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

The patient is a 37-year-old female status post cardiac arrest on 1/24/04. The patient experienced documented ventricular fibrillation in the field and was cool and cyanotic. Down time until initiation of CPR was estimated at six to seven minutes. She experienced hypotension and required advanced cardiac life support, defibrillation (three times) and multiple medications. Post arrest the patient remained in a coma and was noted to have seizures, myoclonus, and cerebral edema. The patient evolved gradually to a coma vigil state. Recent neurologic exams of the patient show open eyes, tracking eye movements, stimulus-induced myoclonus, but otherwise non-responsive. Imaging studies demonstrate the development of cortical ribbon abnormalities, especially in occipital areas bilaterally. EEG studies show diffuse cortical dysfunction. Seizure activity was not detected. Neurological diagnoses include anoxic ischemic encephalopathy; stimulus sensitive myoclonus; and persistent vegetative state. A recent medication trial with Amantadine did not appear to result in any significant change.A request has been made for median nerve stimulation therapy. The Health Plan has denied authorization for the requested therapy on the basis that it is not medically necessary for treatment of the patients condition.Upon review of the sparse medical literature relevant to this case, there are no type 1 studies demonstrating efficacy of median nerve stimulation therapy. In the few studies that have been reported the number of subjects involved is insufficient to draw conclusions that would be considered statistically significant. While not specific for median nerve stimulation therapy in coma, the Cochrane analysis in 2002 fails to identify effectiveness of multi-sensory stimulation programs in the literature. Many of the cases cited in anecdotal reports are related to coma from hemorrhage or trauma. Only a minority of cases involve anoxic encephalopathy. Thus, there is no reliable scientific literature on which to base treatment with median nerve stimulation in coma or persistent vegetative states. More research is needed to confirm or deny its efficacy. In addition, the patients sensitivity to stimuli producing myoclonus is likely a relative contraindication to its use as well.Based upon the information set forth above, I have determined that the requested therapy is not medically necessary for the treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld

A 59-year-old female enrollee has requested 8-10 catheters per month for treatment of her urinary incontinence. Findings:  The physician reviewer found that when a patient is unable to void due to neurogenic bladder, the patient either self catheterizes or wears an indwelling Foley catheter. The preferred method of self catheterization is the intermittent clean technique, which does not require sterile equipment each time. The catheters are reusable. This technique is associated with a low rate of infection and is well accepted in the urologic community. The average life of a catheter is one week. Patients who use this technique usually carry a small kit when they are out in public and wash and reuse the catheters. While this patient reports that she needs additional catheters for travel purposes, the requested number of catheters per month are not necessary from a medical standpoint. The quantity authorized by the Health Plan (4 catheters per month) is appropriate and consistent with Medicare guidelines.
Appeal type: Medical Necessity
Decision: Overturned

A 54-year-old male enrollee has requested for Lyrica 75 mg and a spinal cord stimulator trial implant for treatment of his reflex sympathetic dystrophy. Findings:  The physician reviewer found that Lyrica is medically appropriate for patients with reflex sympathetic dystrophy that is refractory to standard medications. Thus, the use of Lyrica is medically justified as the next appropriate step to help manage the patients pain. However, there is insufficient evidence at this time supporting the efficacy of a spinal cord stimulator trial implant in this clinical setting. No significant trials have been performed, and there is only anecdotal information regarding the possible efficacy of a spinal cord stimulator implant in this group of patients.
Appeal type: Experimental/Investigational
Decision: Upheld

