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 an implantable peripheral nerve stimulation device. While there are many studies evaluating the use of peripheral nerve stimulation, only a handful address peripheral nerve stimulation for the treatment of low back pain. Studies performed by Gilmore and colleagues as well as by Cohen and colleagues appear to be based on the same cohort of nine subjects. Issues with these two studies include a limited number of subjects, the lack of a control group for comparison of efficacy, and numerous conflicts of interest including two of the authors having consulted for the manufacturer and two authors being employees of the manufacturer. Despite a thorough literature review, there is a lack of studies in current medical literature with a control group demonstrating improvement in axial low back pain with the requested device when compared with standard treatment options. Therefore, an implantable peripheral nerve stimulation device is not likely to be more beneficial for treatment of the patients condition than any available standard therapy.Findings:  Two of the three physician reviewers found the requested implantable peripheral nerve stimulation device 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 device 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 and 3 are board certified in anesthesiology with sub-specialty certification in pain medicine and are actively practicing. Physician reviewer 2 is board certified in physical medicine and rehabilitation with sub-specialty certification in pain medicine and is 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: Overturned

The patient is a 42-year-old male who underwent right knee anterior cruciate ligament reconstruction in May 2005. Initially post-operatively the patient was placed in a long brace, which was later replaced with a shorter ACL brace. The Health Plan has denied coverage for the ACL brace.The brace in question was designed for repeated use for treatment of an injury or to improve functioning or deterioration of a malformed body part. In addition, the brace in question was designed to allow for protected motion of the patients knee while keeping the knee stable. Given this patients history, the brace in question was necessary to protect the patients knee while allowing for necessary functioning of the knee. Therefore, I have determined the equipment at issue was medically necessary for treatment of the patients condition. The Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Upheld

A 64-year-old female has requested a bariatric consultation and Lap-Band surgery for treatment of her obesity.  Findings:  The physician reviewer found that in this patients case, the submitted documentation does not establish the medical necessity of the requested services.  The medical records indicate that the patient is 58 and weighed 197 pounds on the said date.  This equates to a body mass index (BMI) of 30. Based upon the National Institutes of Health guidelines, weight loss surgery is not indicated for patients with a BMI less than 35. Patients such as this patient are likely to achieve adequate results from conservative weight loss measures. In this patient population, the benefits of weight loss surgery are outweighed by the potential risks posed by surgical intervention. As such, the requested surgery is not medically indicated for this patient with a BMI of 30.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for gene panel testing to screen for fragile X for evaluation of the enrollee's pregnancy.Findings: The physician reviewer found that Fragile X is the most common cause of inherited intellectual disabilities. Some authors suggest routinely offering fragile X carrier screening to all women because of the high prevalence of the condition and the high sensitivity of the screening test. While there is different language used in published guidelines for testing for fragile X carrier status, a common recommendation is that testing should be offered when there is a family history of undiagnosed intellectual disability.  In this case, the patient reports two paternal family members with autism.  Since the cause of autism is often uncertain, the patient meets the low threshold for offering testing. Thus, the requested gene panel testing to screen for fragile X is likely to be superior over other methods of evaluating this patient.Final Result: All three physician reviewers determined that the requested services are 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 physician reviewers are board certified in obstetrics and gynecology and are actively practicing. The reviewer is an 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

A 23-year-old female enrollee has requested a Real Time System Continuous Glucose Monitor Minimed Pump for the treatment of her type I diabetes. Findings:  Two physician reviewers found that the requested device would ensure proper insulin delivery with real-time glucose monitoring. The reasons this device would benefit this patient is that it would control her widely fluctuating glucose values versus using a syringe and vial system. This MiniMed CGMS would enhance her glucose control and delay or arrest future complications of her type I diabetes mellitus. An OmniPod pump using a finger stick glucose method is inferior to the requested device, and the patient is experiencing failure with her current system.
Appeal type: Experimental/Investigational
Decision: Overturned

A 35-year-old female enrollee has requested for a continuous glucose monitoring system (CGMS) for treatment of her diabetes. Findings:  Three physician reviewers found that the CGMS is FDA approved and the benefits for patients with DM and problems with hypoglycemia have been validated in many studies. The scientific evidence is clear that this device will help to lower the time spent in hypoglycemic range. In addition, the Hgb A1c is often improved while using a glucose sensor. As such, there is evidence that this device improves net health outcomes.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary:   An enrollee has requested magnetic stimulation (TMS) therapy for treatment of his behavioral health condition.  Findings:  The physician reviewer found that TMS therapy was medically necessary for treatment of the patients medical condition. There is sufficient support in the peer-reviewed medical literature for the services at issue in this clinical setting. TMS is a non-invasive brain stimulating procedure utilized in the treatment of major depressive disorder. The American Psychiatric Association (APA) has endorsed TMS for the acute phase treatment of major depressive disorder after failure of at least one antidepressant trial. In this case, the patient had pursued, but not exhausted other standard therapies used to treat depression. However, considering the medical records, endorsement from the APA and the expanding peer-reviewed literature base, TMS represented a safe, appropriate treatment consistent with good medical practice that was reasonably expected to improve the patients condition and prevent a more serious episode of illness. As such, the services at issue were medically necessary for treatment of the patients medical condition.  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 and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

