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

A 46-year-old male enrollee has requested Avastin intravitreal injections for treatment of his retinopathy. Findings:  Two physician reviewers found that treatment with intravitreal bevacizumab for this patient is not more efficacious than standard therapy. There is no medical evidence from appropriate scientific studies that this patients disease would be helped by the treatment at issue.  In this case, the patient has cystoid macular edema likely related to either postoperative inflammation or Coats disease or a combination of the two.  Although bevacizumab has a proven role in treating other exudative retinal diseases, there are only case reports of beneficial treatment in the setting of Coats disease (Goel, et al.; Bohm and Uhlig). Further, there is stronger evidence that bevacizumab does not improve post-cataract surgery cystoid macular edema (Spitzer, et al.). There is also reason to be cautious when using bevacizumab in Coats disease as it may cause additional problems (Ramasubramanian and Shields). The available medical evidence suggests that bevacizumab use for Coats disease or post-cataract cystoid macular edema is not likely to be superior to standard treatment alternatives.
Appeal type: Medical Necessity
Decision: Overturned

A 20-year-old male enrollee has requested for autologous chondrocyte implantation in the knee for treatment of the enrollees osteochondritis dissecans.  Findings:  The physician reviewer found that ACI is standard of care for exactly these types of patients and supported by level 1 evidence. There is sufficient literature demonstrating that ACI has proven benefit for individuals who have been refractory to other treatments and the patient is an appropriate candidate for the procedure.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary:  An enrollee has requested Harvoni for treatment of her hepatitis C virus.  Findings:  The physician reviewer found that according to the most recent guidelines issued state that all patients with chronic hepatitis C should be treated except those with limited life expectancy due to non-liver-related conditions. This applies regardless of fibrosis stage or viral load. Per guidelines, treatment-naive non-cirrhotic genotype 1 patients should be treated with Harvoni for 12 weeks or with Viekira Pak and ribavirin for 12 weeks. These guideline recommendations are based on multiple randomized clinical trials. Because treatment of hepatitis C is medically necessary based on medical literature, and no alternative treatment has been approved at this time, the requested treatment with Harvoni is supported as medically necessary for the treatment of this patients hepatitis C infection. 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 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.
Appeal type: Medical Necessity
Decision: Overturned

The enrollee is requesting authorization and coverage for coverage for a CPAP device; humidifier, heated, used with positive airway pressure device and full night in-lab sleep study. The enrollee has obstructive sleep apnea, with symptoms of excessive daytime fatigue and somnolence. Comorbid conditions include depression, anxiety, and acid reflux. Her Epworth sleepiness scale score is normal and her Stop-Bang score is normal. The enrollee has been obese most of her adult life and has gained over 100 pounds in the last 10 years. She underwent a home sleep study which revealed obstructive, central, and mixed apneas. There were 106 hypopneas and 131 total respiratory disturbance events. The apnea-hypopnea index was 14.4 per hour. According to the literature, there are two categories of enrollees that should be considered for obstructive sleep apnea treatment. Symptomatic enrollees should be treated, regardless of severity, even if the obstructive sleep apnea is mild; as noted by an apnea-hypoapnea index of five to 15. Asymptomatic enrollees should be offered treatment when the apnea-hypoapnea index is greater than 15; even if asymptomatic, due to the risks of cardiovascular morbidity and mortality. Based on the American Academy of Sleep Medicine guidelines, there is no clinical rationale to offer both auto-continuous positive airway pressure at home and in-laboratory positive airway pressure titration to initiate positive airway pressure therapy. Either one is recommended. If the enrollee tolerates auto-continuous positive airway pressure with relief of symptoms, efficacy of treatment can be assessed by data download. If the enrollee is intolerant of auto-continuous positive airway pressure, then a titration can be offered at a later date.Final Result: The reviewer determined that the requested service is partially medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The physician reviewer is board certified in sleep 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 similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement and prospective authorization and coverage for oxycodone hydrochloride 15 mg tablets (#180 tablets per 30 day supply) already purchased, and oxycodone hydrochloride 15 mg tablet every four hours (#180 tablets per 30 day supply).Findings:  The physician reviewer found that (CDC) guidelines state that, Nonpharmacologic therapy and nonopioid pharmacologic therapy are preferred for chronic pain. Clinicians should consider opioid therapy only if expected benefits for both pain and function are anticipated to outweigh risks to the patient . In addition, the American Society of Interventional Pain Physicians (ASIPP) advise that provider establish medical necessity by establishing appropriate physical diagnosis and psychological diagnosis if available . ASIPP recommends a pain management consultation to assist non-pain physicians, if high-dose opioid therapy is utilized. In this case, the patient has chronic low back pain. The patient required a recent visit to the emergency department for breathing related difficulties and he required a blood transfusion. The provider noted that the patient was being treated with oxycodone-acetaminophen 10-325 mg oral tablets every four hours prior to the provider increasing the dosage to oxycodone 15 mg every four hours. However, there is a lack of documentation by the provider of a change in the patients pain patterns or pain intensity scores to merit an increase in dosage. Based on the available documentation, the risk-to-benefit ratio for this patient does not support an increased dose of oxycodone. Moreover, the provider did not document attainable goals for pain improvement or function with use of the increased dosage. All told, the oxycodone hydrochloride 15 mg tablets (#180 tablets per 30 day supply) already purchased, and oxycodone hydrochloride 15 mg tablet every four hours (#180 tablets per 30 day supply) was not and is not medically necessary for treatment of this patient. Final Result: The reviewer determined that the medication dosage at issue was not and 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 management and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested authorization and coverage for 104 hours of applied behavioral analysis (ABA) therapy, 10 hours per month of supervision and 4 hours per month of home care training for treatment of the enrollees autism spectrum disorder.  Findings:  The physician reviewer found that the request for 104 hours ABA therapy, 10 hours per month of supervision and four hours per month of home care training are medically necessary for treatment of the patients medical condition. Mohammadzaheri and colleagues found that ABA is effective in helping with maladaptive behaviors in school age children with autism. In this case, the patient presents with maladaptive deficits that include aggression, destruction of property and elopement. Moreover, the best medical practice dictates that if the patient responds to ABA therapy, then continuation with services should be implemented. In this case, there is documentation supporting that the patient has benefited from ABA services. 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 neurology with special qualification in child neurology 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