Physician 1: The patient is a 40-year-old male with degenerative disc disease. He has had a positive discogram at L5-S1. His provider is recommending artificial disc replacement with the Charite disc. The Health Plan considers this procedure experimental. The Health Plan is correct that the proposed procedure is considered experimental. There is no evidence to support disc replacement surgery for this patient. The proposed procedure is still under investigation and is not considered standard of care. The long-term success rate and safety profile remain unknown. Because there is no evidence supporting the long-term safety and efficacy of the proposed procedure, I have determined the requested procedure is 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. Physician 2: The patient is a 40-year-old male with degenerative disc disease. He is seeking authorization for artificial disc replacement utilizing the Charite disc. The Health Plan has denied this request because it considers artificial disc replacement experimental. The current clinical evidence regarding the Charite III disc has allowed for Food and Drug Administration (FDA) approval that it is not inferior compared to fusion. Similarly, current studies appear to indicate it is not worse than fusion. Additional claims of efficacy are based upon a small number of short-term, non-randomized studies. A 300-patient FDA regulated investigational device exemption trial with long-term follow-up is underway. Without the results of this trial the Charite III disc replacement remains experimental. Furthermore, it is not established as superior to fusion. Therefore, I have determined the requested procedure is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Plans denial should be upheld. Physician 3: The patient is a 40-year-old male with degenerative disc disease at L5-S1. The patient has undergone a number of treatments including traction, chiropractic, epidural injections, and massage therapy without success. He is requesting authorization for artificial disc replacement. The Health Plan has denied authorization for the requested procedure. The proposed procedure is experimental without established long-term efficacy. The best published results reveal outcomes equivalent to fusion. However, the majority of studies show a failure rate of 35%. Furthermore, the long-term safety profile is unknown. In addition, there are other treatments available. For these reasons I have determined the requested procedure is 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.
Appeal type: Medical Necessity
Decision: Upheld

A 55-year-old female enrollee has requested Soma 350 mg two pills three times per day, Percocet 10-325 mg two pills two times per day, and removal of a spinal cyst for treatment of her diagnosis of spinal cyst status post two spinal surgeries.  Findings:  The physician reviewer found that based on the available medical records, this patient has post-operative seroma posterior to the spinal canal, not connected to the spinal canal and not compressing the dura. There is no evidence of a change in size of the seroma on magnetic resonance imaging (MRI) scans and the spinal canal is wide open. Although there is a small amount of an enhancing epidural scar at one level, additional surgery is not indicated or likely to improve her condition as the scar has not been determined to be the cause of her symptoms. Given the patients continued need for narcotic pain medications and muscle relaxants, she should be planned to undergo detoxification with assistance from pain management. All told, the requested Soma 350 mg two pills three times per day, Percocet 10-325 mg two pills two times per day, and removal of a spinal cyst are not supported as medically necessary for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld

A 62-year-old female enrollee has requested epidural steroid injections for treatment of her low back pain. Findings:  The physician reviewer found that the submitted documentation and relevant literature fails to demonstrate the medical necessity of the requested services. According to the American Academy of Neurology, epidural steroid injections may result in some improvement in radicular lumbosacral pain when assessed between 2 and 6 weeks following the injection. DePalma and colleagues critically reviewed trials of the utility of epidural steroid injections to treat lumbosacral radiculopathy. In this case, there was no documentation of a comprehensive physical examination of the lumbar spine. The medical records indicate that the patient did not demonstrate any focal neurologic deficits. In addition, there were no imaging studies or electrodiagnostic reports submitted for review to demonstrate a diagnosis of radiculopathy. Based on the clinical information received for this review, the requested epidural steroid injections are not medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for magnetic resonance imaging (MRI). Findings:  The physician reviewer found that there is currently considerable debate about how best to screen for prostate cancer.  The fact that this patients PSA level is stable does not rule out prostate cancer. Prostate cancer is notoriously slow growing, and the lack of progressive elevation does not exclude a malignancy. In general, PSA levels under 4 are not considered abnormal, whereas levels over 4 are regarded as suspicious.  This patient has a PSA level in the 14 to 16 range and his PSA has been persistently elevated. There are many options for therapy (radical prostatectomy, observation and monitoring, brachytherapy, external bean radiation), with no single therapy clearly advantageous, and all therapies having significant risks of complication. Accordingly, MRI has become a common imaging procedure to better evaluate the prostate. The American College of Radiology (ACR) provides recommendations to help guide clinicians as to the most efficient and efficacious means to evaluate various clinical entities. In their publication concerning patients who are clinically suspected with prostate cancer and who has had a prior negative transrectal ultrasonography-guided biopsy, MRI is felt to be the most appropriate study to perform. They found that MRI is a useful adjunct for tumor localization in biopsy negative patients, as in this patients case. A study concurs with the ACR assessment, MRUS fusion biopsy provides improved detection of PCa in men with prior negative biopsies and elevated PSA values. Most cancers found were clinically significant.  This patient fits the ACR criteria and the medical literature. All told, MRI is medically necessary for the evaluation of this patients medical condition. Final Result: The reviewer determined that the requested services are medically necessary for evaluation of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in diagnostic radiology 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 44-year-old female enrollee has requested for magnetic resonance angiography (MRA) of the head and neck for evaluation of her temporal lobe headaches.  Findings:  The physician reviewer found that there was no history to suggest aneurysm, arteriovenous malformation (AVM), dissection, or other abnormality that required MRA. The MRA studies were ordered without consideration of MRI findings, and a carotid Doppler test was not performed prior to the neck MRA. There are no documented findings that suggest a need for MRA of the head or neck, as MRA is not the standard of care for headache evaluation.
Appeal type: Medical Necessity
Decision: Upheld

