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

A 57-year-old female enrollee has requested for DRX 9000 spinal decompression for treatment of her sciatic pain. Findings:  Three physician reviewers found that non-surgical decompression systems such as the DRX 9000 are promoted as replacing traditional spinal procedures (discectomy, decompression, and fusion). However, although initial results are encouraging, there have not been studies of this treatment that control for placebo effect or spontaneous recovery in the results. At this time, DRX 9000s clinical efficacy is unproven.  Also, in this particular patient, there was no medical indication for the proposed non-surgical spinal decompression.
Appeal type: Medical Necessity
Decision: Overturned

A 47-year-old female enrollee has requested referral to a podiatrist for treatment of her bilateral chronic foot pain and pedal edema. Findings:  The physician reviewer found that disorders of the feet secondary to, or complicated by, chronic disease such as diabetes or disorders of the feet which significantly impair a patients ability to walk are indications for treatment by a podiatry specialist. Review of this patients medical documentation indicates that she has pain after walking and cannot walk more than 10 minutes without pain. It appears that these complaints suggest the presence of a disorder of the feet which significantly impairs the patients ability to walk. A podiatry referral is indicated to rule out pedal pathology as opposed to systemic pathology. For these reasons, the requested referral to a podiatrist is medically necessary to rule out a disorder of the foot which significantly impairs this patients ability to walk.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The parent of a nine-year-old female enrollee has requested authorization and coverage for speech therapy and occupational therapy once per week for treatment of the enrollees intellectual disability and chromosomal anomaly. Findings:  The physician reviewer found that the patient in this case demonstrates significant delays in fine motor, visual-motor, expressive and receptive skills as measured on standardized testing. Direct occupational and speech therapy services were recommended. Direct one-to-one intervention with a speech language therapist can be effective for all areas of language for older children with developmental language disorders, regardless of their gender, receptive language or autism status, or age. Thus, direct speech language therapy services should be available for school-aged children with developmental language disorders, including older children and adolescents with pervasive difficulties.  Consequently, there is a growing demand for rehabilitation services, beginning early, which encompass strategies of prevention, remediation and compensation to maximize a childs function in all activities. For these reasons, the requested speech therapy and occupational therapy services are medically necessary for treatment of this patients medical condition. 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 pediatrics with sub-specialty certification in neurodevelopmental behavioral pediatrics 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 50-year-old female enrollee, who has bilateral silicone breast implants, has requested authorization for a breast ultrasound.Findings:  The physician reviewer found that a Mammography is the only proven screening test for breast cancer. Breast ultrasound is currently under clinical investigation as a screening modality. The indications for breast ultrasound include further evaluation of abnormalities detected either clinically or by mammography, guidance for interventional procedures, and evaluation of problems associated with breast implants. Ultrasound is appropriate as an adjunct exam, but not in lieu of a mammogram.
Appeal type: Experimental/Investigational
Decision: Upheld

A 62-year-old male enrollee has requested minimally invasive lumbar decompression (MILD) procedure for treatment of his lumbar spinal stenosis with neurogenic claudication.  Findings:  Three physician reviewers found that there is limited peer-reviewed medical literature supporting the long-term safety and effectiveness of the requested MILD procedure. Moreover, there are no data demonstrating the superiority of the MILD procedure as compared to standard decompressive laminectomy. All told, the requested procedure is not likely to provide this patient with an improved health outcome when compared with standard therapies.
Appeal type: Experimental/Investigational
Decision: Upheld

