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

A 44-year-old male enrollee has requested an X-STOP procedure for the treatment of his low back pain. Findings:  Two physician reviewers found that this patient has had a 10-year history of low back pain, with radiation to the left lower extremity. On examination, the provider described limited motion and L3 region tenderness, but no loss of strength, sensation or reflexes. A magnetic resonance imaging (MRI) was reported as showing mild degenerative changes throughout, especially at L3-4, with bulging at L3-4. The diagnosis of neurogenic claudication was made and a myelogram was suggested. A myelogram report indicates mild ventral impression at L3-4 and slight impression at L4-5. There was also evidence of bony changes with compression deformity of the superior endplate of the L4 body, both related to the moderate spinal stenosis noted at L3-4. The patients provider has recommended an X-STOP procedure. The issue in this case is whether the requested X-STOP procedure is likely to be more beneficial for the patient than any standard therapy.  Siddiqui and colleagues note that the use of the X-STOP has shown some success in the early years of its use, but Verhoof and colleagues contend that there is evidence of high failure rates in certain situations. The study by Epstein notes that although several studies are in progress, there is currently a lack of data regarding the long-term results of the procedure. Until the findings of these, and other, studies are available, the efficacy of the procedure remains unproven. As such, there is inadequate data to support the contention that X-STOP is likely to result in a superior clinical outcome for this patient.
Appeal type: Medical Necessity
Decision: Overturned

A 23-year-old female enrollee has requested an eating disorder partial hospital program for the treatment of her behavioral health problems. Findings:  The physician reviewer found that this patient has an eating disorder characterized by binging, restrictive patterns, purging, excessive exercise and intrusive thinking about her body and eating. She carries diagnoses of co-occurring diagnoses (PTSD, severe depression and marijuana dependence) and her psychiatric symptoms include panic attacks as well as suicidal ideation with a history of attempts in the past. Her acceptance of treatment seems adequate (with frequent statements about her trying to pursue healthier choices) although throughout the documentation she continues to manifest symptoms of her eating disorder (with episodes of excessive exercise, restrictive and binging eating patterns and preoccupation with her body). The psychiatrist also states that the patient was eating meals outside of the program in an effort to catch up to the controlled meals she received in the partial hospitalization program (PHP). When this information is measured against published standards regarding in what environment treatment for an eating disorder should occur, the patient meets the criteria for a PHP level of care.
Appeal type: Experimental/Investigational
Decision: Upheld

Findings:  The physician reviewer found that An enrollee has requested reimbursement for Zoll LifeVest provided for three months. This patient sustained an episode of ventricular fibrillation due to acute myocardial ischemia that required resuscitation. Although the patient did sustain a ventricular fibrillation arrest, this was due to myocardial ischemia, which was corrected with surgical revascularization. Post-operatively, the patient was provided a LifeVest wearable cardioverter defibrillator for three months to prevent against sudden cardiac death (SCD). Per the current American Heart Association (AHA) recommendations, the LifeVest wearable defibrillator is a class IIB indication for patients following recent coronary revascularization (Piccini, et al.). The AHA further noted that although wearable cardioverter defibrillator therapy is increasingly used in clinical practice, at present, only preliminary data exist on the actual effectiveness of this intervention in improving survival among patients who are at risk for SCD. Accordingly, the Zoll LifeVest provided for three months was not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Findings: Three of the three physician reviewers found the Zoll LifeVest provided for three months was 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 services at issue were not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld.
Appeal type: Experimental/Investigational
Decision: Overturned