A fifty-eight year-old male who is status post right total hip replacement is requesting reimbursement for a fully-electric hospital bed.  Reviewers Findings:  The reviewing physician found that there is insufficient evidence to conclude a fully-electric hospital bed was necessary for this patient.  The reviewing physician found that the Health Plan denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The enrollee has requested authorization and coverage for Acthar 80 units/ml.Madan and colleagues conducted a retrospective case series to examine Acthar gel (adrenocorticotropic hormone, ACTH) in patients with varied-etiology nephrotic syndrome (NS). They concluded that Acthar gel may meet an important treatment need in patients with treatment-resistant NS in response to first-line therapies, patients unable to tolerate first-line therapies, and in patients with advanced disease. Chakraborty and colleagues performed a systematic review to analyze the published literature on ACTH therapy in various NS etiologies, including IgA nephropathy (IgAN), to determine its efficacy. They concluded that ACTH showed benefits in proteinuria reduction across all etiologies of NS. In this case, IgA nephropathy has a significant long-term risk for progressive renal failure in this young patient who presented with nephrotic range proteinuria. IgA nephropathy can be refractory to therapy. Records indicate that the patient has been stable on Acthar 80 units/ml. Stopping or putting on alternate therapy under these circumstances has the potential for causing irreversible long term renal damage and increasing the long-term risk that the patient might need dialysis or a transplant. Accordingly, the requested Acthar 80 units/ml is medically necessary to treat the patients medical condition.Final Result: The reviewer determined that the requested medication is medically necessary to treat the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in internal medicine, with subspecialty certification in nephrology, 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 50-year-old male enrollee has requested reimbursement for the craniotomy for treatment of his grade IV glioblastoma multiforme (GBM). Findings:  The physician reviewer found that GBM is a disease with a poor prognosis. While chemotherapy prolongs patient survival, the gains associated with chemotherapy have been found to be modest. Surgical resection is typically performed as a front line treatment, followed by temozolomide treatment concomitant with radiation therapy. Upon recurrence, the standard sequence of treatment, as feasible, is surgery, radiation, temozolomide and combinations with Avastin, as was suggested in this care. Re-operation is a medically reasonable approach, especially for those with good performance status and young age (Ammirati, et al. and Harsh, et al.). The National Cancer Institutes Physician Data Query indicates that patients with recurrent brain tumors should be considered candidates for clinical trials when they have exhausted standard therapy (www.cancer.gov.).
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for occipital nerve ablation for treatment of her chronic headache. Findings:  Two physician reviewers found that he patient is a 53-year-old female with a history of chronic headaches, vertigo, and prior cervical fusion from C5-6 and C6-7. The patient reported that she has previously been diagnosed with occipital neuralgia, with severe headaches encompassing the whole head, with sensitivity and vomiting. The symptoms had persisted despite C5-7 fusion. Occipital decompression had reportedly helped left sided pain but then caused right sided pain. She described severe headache, nausea, and vertigo. The patient reported that she has been hospitalized for pain control. The patient reported that occipital nerve blocks, while hospitalized, were transiently beneficial. She has had a variety of medications including Imitrex and Lyrica. An examination described non-tender cervical spine, pain on palpation of the muscles in the cervical spine, numbness down the medial sides of the hands, and ataxia. She has had bilateral occipital decompression, but continues to have severe headaches with light sensitivity. Facet injection with Botox was reportedly partially beneficial. There are no records to indicate that she has been evaluated by a neurologic headache specialist. The patient has requested coverage for occipital nerve ablation. The Health Plan denied the requested services as investigational for the treatment of this patient. There is very little evidence based literature to support the long term efficacy of occipital nerve ablation in this clinical setting. This patient has reportedly had severe headaches with nausea and light sensitivity, and she has been prescribed Imitrex. These features support a diagnosis of chronic migraine. Botox injections is the treatment option approved by the U.S. Food and Drug Administration for treatment of chronic migraine. There is a need for high-quality randomized controlled trials supporting the long term efficacy of occipital nerve ablation for chronic headaches.  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: Reviewers 1, 2, and 3 are board certified in neurology 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 44-year-old female enrollee has requested autologous platelet-rich plasma injections for treatment of her plantar fasciitis and Achilles tendinosis. Findings:  Two physician reviewers found that although platelet-rich plasma injections have been used in a variety of applications with reports of success and enhanced wound healing, many of the reports of its clinical use are anecdotal. Few studies have been performed that include controls to characterize the role of the platelet-rich plasma (Eppley and colleagues). The encouraging anecdotal reports have led to increased interest in the service, with the recognition of the need for randomized, controlled clinical studies (Sanchez and colleagues) and caution has been recommended until high-level clinical evidence of the efficacy of platelet-rich plasma is available (Hall and colleagues). The use of this technique for the treatment of chronic Achilles tendinopathy has not been shown to be more effective than saline injections (de Vos and colleagues), and its use in plantar fasciitis remains under investigation (see ClinicalTrials.gov).
Appeal type: Experimental/Investigational
Decision: Upheld