A 44-year-old female enrollee has requested for Avastin (bevacizumab) for treatment of her breast cancer. Findings:  The physician reviewer found that Avastin is one of a new class of drugs that act generally as adjuncts to chemotherapy as inhibitors to tumor angiogenesis. It has been approved for use in metastatic breast cancer, when given as first-line therapy with Taxol. Even as first-line therapy, its benefits were not dramatic in that it did not improved overall survival of patients, but did improve their progression-free survival.
Appeal type: Medical Necessity
Decision: Upheld

A 70-year-old male has requested three to four weeks of acute rehabilitation services for treatment of his medical condition status post cerebrovascular accident.   Findings:  The physician reviewer found that based on review of the available records, the patient had a severe stroke and has aphasia. He will need an extensive period of recovery. The best predictor of stroke outcome is severity of stroke. The intensity of stroke rehabilitation has little impact on outcome (Zhu, et al). It may hasten the time to recovery but will have little to no impact on the outcome at six months (Kwakkel, et al). Care provided in a subacute unit is expected to achieve the same outcome. Overall, the patient is not expected to make full recovery and will remain with significant disability. Discharge to the community will result in similar outcomes as continued stay in the facility, but his needs may exceed what will work for him in the community (Langhorne, et al). The additional services provided in inpatient acute rehabilitation cannot be justified based on the patients needs and expected duration of therapy. All told, the additional services will not improve his outcome or increase his ability to return to the community (Belda-Lois, et al).
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary:  An enrollee has requested authorization and coverage for Entresto 24-26mg. Findings:  The physician reviewer found that The use of sacubitril-valsartan (Entresto) is usually reserved for patients who already take spironolactone and who require additional medication for blood pressure control, and particularly patients with a left ventricular ejection fraction (LVEF) less than 55 percent. Also, in this case, the severity of heart failure symptoms and New York Heart Association (NYHA) class is not clear. It is not clear if his symptoms were improving or worsening with therapy prior to starting Entresto. Additionally, a recent trial by Solomon and colleagues showed no difference in outcomes in patients treated with valsartan alone or sacubitril-valsartan. Solomon and colleagues concluded that, Sacubitril-valsartan did not result in a significantly lower rate of total hospitalizations for heart failure and death from cardiovascular causes among patients with heart failure and an ejection fraction of 45% or higher. The adverse effects, such as hypotension, compared with other antihypertensive agents seem to outweigh the potential small benefits of sacubitril-valsartan. Thus, Entresto 24-26mg is not medically necessary for the treatment of the patients medical condition.Final Result: The reviewer determined that the requested medication is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is board certified in internal medicine with sub-specialty certification in 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.
Appeal type: Medical Necessity
Decision: Upheld

A male enrollee requested spine surgery (CPT codes 22633, lumbar spine fusion combined, CPT 22634, spine fusion extra segment and CPT 22842, insert spine fixation device) with a 3 day hospital stay for medical treatment of his degenerative disc disease and foraminal stenosis.   Findings:  The physician reviewer found that this patient presents with chronic back pain but he has no symptoms or signs of a lumbar radiculopathy with matching motor, sensory, and reflex findings (Tarulli and Raynor). In addition, the patient has persistent hematuria and significant weight loss of unknown etiology, which should be addressed prior to considering major spinal surgery. Further, the patient does not have a lumbar radiculopathy or myelopathy, his imaging is not consistent with his clinical condition, and he does not have spinal stenosis with spondylolisthesis and neurogenic claudication or a progressive neurologic condition. Moreover, he has not had a psychological evaluation nor participated in cognitive rehabilitation sessions. All told, the requested spine surgery (CPT codes 22633, lumbar spine fusion combined, CPT 22634, spine fusion extra segment and CPT 22842, insert spine fixation device) with a 3 day hospital is not medically necessary for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Standard ReviewThe patient has requested authorization and coverage for Vemlidy 25 mg once per day. The Health Plan has denied this request indicating that the requested medication is not medically necessary for treatment of the enrollees chronic hepatitis B virus.Nature of Statutory Criteria/Case Summary: Guidelines for the treatment of hepatitis B from the American Association for the Study of Liver Disease (AASLD) recommend entecavir and tenofovir compared with alternatives for the treatment of chronic hepatitis B (Terrault, et al). In comparison with tenofovir disoproxil fumarate (Viread), which the patient is currently taking, the Vemlidy formulation of tenofovir is effective for hepatitis B, but is associated with lower incidence of side effects such as osteopenia and renal disease (Grant and Cotter). For this reason, the request for Vemlidy 25 mg once per day is medically necessary for the treatment of this patients chronic hepatitis B. 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: Experimental/Investigational
Decision: Overturned