A 50-year-old female enrollee has requested intravitreal injection of Avastin for the treatment of her diabetic macular edema. Findings:  Two physician reviewers found that the scientific literature reveals adequate evidence supporting the efficacy of anti-VEGF medications in the treatment of diabetic macular edema and proliferative diabetic retinopathy. A study by Kook, et al. concluded that even in cases with chronic diffuse ischemic diabetic macular edema, a long-term decrease of central retinal thickness can be observed following repeated intravitreal injections of bevacizumab [Avastin]. In these patients, mean decrease in retinal thickness is aligned with a gain in mean VA [visual acuity]. Further, Centers for Medicare and Medicaid Service (CMS) criteria includes both macular edema and proliferative diabetic retinopathy as appropriate indications for treatment with Avastin. Given this patients diagnoses, intravitreal injection of Avastin is likely to be more effective for her condition than alternative treatment options.
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 tomosynthesis is a technique that was developed several years ago as a problem solving adjunct to routine mammography. Applying the same basic concept as computed tomography (CT) scanning, the logic is that by separating the various layers of breast tissue, providers can better detect abnormalities. Tomosynthesis is rapidly becoming a standard tool in well equipped, respected radiology practices. The problem of evaluating dense breasts or suspicious calcifications is a huge issue for providers. Whenever there are multiple superimposed structures in any organ, imaging that organ with multiple sections (similar to a CT scan), makes sense when those superimposed structures can be better separated and delineated. Tomosynthesis is better than breast sonography as a screening tool, and should lessen the requests for breast magnetic resonance imaging (MRI). For these reasons, breast tomosynthesis was likely to be more beneficial for evaluation of this patients medical condition than any available standard therapy.  Final Result: Three reviewers determined that the diagnostic procedure at issue was 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: Overturned

A 32-year-old male enrollee has requested for surgery performed, preoperative studies and postoperative studies for evaluation and treatment of his brain tumor. Findings:  The physician reviewer found that this was not available in the usual neurosurgical setting or standard neurosurgical operating room. An intraoperative MRI scan was utilized. If abnormal tissue had been found, further surgery would have been performed. If an MRI was performed postoperatively and a lesion was identified, the patient would have to be returned for another operation to secure gross total excision of his lesion.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for a tertiary level of care esophagogastroduodenoscopy procedure. Sheikh and colleagues note that duodenal neuroendocrine tumors are rare. Dewan and colleagues report that most cases of neuroendocrine carcinoma in the duodenum show rapid progression of the disease. Sato and colleagues explain that therapy for duodenal neuroendocrine tumors is based on tumor size, location, histological grade, stage, and tumor type. Herring and colleagues report that the academic tertiary cancer center that this patient is considering has a longstanding and specialized expertise in the diagnosis and treatment of neuroendocrine tumors. In this case, the patient had a rare neuroendocrine tumor with positive lymph node metastasis and is status post total pancreatectomy. In this clinical setting, given the potential for a remaining tumor in the duodenum and the difficulty in finding and identifying such a tumor, requiring the expertise of an endoscopist and pathologist, the requested service is medically indicated. Therefore, a tertiary level of care esophagogastroduodenoscopy procedure is medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested service 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: Urgent Care
Decision: Overturned