A 75-year-old male enrollee has requested authorization and coverage for Natrecor therapy for treatment of his congestive heart failure and cardiorenal syndrome.  Findings:  Two physician reviewers found that the submitted records do not document severe heart failure symptoms or findings. Such evidence is a pre-requisite for treatment with Natrecor, particularly since there is no evidence that Natrecor infusions improve outcome measures other than symptoms. The records provided do not document the cause of the patients renal failure. There is also no objective documentation of benefit after Natrecor. Nor is there evidence the patient has been tried on standard medications that are proven to be beneficial in advanced renal and cardiac failure.
Appeal type: Medical Necessity
Decision: Upheld

A 52-year-old female enrollee has requested a referral to a specialist who treats Barre-Lieou Syndrome for treatment of her neck pain, dizziness, tinnitus and weakness in legs and arms.  Findings:  The physician reviewer found that all board certified neurologists are trained and certified to appropriately diagnose and manage symptoms such as these.  A board certified neurologist can effectively evaluate this patient. There is no documented information in this record that suggests that an outside referral is required or that such a referral would be beneficial.  In this patients case, a referral to a specialist who specifically treats Barre-Lieou Syndrome is not medically indicated.  The submitted documentation does not demonstrate that the requested services are medically necessary. All told, the requested referral is not medically indicated for this patient.
Appeal type: Medical Necessity
Decision: Overturned

A 42-year-old male enrollee requested Procrit for medical treatment of his sickle cell disease.  Findings:  The physician reviewer found that the submitted documentation establishes the medical necessity of the requested medication. This patient has had serious life-threatening complications from his SCD. He has been appropriately treated with hydroxyurea, the only drug that has been proven in randomized trials to reduce the rate of complications such as pain crises and acute chest syndrome (Lanzkron, et al; Brawley, et al; Halsey and Roberts). Unfortunately, hydroxyurea also induces cytopenias and can exacerbate the anemia that is already present in many SCD patients. It is in this context that erythropoietin therapy has been investigated. There are studies that show a benefit when used in combination with hydroxyurea in increasing the hemoglobin F concentration (el-Hazmi, et al; Rodgers, et al). The National Institutes of Health reviewed their use of erythropoietin and they concurred with these previously published studies (Little, et al). In sum, there is sufficient medical evidence to justify its use in this patient. Therefore, the medical necessity of the requested medication has been established in this patients case.