A 59-year-old male enrollee has requested for high dose radiation (HDR) brachytherapy for treatment of his prostate cancer. Findings:  Two physician reviewers found that within the guidelines supporting intermediate risk, recommendation for patients whose life expectancy is greater than ten years includes either radical prostatectomy or radiation. Interstitial implant alone as monotherapy is not listed as a viable option. Within the section for brachytherapy, it lists either iodine or palladium seeds. High dose brachytherapy is not listed as an option. In summary, using HDR delivered in two separate surgical procedures, delivering three fractions for each (six total) would not be considered standard of care.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary:   An enrollee has requested breast tomosynthesis for evaluation of her medical condition.  Findings:  Three physician reviewers found that breast tomosynthesis was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. There is sufficient support for the services at issue in this clinical setting. The study by Skaane and colleagues concluded that The use of mammography plus tomosynthesis in a screening environment resulted in a significantly higher cancer detection rate and enabled the detection of more invasive cancers. In sum, the services at issue are strongly supported by the medical literature cited above.  Final Result: Three reviewers determined that the services at issue were 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: All three reviewers are board certified in diagnostic radiology and are 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: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for anterior Optical Coherence Tomography (OCT) testing. The Health Plan indicates that the services at issue are investigational. Therefore, the Health Plan has denied reimbursement for the services at issue.Findings:  Two out of three physician reviewers found that the OCT testing was not likely to be more beneficial for treatment of the patients medical condition than any other standard therapy. Anterior chamber OCT and other types of anterior chamber imaging have been reviewed and assessed for their usefulness by the American Academy of Ophthalmology (AAO). Although the AAO did not take a final position on the usefulness of this imaging, the Technology Assessment committee concluded that the current literature indicates that anterior segment imaging demonstrates good correlation with gonioscopy and the presence of primary angle closure (PAC). However, there have been few studies that provide level I evidence of its usefulness as a supplement to gonioscopy in the evaluation of patients at risk for primary angle closure glaucoma (PACG). There have been no appropriately powered longitudinal clinical studies demonstrating that imaging can be used to predict the future development of PAC and PACG. Because our understanding of the specific anatomic parameters that may be most useful in the diagnosis of PAC and the prospective validation of such parameters remains incomplete, the added benefit of using these devices for clinical care is not clear.  Other reviews of the current medical literature confirm that further studies are needed to clarify the anterior segment OCT findings that are useful for glaucoma management.  The standard therapy for this patient with anatomically narrow angles is comprehensive ophthalmologic examination with the addition of gonioscopy to evaluate the anterior chamber angle. Therefore, the anterior OCT performed was not likely to be more beneficial for treatment of the patients medical condition than any available standard treatment.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 ophthalmology and are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has been diagnosed with pancreatic insufficiency, cystic fibrosis (CF) and severe obstructive airway disease. The patient is managed with maximal medical therapy, which includes Pulmozyme, hypertonic nebulized saline, azithromycin, and an airway clearance device. She is currently using a Hill-ROM vest, which provides high-frequency chest wall oscillation. The patients pulmonary tests have been stable per the records provided.  The patient has requested authorization and coverage for a high frequency chest compression device (Monarch Vest System). The Health Plan has denied this request, indicating that the requested device is not medically necessary for the treatment of this patient. The patient has requested an upgraded device for airway clearance. Current literature does not indicate differences in efficacy between devices for airway clearance. Although high-frequency chest wall oscillation may be useful in adult patients, there is a lack of data indicating that it is superior to positive expiratory pressure therapy or other clearance techniques.  This patient already has a high-frequency chest wall oscillation system that she uses regularly. Her adherence is good. The records do not document a medical reason for changing devices. A review of the specifications from the U.S. Food and Drug Administration (FDA) shows a lack of significant difference between the models. Thus, the requested high frequency chest compression device (Monarch Vest System) 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 certified in internal medicine with sub-specialty certification in pulmonary disease and critical care medicine and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary:   An enrollee has requested three-dimensional breast tomosynthesis for evaluation of her medical condition.  Findings:  Two physician reviewers found that there is sufficient support for the services at issue in this clinical setting.  Breast tomosynthesis allows radiologists to separate dense glandular tissue from architectural distortion, thereby resulting in a decrease in callbacks and increase in detection of small cancers.  The medical literature supports breast tomosynthesis in this patients case.  All told, the addition of three-dimensional breast tomosynthesis was more likely to be beneficial to the patient than had the mammogram been done with the two-dimensional technique alone.  Final Result:   Two reviewers determined that the services at issue were 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:  All three reviewers are board certified in diagnostic radiology and are 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 36-year-old male enrollee has requested Norco for treatment of his pain. Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested medication in this patients case.  The medical records document multiple medical problems, including a recent myocardial infarction and chronic abdominal/groin pain.  The documentation notes that the patient has been using medical marijuana.  There is a lack of support for Norco in this clinical setting.  Reisfield and colleagues noted cannabis use is prevalent in patients prescribed chronic opioid therapy and is associated with opioid misuse.  This patient has been appropriately screened with Opioid Risk Tool (ORT), and this revealed high risk.  Per the records, there are adjunctive pain medications which have not been tried.  All told, the requested Norco is not medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld

A 57-year-old male enrollee has requested Zohydro extended release (ER) 50mg, #60 for treatment of his arachnoiditis.  Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested medication.  The current medical evidence does not support the requested medication in this clinical setting.  This patient has non-malignant chronic pain, which will often worsen or recur as a result of opioid rebound.  The current standard of care for chronic pain is treatment in a multidisciplinary practice to include physical therapy, massage therapy, cognitive behavioral therapy, and injections to help reduce pain.  Baron and McDonald reported that high-dose opiates might contribute to pain sensitization via opioid-induced hyperalgesia, decreasing patient pain threshold and potentially masking resolution of a preexisting pain condition.  High-dose opiates may also cause adverse outcomes.  Ballantyne and Mao reported that prolonged use of high-dose opiates might induce tolerance, abnormal pain sensitivity, and hormonal effects.  The aim of current guidelines is to protect patients from the adverse effects of opioid therapy.  All told, the requested Zohydro extended release (ER) 50mg, #60 is not medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Overturned

