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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for cervical artificial disc replacement. Findings:  The physician reviewer found that evidence based medical guidelines and peer reviewed literature do not support the use of an artificial disc replacement adjacent to a prior anterior cervical discectomy and fusion and in the setting of multilevel degenerative disc disease. This patient presents with persistent neck pain radiating into the right upper extremity with constant numbness and tingling into the fingers. He has reported decreased right hand dexterity and functional difficulty in activities of daily living and recreational pursuits. This patient is status post mature fusion at the C5-6 and C6-7 levels. Clinical examination findings have evidenced sensory and motor loss and reflex changes consistent with imaging evidence of degenerative disc disease, severe at C4-5 and mild at C3-4, with severe neuroforaminal stenosis and cord contact at the C4-5 and C3-4 levels. Evidence of reasonable and/or comprehensive nonoperative treatment protocol trial and failure has been submitted. However, there is a lack of long term large volume studies to support the superior efficacy of this procedure in the presence of apparent multilevel degenerative disc disease. Therefore, cervical artificial disc replacement is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Final Result: The reviewers determined that 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. Credentials/Qualifications: Physician reviewers 1, 2, & 3 are board certified in orthopedic surgery 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: An enrollee has requested authorization and coverage for OxyContin for treatment of the enrollee, who has been diagnosed with ulcerative colitis. Findings: The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested medication in this clinical setting. It is not medically reasonable to treat chronic abdominal pain from ulcerative colitis with chronic opiate therapy.  There are other non-opiate medications and regional blocks that have proven efficacy for chronic abdominal pain. Long and colleagues identified a number of risk factors involved in the use of chronic opiates in inflammatory bowel disease.  The authors concluded that opiates are a poor choice for pain control in these patients.  Similarly, Docherty and colleagues have identified several alternative approaches to managing abdominal pain and noted the risks of chronic opiate use in these patients. In sum, chronic opiate use is a poor choice for pain management in this patients case.  All told, OxyContin 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 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.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for New Ride Custom Cushion The submitted documentation fails to demonstrate the medical necessity of the requested equipment. There is an increased risk of low back pain for individuals who spend prolonged periods of time in wheelchairs. Weight shift behaviors in individuals who spend prolonged periods of time in wheelchairs are generally reduced and irregular.  This can result in poor posture, such as sacral sitting, with posterior pelvic tilt and lumbar kyphosis. In this case, the back of the patients wheelchair has been adjusted to provide better lumbar support. Some posterior pelvic tilt remains. This can be addressed by better posture  or adjusting frame angles.  The latter would be a more stable correction than a custom-fit cushion that may help initially, but will deform over time. The records do not document that these alternative interventions have been attempted and/or ruled out. Therefore, the requested New Ride Custom Cushion  is not medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested equipment 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 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: An enrollee has requested authorization and coverage for incontinence supplies (adult diapers). This patients medical records document the presence of urinary incontinence, both stress and functional. Thus, the use of certain incontinence supplies including adult diapers is medically necessary to manage the patients urinary incontinence. There is no report of any skin changes or complications related to incontinence. Thus, additional items would be for convenience. All told, the incontinence supplies (adult diapers) are medically necessary for treatment of this patients medical condition. Final Result: The reviewer determined that the requested supplies 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 urology 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 authorization and coverage for percutaneous implantation of neurostimulator electrode array, epidural procedure. Researchers completed a study of 12 patients who underwent high cervical lead placement of a spinal cord stimulator in the epidural space. The authors found that, When compared with the baseline, the mean reduction achieved in the postoperative average numeric rating scale was 4 points, accounting for a 57.1% pain reduction. Researchers analyzed spinal cord stimulation therapy for cervical and facial pain. The authors concluded that this spinal cord stimulation therapy is safe and effective for head and face pain indications including trigeminal neuralgia. This patients records document severe lifestyle limiting trigeminal neuralgia due to multiple sclerosis. The patient has been treated with most noninvasive and invasive treatment modalities including medication management and peripheral nerve blocks without significant durable relief. The patient has also undergone more invasive surgical therapy with balloon compression. The patients providers have recommended high cervical spinal cord stimulation in the epidural space to treat her trigeminal neuralgia at the cervicomedullary junction. Given the refractory nature of this patients trigeminal neuralgia secondary to multiple sclerosis, the requested percutaneous implantation of neurostimulator electrode array, epidural procedure is 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 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: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for HP Acthar Gel 80 Units subcutaneously twice per week. The review of the multiple non-biological and non-steroid related therapies found to be effective for the treatment of non-infectious uveitis and did not include Acthar Gel. Similarly, a stepwise approach in terms of immunosuppressive therapies, which did not include Acthar gel. The records provided for review do not document that this patient has active synovitis on current therapy, which includes methotrexate 20 mg weekly. Current medical literature supports methotrexate dosing up to 25 mg weekly and data suggests that the methotrexate might be better absorbed parenterally than orally. The patients ocular disease has not responded to high dose steroids up to 40 mg daily, thus her condition is not likely to respond to Acthar Gel, which also has corticotrophin-related efficacy. The combined toxicity of high dose steroids in addition to Acthar Gel is concerning in terms of risk for glaucoma, hypertension, osteoporosis, osteonecrosis and infection. The patient has not exhausted standard maintenance therapies such as cyclosporine, Imuran, and tacrolimus. The patient is also not receiving maximal dose methotrexate and the CellCept dosing is not stated. This patient requires a standing maintenance therapy and Acthar Gel is not meant to be this type of therapy but rather a bridge therapy until other medications have started to work. It is not an appropriate medical option in this case and has not been adequately studied in patients with bilateral panuveitis in rheumatoid arthritis when the arthritis component of the condition is stable. Based on the current peer-reviewed medical literature, HP Acthar Gel 80 Units subcutaneously twice per week 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 internal medicine with subspecialty certification in rheumatology 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 45-year-old female enrollee has requested Oncotype DX tumor assay for evaluation of her breast cancer.  Findings:  Two physician reviewers found that Oncotype DX is a clinically validated assay of the breast tumors expression of 21 genes. This tumor assay quantifies the likelihood of distant recurrence in a select group of women. The assay has been validated for ER/PR positive, HER-2/neu positive or negative and node negative patients. The patient in this instance is a premenopausal woman with early stage breast cancer. Favorable characteristics include small size, ER/PR positive, and HER-2/neu negative. Complicating the issue is the micrometastasis. In this setting, the Oncotype assay offered no additional information. It is well understood that for staging considerations, the patient may be considered node negative. However, recent data presented at the SABC in December 2006 suggests that micrometastasis may be more significant than originally thought. The issue of micrometastasis has not been studied prospectively, and as such the assay remains investigational in that setting.
Appeal type: Medical Necessity
Decision: Overturned