A 26-year-old female enrollee has requested x-ray services on an urgent basis for treatment of her medical condition. Findings:  The physician reviewer found that at issue in this case is whether a reasonable and prudent layperson in the patients circumstances would believe he or she was experiencing an urgent medical condition. Urgently needed services are those services necessary to prevent serious deterioration of the health of an enrollee, resulting from an unforeseen illness, injury or complication of an existing condition, including pregnancy, for which treatment cannot be delayed until the enrollee returns to the Plans service area. A foreign body in the gastrointestinal system can be potentially life threatening. A layperson who is contacted by a physician with a questionable foreign body in the stomach and advised to have a follow-up x-ray would reasonably comply with obtaining a follow-up study as soon as possible.  It is recommended that anyone with a suspected or known foreign body in the stomach or small intestine have a plain radiograph to confirm the presence of a foreign body and define its size in order to plan for safe management. If a foreign body had actually been present, it could have traveled to the small intestine and caused perforation with peritonitis. Therefore, the patients decision to pursue follow-up of the suspected foreign body prior to returning to the Plans service area was appropriate and consistent with the response a prudent layperson would have in these circumstances.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for liver transplant. Based on the available documentation, this patients  clinical status, with worsening decompensated cirrhosis complicated by hepatorenal syndrome, meets the American Association for the Study of Liver Disease (AASLD) guidelines for evaluation for liver transplantation (Martin, et al.). However, these guidelines also state that alcohol abuse is a contraindication to liver transplant. The United Network for Organ Sharing (UNOS) established a six-month alcohol abstinence requirement, which allows for assessment for improvement of liver disease (Marroni, et al.). In this case, the patient has documented significant recent alcohol abuse established by the presence of alcoholic hepatitis. There is a lack of research to support that patients may succeed if granted an exception to the six-month alcohol abstinence guidelines in this clinical setting (Daswani, et al.; Leon, et al.; Kodali, et al.). As six months of alcohol abstinence has not been established in this patients case, a liver transplantation listing is not supported by current guidelines and medical literature. For these reasons, the requested liver transplant is not medically necessary for 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. Credentials/Qualifications: The reviewer is board certified in internal medicine with subspecialty 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 parent of a two-year-old male enrollee has requested weekly speech therapy services, occupational therapy services and physical therapy services for treatment of the enrollees multiple medical conditions.  Findings:  The physician reviewer found that the patient does have an anatomical abnormality, as he has been diagnosed with hypotonia. Additionally, he has a diagnosis of translocation which is a defined pathological dysfunction. Further, there is evidence of a physical abnormality, as the patient requires lower extremity bracing. Thus, the patients diagnoses and functional impairments render him an appropriate candidate for the requested speech, physical and occupational therapy. While there is a lack of peer-reviewed data studying the effects of therapeutic interventions for individuals with this patients diagnoses, a trial of weekly speech, physical, and occupational therapy is medically reasonable and appropriate in this case. The patient should be reassessed in each of these areas in six months to assess his progress and determine the need for continued services.
Appeal type: Medical Necessity
Decision: Overturned