The patient is a 46-year-old woman with severe back pain. She was initially treated with medications and rest, but her pain persisted. She underwent an evaluation with a physician and it was recommended she undergo an MRI study. The MRI was performed in March 2006 and the patient has requested reimbursement for the procedure. The Health Plan has denied her request citing a lack of medical necessity for the study.The patients physician evaluated the patient and diagnosed her with sciatica. Based upon the clinical presentation and his examination of the patient, the physician determined an MRI was indicated to further investigate the cause of the patients pain and to better plan her treatment. As the patient has persistent pain that was unresponsive to conservative treatment, and has sciatica, an MRI study was medically prudent and clinically indicated. Accordingly, I have determined the MRI at issue was medically necessary for evaluation of the patients medical condition. The Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Selzentry tablets. Findings: There is a lack of evidence in current medical literature supporting the use of maraviroc as a therapeutic regimen for post-COVID symptoms. The Centers for Disease Control (CDC) states regarding the management of post-COVID conditions, Some treatments have been offered that lack evidence of efficacy or effectiveness, and could be harmful to patients. Healthcare professionals should inquire about any unprescribed medications, herbal remedies, supplements, or other treatments that patients may be taking for their post-COVID conditions. Given the lack of clinical studies on the efficacy of maraviroc in this clinical setting, the requested medication is not medically indicated. Therefore, Selzentry tablets are not medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested medication is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is board certified in internal medicine with sub-specialty certification in infectious disease 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 45-year-old male enrollee has requested Afinitor for treatment of his metastatic calcitonin secreting pancreatic neuroendocrine tumor.  Findings:  Three physician reviewers found that Afinitor is one of a relatively new class of drugs known as mTOR inhibitors, and mTOR is an enzyme that is significant in a number of pathways that appear to be important in neuroendocrine tumor growth.  Additionally, mTOR may regulate angiogenesis. Routine chemotherapy has been of limited benefit in this type of rare cancer, a metastatic neuroendocrine tumor.  Duran and colleagues studies 37 such patients and noted that although the response rate was low, 64% of patients had some degree of disease control.  Yao and colleagues also demonstrated some activity in these tumors.  In this patients case, the use of Afinitor is likely to be more beneficial than any other available treatment for this condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for botulinum toxin (Botox) for treatment of the enrollees chronic headaches. Findings:  The physician reviewer found that the medical literature supports the medical necessity for the requested medication in this clinical setting. This patient has well documented record of migraines, and has tried and failed the medication topiramate. Per the International Headache Society classification of headache disorders, chronic migraine is defined as greater than 15 headache days per month for greater than three months, headache is not attributable to another disorder, at least two characteristics of unilateral, pulsatile, moderate to severe in intensity, or aggravation by or causing avoidance of routine physical activity. Additionally, there must be one characteristic of nausea and/or vomiting, photophobia and phonophobia. Botox is a tool in the management of chronic migraine which has shown effectiveness. Significant reductions from baseline were observed for onabotulinumtoxinA for headache and migraine days, cumulative hours of headache on headache days and frequency of moderate/severe headache days, which in turn reduced the burden of illness in adults with disabling chronic migraine. Concluded that onabotulinumtoxinA is effective for prophylaxis of headache in adults with chronic migraine. Repeated onabotulinumtoxinA treatments were safe and well tolerated.  As a result of these studies, Botox has been approved by the U.S. Food and Drug Administration for use in prophylactic management in chronic migraine. In addition to Botox, the only prophylactic medication that has been shown to be effective is topiramate in the management of chronic migraine. Considering the reported trial and failure of topiramate, Botox would be the most appropriate next step in the management of this patient for chronic migraine. Therefore, in this patients case, botulinum toxin (Botox) is medically necessary for treatment of this patients medical condition.  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 neurology 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: Urgent Care
Decision: Upheld

A 27-year-old female enrollee has requested emergency services for the treatment of her abscess and cellulitis in her hip. Findings:  The physician reviewer found that when this patient presented to the Emergency Department with a complaint of hip pain and cellulitis, she did not exhibit any signs of systemic infection and had no known co-morbidities. She had been on a course of medication as an outpatient and the infection had not responded to it. The patient was admitted with a diagnosis of abscess, but there is no documentation of abscess. There is no record of any incision and drainage. The patient remained afebrile while in the hospital. Her infection was 6 cm x 6 cm, which is small in size. The patient did not require inpatient therapy for this infection.  Her condition could have been managed as an outpatient with 24-hours intravenous antibiotics and discharge on the appropriate oral regimen.  She also remained medically stable when she began to exhibit signs of opioid withdrawal. There is insufficient documentation in the medical record to support this admission at an inpatient level of care. Furthermore, a prudent layperson with an average knowledge of medicine and health would not have thought their health was in serious jeopardy had he or she not sought immediate medical attention for his or her complaint of redness and swelling in the hip.