A 58-year-old female enrollee requested authorization and coverage of the medication Remicade. The Health Plan  denied the request indicating that the requested medication is not medically necessary for treatment of the enrollees rheumatoid arthritis. One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer overturned the Health Plans denial on the basis that the requested medication is medically necessary.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for hydrocodone (Norco). The Centers for Disease Control and Prevention (CDC) guidelines for prescribing opioids for chronic pain state that providers should consider opioid therapy only if expected benefits for both pain and function are anticipated to outweigh risks to the patient. The CDC states that opioid benefit should be clinically meaningful and defines this as clinically meaningful improvement has been defined as a 30% improvement in scores for both pain and function. The Federation of State Medical Boards (FSMB) guidelines recommend opioid therapy for chronic pain that is not cancer-relatedonly when non-opioid and non-pharmacological options have not been effective, and maintain opioid dosage as low as possible and continue only if clear and objective outcomes are being met. In this case, the patient has chronic pain that has been treated with Norco as well as Flexeril and Robaxin. The patient also takes Soma, which is a muscle relaxer. The providers notes document concern over the concurrent use of Norco and Soma due to the risks of dependence, sedation, and possible overdose. Based on the CDC guidelines, the patients pain scores demonstrate less than 30% improvement in pain, which is not clinically meaningful. All told, the requested hydrocodone (Norco) 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 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: Experimental/Investigational
Decision: Overturned

A 60-year-old male enrollee has requested intensity modulated radiation therapy for treatment of his recurrent prostate cancer.  Findings:  Three physician reviewers found that this patient developed recurrent prostate cancer in prostate fossa after radical prostatectomy. After radical prostatectomy, the bowels drop into the pelvis and if high dose radiotherapy is used, the bowels may be exposed to doses above the level tolerated by the bowels. In order to avoid toxicity to the bowels and rectum, IMRT can deliver more conformal high dose to concave and convex targets and avoid excessive radiation therapy to critical organs at risk. Pinkawa and colleagues demonstrated that post-prostatectomy radiation therapy yields a lower dose to the bladder with improved non-target tissue and bladder volume sparing. Teh and colleagues found that the treatment related morbidity profile was favorable with IMRT, and this delivery method allowed dose escalation, leading to better tumor control. A study showed that acute and late rectal toxicities seem to be significantly reduced compared with what has been observed with conventional 3D-conformal radiation therapy techniques (Zelefsky and colleagues). Short-term PSA control rates appear to be comparable to those achieved with 3D-conformal radiation therapy at similar dose levels. Based on this favorable risk-to-benefit ratio, IMRT has become a well-accepted mode of conformal treatment delivery for localized prostate cancer. A study confirmed the safety of IMRT for clinically localized prostate cancer (Zelefsky and colleagues). The incidence of rectal bleeding at 8 years was less than 2%, and the authors concluded that excellent long-term tumor control outcomes were achieved.
Appeal type: Medical Necessity
Decision: Overturned

