient has gastrointestinal issues that would require the use of a proton pump inhibitor. Therefore, the requested Vimovo DR medication is not medically necessary for treatment of this patients medical condition. 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

A 60-year-old female enrollee has requested for a vertical sleeve gastrectomy for treatment of her obesity. Findings:  Two physician reviewers found that the vertical sleeve gastrectomy has been shown to be an efficacious surgical procedure for the treatment of obesity. The procedure is approved as a primary treatment for severe obesity in the well-selected patient by the American College of Surgeons and the American Society for Metabolic and Bariatric Surgery (ASMBS) based on the medical literature documenting safety, efficacy and the availability of five-year data. There are multiple studies involving a total of 2,570 patients with intermediate term follow-up reported in the literature at 3, 4, and 5-year intervals. These studies suggest comparable rates of improvement and remission of diabetes, hypertension and sleep apnea compared to other restrictive procedures, with relatively low major complication rates.
Appeal type: Medical Necessity
Decision: Upheld

The patient is a 51-year-old female with asthma. She was diagnosed with allergic bronchopulmonary aspergillosis (ABPA), which is characterized by an allergic reaction to aspergillus antigens, asthma, proximal bronchiectasis, infiltrates, elevated IgE levels, eosinophilia, serum precipitating antibodies to aspergillus and skin test to aspergillus. The patient has been on Sporanox for many years and has requested authorization for continued treatment with Sporanox. The Health Plan has determined Sporanox is not medically necessary for the patient.Steroids are the mainstay of treatment of ABPA. Treatment with anti-fungal agents is also indicated. The length of treatment if Sporanox is used as the antifungal agent is approximately 12 months. There are studies of use from one month to 20 months. The patient was diagnosed with ABPA in 1992. She has been treated with Sporanox since the time of diagnosis, approximately 13 years. Lifetime use of Sporanox for ABPA is not clinically indicated. Moreover, the patient requires no further treatment with Sporanox. Therefore, I have determined that the requested medication is not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for twice weekly psychotherapy sessions. Geddes and Miklowitz note that long-term maintenance and stabilization of depression in patients with bipolar disorder can be enhanced by the combination of psychosocial treatments with drugs. Swartz and Swanson note that evidence demonstrates that bipolar disorder-specific psychotherapies, when added to medication for the treatment of bipolar disorder, consistently show advantages over medication alone on measures of symptom burden and risk of relapse. For a patient with acute symptoms of bipolar disorder, psychotherapy once weekly with additional group psychotherapy and case management, as needed, is appropriate. In this case, the patient has symptoms of anxiety, posttraumatic stress disorder, and bipolar disorder. The records show that the patient failed to utilize resources other than individual therapy and psychiatrist sessions. In this clinical setting, individual therapy once weekly is standard of care and medically indicated. Given the patients demonstrated inability to utilize services at a higher level of care effectively, and as the records do not reflect evidence of twice weekly psychotherapy previously, twice weekly psychotherapy is not medically indicated. Therefore, once weekly psychotherapy sessions are medically necessary for the treatment of this patient.Final Result: The reviewer determined that a portion of the requested services are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be partially 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: Medical Necessity
Decision: Overturned

The parent of a nine-year-old male is requesting occupational therapy for treatment of the enrollees autism.  Findings:  The physician reviewer found that the prevalence of impairments in fine and gross motor skills appears to be relatively high, based on the few studies that have included such information on autism. Occupational therapists work as part of a team that includes parents, teachers, and other professionals. They help set specific goals for the person with autism. These goals often involve social interaction, behavior, and classroom performance. Occupational therapists can help in two main ways: with evaluation and therapy. To support the need for occupational therapy (OT), studies have shown benefits that prevents a deterioration or reversal of function and a significant improvement in activities of daily living. This patients summary treatment plan clearly documents his improvements toward specific goals set based upon his individual needs. Despite his improvement, the patient continues to present with delays that are likely amenable to further treatment with OT services. Thus, the OT services at issue have been demonstrated to be medically necessary for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned

A 45-year-old female enrollee has requested a home phototherapy (UVB) unit for treatment of her dermatitis.  Findings:  The physician reviewer found that dermatitis is histologically diagnosed based on specific findings. The histology is useful to exclude other diagnoses, but requires clinical correlation to establish a more specific diagnosis of eczema. Acute eczema is characterized by spongiosis, a mainly intercellular edema between the epidermal keratinocytes leading to micro or macro vesicles (Boguniewicz and Leung). Treatment of chronic eczema usually starts with topical agents, such as corticosteroids as well as phototherapy, including broad-band UVA (UVB-BB), UVA with psoralen, and UVA-1. More recently, narrow-band UVB has emerged as an effective treatment modality (Majoie, et al). This patients skin disease is consistent with the diagnosis of chronic eczema. According to the medical records, the use of UVB was required to get the disease under control. Eczema is an indication for UVA/UVB therapy. Therefore, the requested home phototherapy (UVB) unit is considered medically necessary in this clinical setting.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for bilateral injections of Synvisc-One. The medical evidence supports the services at issue in this clinical setting. Viscosupplementation is widely used for the treatment of knee osteoarthritis. Researchers compared the efficacy and safety of a single intra-articular injection of Hya-Joint Plus with a single injection of Synvisc-One in patients with knee osteoarthritis. The researchers noted that both were safe and effective for six months in patients with knee osteoarthritis. The literature indicates that both the single injection regimens as well as the multiple injection regimens are safe and effective. All told, the services at issue were medically indicated in this patients case. Therefore, bilateral injections of Synvisc-One were medically necessary for the treatment of this patient. Final Result: The reviewer determined that the services at issue were medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in orthopedic surgery and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

The parent of an eight-year-old male enrollee has requested weekly psychotherapy sessions with a child psychologist for treatment of the enrollees attention deficit/hyperactivity disorder. Findings:  The physician reviewer found that the submitted documentation demonstrates the medical necessity of a portion of the requested services.  Psychotherapy is a trusted intervention for children with behavioral issues, affective symptoms, anxiety, interpersonal conflict, and family discord.  Per the submitted documentation, this patient is experiencing functional impairment due to behavioral dysregulation.  Considering this patients history, primary diagnosis, and prominent symptom complex, psychotherapy is medically appropriate.  Based upon the medical records, a time-limited, problem-focused course of weekly psychotherapy sessions for a period of 12 weeks is medically indicated.  All told, a portion of the requested services is medically indicated in this clinical setting.
Appeal type: Experimental/Investigational
Decision: Overturned

A 56-year-old female enrollee has requested radiofrequency neurolysis of the sacroiliac joint for treatment of her pain. Findings:  Two physician reviewers found that in this patients case, the requested services are likely to be superior over other available treatment options.  Sacroiliac joint pain is a well-documented syndrome.  Conservative measures for treating this condition include anti-inflammatory medications, heat, and ice.  Additionally, sacroiliac joint injections may be beneficial.  Patel and colleagues conducted a randomized placebo-controlled study assessing the effectiveness of lateral branch neurotomy for chronic sacroiliac joint pain.  The study involved 51 subjects who were randomized to lateral branch neurotomy and sham groups.  The authors noted that the treatment group showed significant improvements in disability, pain, physical function, and quality of life as compared with the sham group.  Thus, the requested radiofrequency neurolysis of the sacroiliac joint is likely to be more effective than other available treatment options.
Appeal type: Experimental/Investigational
Decision: Upheld

A 60-year-old male enrollee has requested proton beam therapy for treatment of his hepatocellular carcinoma. Findings:  Two physician reviewers found that proton beam therapy is not likely to be more effective for this patient than other available options. The advantage of proton beam therapy is the precision of the radiation and control of dosage delivered to the tumor site. However, the requested therapy is not indicated in this patient as he needs palliative radiation treatment which can be done with conventional treatments such as 3D conformal or intensity modulation radiation therapy (IMRT). Moreover, the efficacy and safety of proton beam therapy for treatment of hepatocellular carcinoma has not been established as it is still being evaluated in a phase I-II trial (Bush et al). Based on the documentation submitted for review, the requested services are not likely to be more beneficial than standard medical therapy.
Appeal type: Medical Necessity
Decision: Upheld

The patient is a 36-year-old male with a history of chronic daily headaches status post head trauma two-and-a-half years ago. Numerous diagnostic tests have been performed but the etiology of the patients headaches is unclear. The patient has been tried on prophylactic agents, which have not been very successful in ameliorating the patients headaches, and triptans used as abortive agent have been of marginal success. The patient was authorized to undergo two trials of Botox injections, which occurred on 7/30/03 and 9/16/03. According to the patients provider, the first course of Botox injections resulted in pain relief for two weeks, but the second course of Botox injections resulted in no pain relief. The patient requests authorization for additional Botox injections. The Health Plan has denied the patients request on the basis that Botox injections are not medically necessary.There is insufficient evidence in the peer-reviewed literature to support Botox injections for the treatment of chronic daily headaches in this patient. Furthermore the patient already received two courses of Botox injections and only the first course of injections provided pain relief (and only for two weeks). In light of the lack of evidence supporting the Botox therapy and the patients lack of response to previous Botox injections, further Botox therapy is not medically indicated. Therefore, I have determined that the requested therapy is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.
Appeal type: Experimental/Investigational
Decision: Overturned