The parent of a nine-year-old male enrollee has requested reimbursement for speech therapy provided over a 32-month period for treatment of the enrollees auditory processing disorder.  Findings:  The physician reviewer found that the initial speech and language therapy evaluation involved the use of informal assessment measurements. Speech and language evaluation typically includes formal testing with a measurable language tool to determine a patients deficit or quantified delay. Formal central auditory processing testing can be done by an audiologist, which will identify overall deficits (Carey, et al.). The initial audiology or ENT evaluation was not included for review in this case. Otitis media in the first year of life may slow auditory cortical structure compensatory changes however this typically disappears by four years of age (Maruthy, et al.). The study by Maruthy and colleagues examined auditory processing disorders in children and evidenced some support that the use of speech and language interventions has improved auditory function in children with auditory processing disorders. However, the current body of evidence-based research is limited and does not provide a clear treatment model for speech and language pathologists who treat children with auditory processing disorders. All told, the current data available in the peer reviewed medical literature does not support the efficacy of speech therapy in this patients case. As such, the speech therapy services at issue were not medically necessary for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary:   An enrollee has requested the Bruno valet seat for treatment of his Angelman syndrome and cerebral palsy.  The physician reviewer found that the request for a Bruno valet seat is not medically necessary as it does not meet the definition of durable medical equipment per the Centers for Medicare and Medicaid Services (CMS). This definition states that the equipment is appropriate for use in the home but may be transported to other locations to allow the patient to complete instrumental activities of daily living which are more complex tasks required for independent living. The requested item will not be used in the home and therefore is not medically necessary for this patient to complete instrumental activities of daily living. Final Result: The reviewer determined that the requested device 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 physical medicine and rehabilitation with sub-specialty certification in neuromuscular 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

The enrollee requested reimbursement for Oncotype DX Prostate Cancer Assay. The enrollee has prostate cancer and the biopsy report showed prostatic adenocarcinoma. The Oncotype DX Prostate Cancer Assay determined the enrollees genomic prostate score, indicating unfavorable intermediate risk, and his prostate specific antigen level was 5.2 nanograms/milliliter. The enrollees physician ordered the test to identify the specific risk of aggressive prostate cancer. Professional society guidelines note that men with low or favorable intermediate disease may consider the use of Decipher, Oncotype DX Prostate, Prolaris, or ProMark during initial risk analysis. This testing is recommended for very low, low risk, and favorable intermediate risk prostate cancer individuals with at least 10 years life expectancy who have not received treatment for prostate cancer and who are candidates for active surveillance or definitive therapy. Medical records indicate the enrollee meets these criteria and would, therefore, be considered appropriate.  The testing has very recently become more widely used. The latest version of the professional society guidelines now recommends the use of the requested testing in this enrollee's clinical scenario.Final Result: Two of the three reviewers determined that the requested services are likely to be more beneficial than any available standard therapy for treatment of the enrollees medical condition. Credentials/Qualifications: Three reviewers are board certified in urology 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: Overturned

An enrollee has requested authorization and coverage for an Intracept procedure (intraosseous basivertebral nerve ablation). Current medical literature supports the use of the requested services in this clinical setting. Truumees and colleagues reported significant improvement in pain and function in patients with vertebrogenic-related chronic low back pain treated with minimally invasive radio frequency ablation of the basivertebral nerve. Markman and colleagues noted an association between functional benefit from basivertebral nerve ablation and reduced opioid use. In this case, the requested service is an outpatient procedure that would allow the patient to avoid more invasive alternatives such as fusion and or artificial disc replacement while maintaining the structural integrity of the spine and allow to patient to avoid or reduce opioid use. Therefore, an Intracept procedure (intraosseous basivertebral nerve ablation) is likely to be more beneficial for treatment of the patients condition than any available standard therapy.
Appeal type: Medical Necessity
Decision: Upheld