A 53-year-old female has requested transcranial magnetic stimulation (TMS) therapy for treatment of her major depressive disorder.  Findings:  The physician reviewer found that the submitted documentation demonstrates the medical necessity of the requested services.  TMS therapy has been endorsed by the American Psychiatric Association in its current clinical practice guideline for the treatment of patients with depression.  In this patients case, the records document an acute major depressive episode that is causing significant morbidity and functional impairment.  She has pursued other standard therapies used to combat depression.  Per the current peer-reviewed medical literature, TMS therapy is medically indicated to treat this patients depressive symptoms.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patients parent has requested reimbursement for residential treatment facility (RTC) services. The Child and Adolescent Level of Care Utilization System (CALOCUS) provides a framework for determining the clinically appropriate level of care for a child or adolescent in mental health treatment. With regard to risk of harm, the records support a score of 4. The patient had a serious risk of harm, due to a history of self-harm, two past suicide attempts, and prior suicidal ideation. In terms of functional status, the records support a score of 3. The documentation noted the patient was able to focus in school and complete her work. With regard to comorbidity, the records support a score of 4. The patient had significant comorbidity, due to the presence of hypothyroidism.In terms of level of stress of the recovery environment, the records support a score of 2. The patient had a mildly stressful environment due to the patients concerns about parental expectations.With regard to level of support of the recovery environment, the records support a score of 1 due to parental engagement in family therapy. In terms of resiliency and treatment history, the records support a score of 4. The patient had poor resiliency and/or response to treatment as previous outpatient treatment did not ameliorate anxiety, depressive symptoms and suicidal ideation. The patient continued to struggle with cognitive rigidity and emotional lability. With regard to treatment acceptance and engagement, the records support a score of 2. The patient was able to engage in treatment and demonstrated continued growth in challenging herself to be authentic. Thus, the patient has a total score of 20 which is consistent with Level 4 services. However, the score of 4 for risk of harm and comorbidity support a higher level of care which is Level 5- medically monitored residential care. Therefore, RTC services were medically necessary for treatment of this patient.Final Result: The reviewer determined that the services at issue were 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 psychiatry with sub-specialty certification in child and adolescent psychiatry 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:  A patient has requested authorization and coverage for brand name Zoloft.Findings: The use of a SSRI, serotonin-norepinephrine reuptake inhibitor (SNRI), tricyclic antidepressant (TCA), benzodiazepine, or CBT as the initial treatment for panic disorder is strongly supported by demonstrated efficacy in numerous randomized controlled trials. If a patients first unsuccessful treatment is with an SSRI or an SNRI, a recommended approach is to switch to a different SSRI or SNRI. If the patients symptoms do not respond to two different SSRIs or SNRIs, switching to or adding other classes of medication that have demonstrated efficacy for panic disorder may be considered. In this case, the patient has not had full remission of symptoms even on the generic sertraline. Additionally, the records do not document that the patient has tried an SNRI, which would likely be more beneficial than a brand name SSRI at higher than approved doses. Additionally, studies have shown that the generic and brand name sertraline (Zoloft) are bioequivalent so there would not be any further gains made for this patient at the brand name of this medication compared to the generic. For these reasons, brand name Zoloft is not medically necessary for treatment of this patient. The requested medication is not in accordance with the generally accepted standards of mental health and substance use disorder care. The requested medication is not clinically appropriate in terms of type, frequency, extent, site, and duration. The requested medication is primarily for the economic benefit of the health care service plan and subscribers or for the convenience of the patient, treating physician, or other health care provider.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 psychiatry 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 29-year-old male enrollee has requested riboflavin-mediated crosslinking treatment and posterior segment intraocular lens for treatment of his keratoconus and myopia.  Findings:  Two physician reviewers found that this patient has been diagnosed with keratoconus and has experienced a progressive loss of vision. With his vision declining beyond what could be adequately corrected with contact lenses, the patient underwent placement of Intacs in the right eye. This is an appropriate first step in an attempt to stabilize the progressive degeneration.  However, the patients vision continued to decline despite Intacs. The classic treatment of keratoconus-induced visual decline is a corneal transplant.  This procedure involves a risk for significant complications. In this patients case, the riboflavin-mediated crosslinking treatment was likely to be more beneficial as compared to other available treatments. Riboflavin-mediated crosslinking involves less risk than the alternative. The purpose of the Visian intraocular lens is to compensate for a patients refractive error and thus minimize the need for external optical correction (spectacles or contact lenses).  The submitted documentation fails to establish the medical indication for the posterior segment intraocular lens. Therefore, although riboflavin-mediated crosslinking treatment was likely to be of greater benefit than other treatment options, the posterior segment intraocular lens was not likely to be superior over other available alternatives.
Appeal type: Experimental/Investigational
Decision: Upheld

A 64-year-old female enrollee has requested electrical stimulation therapy for the treatment of her low back pain. Findings:  Two physician reviewers found that the efficacy of ESTIM has not been definitively proven for use in chronic low back pain. A review of the literature reveals that there is inadequate data demonstrating that the use of ESTIM results in improved clinical outcomes for this patients diagnosis. Thus, ESTIM is of questionable benefit for this patients condition. Furthermore, the submitted clinical records do not include evidence that the therapy was administered with a clear objective, defined functional goals, or a method to monitor response to the intervention. All told, there is inadequate evidence in both the scientific literature and the submitted clinical documentation to support the use of ESTIM in this case.
Appeal type: Experimental/Investigational
Decision: Upheld

A 68-year-old male enrollee requested gene testing (CPT codes 81201, 81210, 81211, 81235, 81270, 81275, 81292, 81295, 81298 and 81321) for medical evaluation of his adenoid cystic carcinoma.  Findings:  Two physician reviewers found that in this patients case, these services were not likely to have been more effective than other available options.  The Foundation One assay seeks to find a genomic alteration that could be used as a target for a particular drug.  Generally, the focus has been on the analysis of breast, colon and lung cancers, with a small sampling of adenoid cystic carcinomas.  At this time, the National Comprehensive Cancer Network guidelines have not recommended this testing.  There is a lack of data demonstrating that use of this assay can improve survival in patients with metastatic cancer.