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

The parent of a 10-month-old female enrollee has requested occupational therapy for treatment of the enrollees Down syndrome.  Findings:  The physician reviewer found that individuals with fine motor delays secondary to Down syndrome require occupational therapy via early intervention services to facilitate continued improvement in fine motor skills acquisition and to promote arm and hand movements that lay the foundation for later developing fine motor skills. Occupational therapy helps to provide initial learning steps for feeding and dressing independently. The long-term benefit of occupational therapy is that it helps prevent compensatory movement patterns that individuals with Down syndrome are prone to developing. Occupational therapy is medically necessary for individuals with fine motor delays greater than 25%. Based upon the documentation provided, this patient does not have significant fine motor delays. Re-evaluation of fine motor and adaptive abilities should be performed in 4 months. If delays greater than 25% are noted, occupational therapy would then be considered medically necessary.
Appeal type: Medical Necessity
Decision: Upheld

A 47-year-old female enrollee has requested a power wheelchair for treatment of her chronic low back pain. Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested equipment in this patients case.  Wheelchair prescriptions are best completed using a team-oriented approach, in order to optimize the appropriateness of the device for the patients individual needs.  In this case, the patient was assessed in the community by a physical therapist and was noted to be able to ambulate in the household setting without need for an assistive device or power mobility device.  Overall, the records from the patients physicians and the specialized mobility evaluation do not support the medical necessity of a power mobility device such as a power wheelchair in this case.  All told, the requested power wheelchair is not medically indicated.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Supartz injections in the right knee. Evidence from systematic reviews and randomized controlled trials indicate that although viscosupplementation may relieve knee pain in some patients with osteoarthritis, data has not established which patients will benefit. Guidelines from the American Academy of Orthopedic Surgeons (AAOS) indicate that the data on safety and efficacy of viscosupplementation remain inconclusive. As such, the AAOS does not currently recommend viscosupplementation as standard treatment for osteoarthritis of the knees. Viscosupplementation is reserved for patients with a history of lasting benefit from prior injections and in cases where the remaining options are limited. In this case, the patient has a history of chronic right knee pain due to mild osteoarthritis. The pain is mostly anterior and has been present for several months. The patient experienced a temporary response to a corticosteroid injection into the knee and non-steroidal anti-inflammatory drugs (NSAIDs) were not adequately effective. The provider found a mild to moderate joint effusion and restriction of range of motion of the right knee on examination. An MRI scan revealed grade II chondral surface irregularity of the medial femoral condyle, bone edema of the tibial plateau, and chondral fissuring of the patella. Given the support in the medical literature, the requested Supartz injection in the right knee are medically necessary for 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 authorization and coverage for Vyvanse 50 mg for treatment of the enrollees narcolepsy. Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested medication.  Vyvanse is U.S. Food and Drug Administration (FDA) approved as a safe and effective medication for binge eating disorder and for attention deficit/hyperactivity disorder. This patients records do not document these conditions. Nuvigil does not stimulate the heart like other stimulants do, and the records do not show that she has tried this medication. Nuvigil is an FDA approved treatment for narcolepsy. There is no documentation that she has tried the long acting stimulants which are preferred medications according to her Health Plan, including Concerta, Ritalin LA and Adderall XR.  There are alternative drugs that are FDA approved for narcolepsy, including Xyrem. All told, the requested Vyvanse 50 mg is 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 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

A 62-year-old male enrollee has requested reimbursement for percutaneous hemilaminectomy for treatment of the enrollees degenerative disc disease.  Findings:  Three physician reviewers found that the patient has an approximately seven-year history of low back pain, bilateral leg pain, numbness and tingling. On neurological testing, he has some hypesthesia in the right S1 distribution, with 5/5 strength throughout in both lower extremities and normal symmetric reflexes. His lumbar magnetic resonance imaging (MRI) revealed advanced degenerative disc disease at L1-2 and L2-3, small posterior annular fissure at L3-4, mild spinal canal stenosis at L2-3 through L4-5, possible nerve root impingement on the left side on the exiting left L3 and L4 nerve roots, and possible right-sided nerve root impingement on the exiting right L5 nerve root. A lateral spine x-ray shows no instability. The records indicate the patient underwent a percutaneous hemilaminectomy. The patients request for reimbursement for the procedure has been denied by the Health Plan as investigational. In one of the most comprehensive reviews to date, Boswell and colleagues sought to develop evidence-based clinical practice guidelines for interventional techniques in the diagnosis and treatment of chronic spinal pain, utilizing all types of evidence and to apply an evidence-based approach, with broad representation by specialists from academic and clinical practices. With regard to percutaneous discectomies, the authors reported that there was limited and contradictory evidence that automated percutaneous discectomy gives poorer clinical results than alternative surgical techniques with which it has been compared. The authors concluded that the evidence is moderate for short-term and limited for long-term relief. In another review, Freeman and Mehdian reviewed the current evidence for intradiscal electrothermal therapy (IDET), percutaneous discectomy, and nucleoplasty. The authors concluded that trials of automated percutaneous discectomy suggest that clinical outcomes after treatment are at best fair and often worse when compared with microdiscectomy. Based on these two comprehensive reviews, the safety and efficacy of percutaneous discectomy have not been demonstrated. Therefore, the procedure was not likely to have been more beneficial than any available standard therapy in managing this patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned

A 47-year-old female enrollee has requested surgery consisting of procedure code 11423  excision, benign lesion, including margins (labioplasty) for treatment of her dyspareunia due to elongated labia minora. Findings:  The physician reviewer found that based on review of the available records, the patient has an abnormal enlargement/elongation of the labia minora that is causing functional impairment. As documented in the medical literature, there are functional concerns related to labial hypertrophy which can be improved with surgery. Maas and Hage noted that, enlarged or hypertrophic labia minora can be functionally or psychosocially bothersome. Local irritation, problems of personal hygiene during menses or after bowel movements, interference with sexual intercourse, and discomfort during cycling, walking, or sitting are generally accepted as indications for surgical reduction. The authors concluded that, reduction of the labia minora may improve psychosocial and physical comfort and sexuality in some women. Rouzier and colleagues reported that hypertrophy resulting from various factors can be unilateral or bilateral and that such hypertrophy can be the source of incapacitating discomfort and may lead the patient to request a surgical operation involving labioplasty. The authors also noted that no surgery-related significant complications were observed and that overall the procedures were successful. Consistent with these findings, the requested procedure code 11423  excision, benign lesion, including margins (labioplasty) is reconstructive in nature and medically necessary for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Salicylic acid 20% ointment twice weekly. Findings:  The physician reviewer found that The records document that this patient has a long history of ichthyosis vulgaris. The provider noted that the patient has been treated with Amlactin and tretinoin, which were ineffective. The provider noted that the patient has experienced adequate relief with 20% salicylic acid ointment. Fenner and Silverberg reported that, Atopic dermatitis is a common chronic pruritic inflammatory skin disorder, characterized by an abnormal skin barrier, immune dysfunction, and an altered skin microbiome. The authors noted that, Skin disorders associated with atopic dermatitis include diseases sharing similar genetic origins like ichthyosis vulgaris. There are several topical treatment options available for the treatment of patients with various ichthyoses of the skin. The mainstay of treatments are keratolytics, including ammonium lactate, urea, salicylic acid, and moisturizers. This patients records do not document adequate treatment and failure of salicylic acid 6% lotion, foam, or shampoo, which have been approved by the Health Plan and do not require compounding. The records do not support that the patients condition is unlikely to respond to treatment with 6% salicylic acid preparations to support an indication for treatment with salicylic acid 20% formulation. For these reasons, the requested salicylic acid 20% ointment twice weekly is not medically necessary for 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 dermatology 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 67-year-old male enrollee has requested for Aranesp and Neumega for treatment of his prostate cancer. Findings:  The physician reviewer found that Aranesp is a long-acting version of Procrit. Both are used to increase hemoglobin levels, particularly in patients developing chemotherapy-related anemia. It is often used if Procrit fails, even when the patient is not on chemotherapy at that specific time. Overall, it is indicated when the hemoglobin falls below 10. It appears the patient was on Procrit, but his hemoglobin remained below 9 despite this. Thus, it would be medically reasonable and indicated to attempt treatment with Aranesp. Considering that a patient with hemoglobin below 9 is likely to be symptomatic, Aranesp is medically indicated for this patient.
Appeal type: Medical Necessity
Decision: Upheld

The parent of an 11-year-old male enrollee has requested for occupational therapy utilizing sensory integration techniques once per week for treatment of the enrollees Aspergers syndrome.  Findings:  The physician reviewer found that in reviewing the progress reports, only the Quick neurological screening test II (QNST-II) was utilized to evaluate this patient. The deficits as described do not clearly relate to the goals outlined. The provider indicates that maintaining prone extension is a functional goal however the reasoning for this is unclear. Further, although following a 2-3 step command is a functional goal, the records provide no baseline, and thus no ability to evaluate the patients improvement. In addition, the provider did not relate the 2-3 step commands to an activity of daily living (ADL) in order to make it a functional goal. In review of the literature, there is a paucity of supporting documentation to validate the QNST-II as a valid tool to measure a patients progress over time.
Appeal type: Medical Necessity
Decision: Upheld