The parents of a 13-year-old male enrollee have requested group therapy for treatment of his Aspergers syndrome.  Findings:  The physician reviewer found that Aspergers syndrome, often considered a mild autistic spectrum disorder, is typically diagnosed based on a core group of behaviors. The presence of these behaviors indicate deficits in communication and social interaction. There are three recognized treatment options for this syndrome: (1) communication and social skills training; (2) cognitive behavioral therapy; and (3) medication, as needed, for co-morbid diagnoses including anxiety, depression and hyperactivity. For most individuals with AS, an extremely important aspect of their treatment strategy is an opportunity to enhance their communication and social correspondence. Social skills therapy enables the individual to cope better with social and interpersonal expectations. The patient is likely to benefit from this therapy.
Appeal type: Experimental/Investigational
Decision: Upheld

A 62-year-old female enrollee has requested Neurostar transcranial magnetic stimulation (TMS) therapy for treatment of her major depressive disorder, single episode, severe.  Findings:  Three physician reviewers found that peer-reviewed literature addressing the topic of antidepressant treatment consists of varying reports on the efficacy, especially long-term, and potential side effect profile along with case selection for benefit of repetitive transcranial magnetic stimulation.  Gross and colleagues provided an updated meta-analysis of studies related to this treatment modality.  The authors concluded that although results are suggestive that repetitive transcranial magnetic stimulation has significant antidepressant effects, larger multicenter studies are necessary to confirm these trends. Lam and colleagues concluded that for patients with treatment-resistant depression, transcranial magnetic stimulation appears to provide significant benefits in short-term treatment studies. However, the relatively low response and remission rates, the short durations of treatment, and the relative lack of systematic follow-up studies suggest that further studies are needed before repetitive transcranial magnetic stimulation can be considered as a first-line monotherapy treatment for treatment-resistant depression.  All told, in this clinical scenario, the superior efficacy of the requested Neurostar transcranial magnetic stimulation therapy has not been established.
Appeal type: Medical Necessity
Decision: Upheld

The patient has requested authorization and coverage for a sleep study (CPT codes 95810 and 95811). The American Academy of Sleep Medicine (AASM) guidelines established clinical practice recommendations for the diagnosis of OSA in adults. The AASM recommends that polysomnography, or home sleep apnea testing with a technically adequate device, be used for the diagnosis of OSA in uncomplicated adult patients presenting with signs and symptoms that indicate an increased risk of moderate to severe OSA. The AASM noted that, if a single home sleep apnea test is negative, inconclusive, or technically inadequate, polysomnography be performed for the diagnosis of OSA. This patient has a high probability for OSA, given his history of snoring, difficulty sleeping, daytime sleepiness and obesity. The AASM supports use of a home sleep study in this clinical setting. If the home sleep study is non-diagnostic, then the patient might require further evaluation with a lab-attended sleep study. The physician reviewer found that  the patient can proceed with a home sleep study. Therefore, the requested sleep study (CPT codes 95810 and 95811) is not medically necessary for evaluation of this patient. Final Result: The reviewer determined that the requested services are not medically necessary for evaluation of the patients medical condition. Therefore, the Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested the LifeVest wearable cardiovascular defibrillator for treatment of his medical condition.  Findings:  The physician reviewer found that  based on the records provided there is potential for improvement in left ventricular ejection fraction with time and medical therapy and there was no indication for immediate placement of a defibrillator such as documented sustained or inducible ventricular tachycardia, syncope or aborted sudden cardiac arrest.  Placement of a prophylactic defibrillator is not recommended until a period of time of more than 90 days where continued left ventricular dysfunction (ejection fraction  35%) is documented to persist in spite of appropriate treatment.  A prophylactic defibrillator (wearable or implantable) before this time has not been demonstrated to improve outcome.  Studies assessing efficacy of prophylactic defibrillators early after diagnosis of myocardial infarction and reduced ejection fraction  35% before ventricular function has had a chance to recover have not demonstrated improved outcome. Also, studies evaluating wearable defibrillators during periods of increased risk where criteria for implantable defibrillators have not yet been met are largely comprised of registry data without adequate control groups. At this time prophylactic wearable external defibrillator would be indicated only if accepted criteria for an implantable defibrillator were met and an implantable defibrillator could not be placed, needed to be significantly delayed (due to infection, for example) or required explantation. Therefore, the medical necessity for the wearable defibrillator provided in this circumstance has not been demonstrated by existing scientific literature at this time.   Final Result: The reviewer determined that the services at issue were not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.  Credentials/Qualifications: The reviewer is board certified in internal medicine and cardiovascular 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.