A 29-year-old female, who is pregnant, has requested delivery at a hospital with a Neonatal Intensive Care Unit (NICU).   Findings:  The physician reviewer found that her prenatal course reveals several visits to evaluate her for premature labor, and terbutaline, a tocolytic, at an unknown point during the pregnancy. However, there is no evidence that she has had a diagnosis of premature labor. Now at term, she is not at risk for prematurity. In addition, a review of the prenatal record reveals there is no evidence that the pregnancy is high-risk in nature.
Appeal type: Experimental/Investigational
Decision: Upheld

A 62-year-old male enrollee has requested authorization and coverage for bilateral radiofrequency treatment for treatment of the enrollees sesamoidal issues and a plantar ligament tear of the metatarsophalangeal joint complex. Findings:  Three physician reviewers found that the patient has pain at the left second metatarsophalangeal joint. The patient has documented sesamoiditis at the left first metatarsophalangeal joint. An MRI revealed no changes in the left second metatarsophalangeal joint. The patients provider indicated a possible tear of the left second metatarsophalangeal joint, however, this is not evident from the documentation that was provided. The patients provider has recommended bilateral radiofrequency treatment. The Health Plan has denied this request as investigational. There is a paucity of literature examining the safety and efficacy of the proposed radiofrequency treatment. Although this patient has failed conservative treatment for his foot pain, the requested procedure has not been proven to be more beneficial for treatment of this patients medical condition than other available standard treatments. Thus, the requested procedure remains investigational in regards to the foot. In sum, the Health Plans denial was appropriate and should be upheld.
Appeal type: Experimental/Investigational
Decision: Upheld

A thirty year-old female with locally advanced colon cancer is requesting coverage for bevacizumab and trastuzumab.  Reviewers Findings:  The three reviewing physicians found that the addition of bevacizumab in the adjuvant setting is not yet proven to be effective or within the standard of care. Furthermore, there is no evidence supporting the addition of trastuzumab in any setting for colon cancer and its addition to this particular regimen is entirely unproven.  The reviewing physicians found that the Health Plan denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested septoplasty and submucous resection inferior turbinate for treatment of his medical condition.  Findings:  The physician reviewer found that septoplasty and submucous resection inferior turbinate are medically necessary for treatment of the patients medical condition. The medical literature reports that nasal airflow was measured before and after septoplasty due to nasal obstruction because of septal deviation. The medical literature included 536 participants and all participants showed objective evidence that septal surgery improves nasal patency. Moreover, a medical study conducted a prospective observational outcomes multicenter study to assess disease-specific quality of life outcomes after nasal septoplasty in adults with nasal obstruction. The authors concluded that in patients with septal deformity, nasal septoplasty results in significant improvement in disease-specific quality of life, high patient satisfaction, and decreased medication use. According to the documentation submitted for review, the patient presents with persistent and symptomatic nasal airway obstruction which has remained refractory to medical management. The patient has been properly managed with a trial of topical medications and allergy immunotherapy. The patient did have some improvement of symptoms of nasal blockage with the use of one topical medication, but due to the risks of development of rhinitis medicamentosa, that medication was discontinued. Although this patients symptoms improved with the use of a topical medication, the use of topical vasoconstrictor medications that contain preservatives have a deleterious effect on the nasal mucosa. Most providers utilize this technique to determine whether the patient may benefit from surgical procedures, and remind patients to use the medication only for a trial period. In this case, the patient has physical evidence of both deviation of the septum and inferior turbinate hypertrophy which failed medical therapy. As such, the requested services are medically necessary for treatment of the patients nasal obstruction.  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 otolaryngology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement and prospective authorization and coverage for lumbar/sacral interlaminar epidural injections. The American Society of Interventional Pain Physicians (ASIPP) guidelines on epidural interventions in the management of chronic spinal pain note, Based on relevant, high-quality fluoroscopically guided epidural injections, with or without steroids, and results of previous systematic reviews, the evidence is Level I for caudal epidural injections, lumbar interlaminar epidural injections, lumbar transforaminal epidural injections, and cervical interlaminar epidural injections with strong recommendation for long-term effectiveness. In a systemic review of the efficacy and safety of transforaminal epidural steroid injections, researchers report, There is Level I evidence for the use of transforaminal injections for radicular pain from disc herniations. In this case, the patient has chronic lumbar radiculopathy with radiation into the lower extremities. MRI showed degenerative disc changes leading to neuroforaminal stenosis. The patient has tried and failed conservative care using medication management, physical therapy, and a home exercise program. The patient reported pain relief with a previous epidural steroid injection. Given that current medical literature supports the efficacy of lumbar epidural steroid injections in reducing radicular pain, the services at issue are medically indicated. Therefore, lumbar/sacral interlaminar epidural injections were and are medically necessary for the treatment of this patient. Final Result: The reviewer determined that the services at issue were and are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in anesthesiology with sub-specialty certification in pain medicine and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.