Findings:  The physician reviewer found that The patient has requested authorization and coverage for proton beam radiation therapy (high dose of 70 Gy in 28 fractions). Proton beam has unique properties compared to standard photon or x-ray beam in its ability to deposit radiation doses. The use of proton beams potentially results in fewer areas of low scattered radiation dose as fewer proton beams may be used to achieve a dose distribution similar to standard photon beams. Proton therapy is currently utilized and strongly indicated in settings where severe toxicities would result if normal tissue constraints cannot be met by photon beam. However, in the setting of early stage prostate cancer there has not been a demonstrable clinically significant improvement in either quality of life or reduction of high grade toxicities. Sheets and colleagues report that among patients with nonmetastatic prostate cancer, and  intensity-modulated radiation therapy (IMRT) compared with proton therapy was associated with less gastrointestinal morbidity. Royce and Efstathiou report that the result of data on clinical evidence for proton efficacy and toxicity derived from both large claim-based datasets and prospective patient-reported data is mixed. There is a lack of evidence demonstrating a significant difference in overall survival or normal tissue toxicities over photon beam for early stage prostate cancer. While there are ongoing prospective trials investigating the potential benefits in disease outcomes and toxicities in this setting, no definite benefit has been demonstrated for proton beam in the setting of early stage prostate cancer. In this case, the patient has appropriately been recommended a course of definitive radiation treatment for intermediate risk prostate cancer, as recommended by National Comprehensive Cancer Network (NCCN) guidelines. Given the lack of data supporting the utility of proton beam radiation for early prostate cancer, particularly for patients where the prostate and seminal vesicles rather than the comprehensive pelvic nodal chains are irradiated, the requested services are not medically indicated. Therefore, proton beam radiation therapy (high dose of 70 Gy in 28 fractions) 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.
Appeal type: Experimental/Investigational
Decision: Upheld

A female enrollee requested L4-5 artificial lumbar disc replacement with ProDisc-L for medical treatment of her L4-5 postlaminectomy syndrome and degenerative spondylosis. Findings:  Three physician reviewers found that anatomical testing documents multilevel intervertebral disc, facet joint, neural foraminal and central spinal changes that reasonably may be the source of this patients lumbosacral pain. The clinical record supports a diagnosis of complex regional pain syndrome rather than a more specific diagnosis justifying specific intervention at a single level. Consistent with these findings, the requested L4-5 level artificial disc replacement with ProDisc-L is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the genetic testing for evaluation of her cutaneous melanoma.  Findings:  Two physician reviewers found that the DecisionDx melanoma assay tests the tissue genetics of the melanoma to help stratify whether a melanoma is high risk for metastasis. The DecisionDx test has shown some impressive accuracy in thin melanomas like this patients tumor. However, there is a lack of scientific evidence permitting conclusions concerning the effect of this test on health outcomes. The test is not considered routine standard of care and is not recommended by the National Comprehensive Cancer Network (NCCN) guidelines. Overall, there is not enough published data to support its routine use. Since this test has not been demonstrated to provide a benefit more than established tests, the DecisionDx melanoma assay was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Final Result: The reviewers determined that the testing at issue was 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: Reviewers 1, 2, and 3 are board certified in dermatology and is actively practicing. The reviewers are expert sin 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 43-year-old male enrollee requested post-acute neuro/brain rehabilitation for medical treatment of his traumatic brain injury (TBI).   Findings:  The physician reviewer found that the patient has had substantial neurocognitive residuals from TBI, with impaired concentration and cognitive fatigue. He has completed acute rehab, skilled nursing facility rehabilitation, and home therapies. He has potential for further gains as noted by neuropsychological assessment. The medical literature notes long timelines for recovery after TBI, with potential for better recovery with structured rehabilitation programs. Based on the medical literature cited above and the documentation submitted for review, the requested services are medically necessary for treatment of the patients medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned

A 61-year-old male enrollee has requested the medication Gleevec (400 mg) daily for treatment of his melanoma.  Findings:  Two physician reviewers found that the patient was found to have metastases in the lung, bowel and brain. The brain metastases were treated with whole brain radiation, and he was started on a clinical trial of Gleevec to treat his other sites of metastasis. The patient was subsequently taken off the clinical trial of Gleevec. In view of the excellent response of the patients lung metastases to the Gleevec, it is now recommended that he resume treatment with this agent.Gleevec is a medication which, among other mechanisms of action, takes advantage of C-KIT mutations. These are common in gastrointestinal stromal tumors and Gleevec has been very effective in the treatment of such tumors. In general, melanomas do not often have a C-KIT mutation, but according to this patients medical records, his melanoma does. This fact was evidently the reason he was initially started on a trial of Gleevec. A small study demonstrated two complete remissions of carcinoma in patients treated with Gleevec (Carvajal and colleagues). According to the records, his non-brain metastases responded very well to the Gleevec, but his brain metastases worsened. The patient was subsequently taken off the clinical trial of Gleevec.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: A patient has requested authorization and coverage for Mavyret for eight weeks. The Health Plan has denied this request indicating that the requested medication regimen is not medically necessary for treatment of the patients chronic hepatitis C virus (HCV), genotype 1a. The submitted documentation supports the medical necessity of the requested medication regimen. The submitted documentation supports the medical necessity of the requested medication regimen. According to the most recent joint guidelines issued by two associations, all patients with chronic hepatitis C should be treated except those with limited life expectancy due to nonliver-related conditions. The guidelines recommend that all patients should be treated, regardless of fibrosis stage. The guidelines recommend that non-cirrhotic, treatment naive, genotype 1a patients should be treated with Mavyret for eight weeks. These guidelines cite data showing reduced survival with delayed treatment. For these reasons, Mavyret for eight weeks is medically necessary for this patient.Final Result: The reviewer determined that the requested medication regimen 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 internal medicine with sub-specialty certification in gastroenterology 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.