The parent of a male enrollee requested genetic testing for Brugada syndrome (CPT code 81281) for medical evaluation of the enrollees medical condition.  Findings:  Three physician reviewers found that Brugada syndrome is a rare autosomal dominant cardiac genetic disorder caused predominantly by SCN5A genetic mutations and resultant channelopathy.  Complications include ventricular fibrillation and sudden cardiac death in structurally normal hearts.  The treatment is implantation of a pacemaker.  The indications for genetic testing include family members following identification of the mutation.  In the case, the patients father has both a clinical and genetic diagnosis of Brugada syndrome.  Based on the current literature, it is necessary to perform appropriate genetic testing to identify the SCN5A mutation.  All told, genetic testing for Brugada syndrome was likely to have been superior over other methods of evaluating this patient.
Appeal type: Experimental/Investigational
Decision: Upheld

A 44-year-old male enrollee has requested authorization and coverage for autologous stem cell transplant via participation in a clinical trial at Northwestern Memorial Hospital for treatment of his multiple sclerosis (MS). Findings:  Two physician reviewers found that this patient has a moderately progressive course of relapsing-remitting MS. He  has failed treatment with B-interferon 16 (Betaseron). The patient has mild to moderate disability with an EDSS equal to 2.5. Multiple FDA approved therapies for the treatment of aggressive MS are available such as Novantrone and Tysabri. The patient has just begun treatment with Copaxone, and treatment failure has not been established. There are multiple interventional, mostly open label studies of autologous stem cell transplant underway. The data is promising, but the clinical improvements are limited to one to four years and long-term benefit has not been demonstrated. Autologous stem cell transplant is frequently associated with adverse events. Aggressive standard therapy is still the best approach for the treatment of relapsing-remitting MS.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Euflexxa injections x 3 in both knees. Per the medical literature, although viscosupplementation may relieve knee pain in some individuals with osteoarthritis, it is not known as to which individuals will benefit. The current evidence is limited, and guidelines from organizations such as the American Academy of Orthopedic Surgeons indicate that the evidence is not conclusive. In light of the foregoing, viscosupplementation can only be recommended in individuals with a history of lasting benefit from prior injections, and in carefully selected cases where everything else has been tried, and the options are limited.  In this case, the patient has a history of relief from prior injections of Euflexxa in both knees. The patient has tried and failed other conservative treatments, including naproxen and physical therapy without relief. Given the patients limited options and based on the current medical literature, the requested services are medically indicated. Therefore, Euflexxa injections x 3 in both knees 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.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for vision therapy services for treatment of the enrollees bilateral essential emmetropia. Findings:  The physician reviewer found that there is a lack of scientific evidence that vision therapy is of benefit for a young patient who has trouble reading but has a normal eye exam. There has been a great deal of controversy on this topic over time, but to date, there is no data to suggest that such therapy helps. There can be a multitude of reasons why a patient at this age has difficulty with reading, which may have nothing to do with the eyes if the vision and eye exam is normal. The American Academy of Ophthalmology and the American Academy of Pediatrics have both stated that they do not endorse vision therapy as a valid treatment in this clinical setting. 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 reviewer is board certified in ophthalmology 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 enrollee has requested authorization and coverage for proton beam therapy for treatment of the enrollees recurrent astrocytoma. Findings:  The physician reviewer found that review of the submitted documentation and relevant literature fails to demonstrate the medical necessity of the requested service. There is a lack of peer-reviewed literature supporting proton therapy as superior to photon therapy to health outcomes for astrocytoma. The National Comprehensive Cancer Network (NCCN) guidelines do not address proton therapy for gliomas, either as salvage therapy or upfront therapy. The documentation submitted for review lacks a dosimetric rationale for the need of proton therapy for this patient. Reirradiation with intensity-modulated ration therapy (IMRT) or other photon based techniques with cumulative doses of 100+ Gy are generally tolerated. In addition, the medical records do not adequately document that an IMRT plan would be unacceptable using quantifiable dosimetric measures. In the absence of dosimetric evidence supporting proton beam therapy, the request for proton beam therapy has not been established as medically necessary for the treatment of the patients medical condition.  Final Result: The reviewer determined that the requested service 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 radiation 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 FoundationOne genetic testing. Findings:  Two of the three physician reviewers found that FoundationOne assay is a molecular assay that explores the mutations of an individuals cancer cells. The hope is that the assay will identify a specific mutation or target which could guide the provider as to which chemotherapeutic drug would be useful. However, at this time, there is a lack of convincing evidence that the assay adds to the decision making ability or yields a result that is reliably clinically beneficial. There are a variety of non-randomized studies exploring the value of molecular profiling, none of which have been convincing as to the efficacy of such analyses.  A randomized trial did not demonstrate a significant clinical benefit from choosing therapy based on molecular targets versus by the oncologists clinical judgment. Additionally, finding a mutation does not guarantee that a treatment directed at that mutation will produce a clinically meaningful response. Therefore, FoundationOne genetic testing was not likely to have been of greater benefit than other methods of evaluating this patient. 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 reviewers 1, 2 and 3 are board certified in internal medicine with sub-specialty certification in medical oncology 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.