A 62-year-old female enrollee has requested Botox injections for the treatment of her migraine headaches. Findings:  Two physician reviewers found that this patient has severe migraine headaches that have been refractory to multiple medications.  The patient has taken both prophylactic and abortive agents without sustained relief.  Although not a first-line therapy for migraine, Botox has been shown to be effective in a subset of patients.  The medical literature demonstrates that Botox can reduce headache severity and limit other medication use. For this reason, a trial of Botox is medically reasonable and appropriate. If the therapy is effective, it should continue to be authorized.
Appeal type: Experimental/Investigational
Decision: Overturned

A 58-year-old male has requested ongoing PET/CT scans for the evaluation of aggressive gastrointestinal stromal tumor.   Findings:  Two physician reviewers found that there is documentation of the unique utility of PET in the management of GIST with imatinib therapy(1-6), especially combined PET/CT. PET seems to be more sensitive to residual or recurrent disease than CT. PET/CT is superior to either technique separately. The operative term here is long term efficacy. Time is of the essence with this aggressive malignancy, and this patient needs PET now. The literature suggests no real alternative. PET should be approved for this patients rare, aggressive tumor.
Appeal type: Experimental/Investigational
Decision: Upheld

A 57-year-old female enrollee has requested left side radiofrequency neurolysis for treatment of her chronic low back pain and right leg pain. Findings:  Three physician reviewers found that the standard of care requires a diagnostic block to be conducted prior to a therapeutic block and this was not done in this patients case. Manchikanti and colleagues stated that, For therapeutic interventions, the diagnosis (of facet joint pain) must be established with a positive response to controlled local anesthetic blocks with 80% relief. It does not appear that a diagnostic block has been performed in this case. Further, Nalini and colleagues concluded that the available literature Pointed to strong evidence for controlled comparative local anesthetic facet joint medial branch blocks in the diagnosis of neck and low back pain. Moreover, all of the studies that were used to prove the efficacy of medial branch blocks were conducted in patients who did not have prior surgery at the planned block levels. Thus, the requested procedure in this patient should not be expected to provide her with benefits beyond that anticipated with standard treatment modalities and was appropriately denied.
Appeal type: Urgent Care
Decision: Overturned

A 17-year-old female enrollee has requested emergency services for the treatment of her medical emergency. Findings:  The physician reviewer found that the symptoms of shoulder pain after a motor vehicle crash could be indicative of a fracture, dislocation or bruise of the shoulder. Although rarely life-threatening, it is critical to evaluate patients who might have such injuries in order to manage these injuries in a timely fashion. A delay in diagnosis and treatment can lead to loss of function of the limb. Other disorders of the thorax, such as pneumothorax, may also manifest as shoulder pain and need to be ruled out given the mechanism of injury.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for two (2) psychotherapy sessions per month for treatment of the enrollees behavioral health condition. Findings:  The physician reviewer found that there are several evidence-based psychotherapeutic interventions for bipolar illness such as cognitive behavioral therapy, family therapy and interpersonal and social rhythm therapy. Additionally, due to abuse history, the patient may meet diagnostic criteria for posttraumatic stress disorder (PTSD). Trauma-focused psychotherapies represent the gold-standard treatment for individuals diagnosed with PTSD. The evidence-based therapies for PTSD, such as prolonged exposure and cognitive processing therapy, much like the therapies for bipolarity, are typically delivered in time-limited fashion on a weekly basis. Considering that different therapeutic modalities may be necessary throughout the course of a chronic, complex mental illness burden, an updated psychological assessment and outpatient treatment plan is indicated to determine the patients current clinical status and treatment needs. In the absence of an updated psychological evaluation, the request for two psychotherapy sessions per month are not medically necessary for treatment of the patients medical condition. Final Result: The reviewer determined that the requested services are not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in 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: An enrollee has requested Aromasin (exemestane) for treatment of her breast cancer.  Findings: The physician reviewer found that women with hormone receptor positive breast cancer usually receive pharmacologic therapy to inhibit the estrogen-induced growth of the cancer. The interventions differ however for those who are premenopausal versus postmenopausal. This distinction is extensively supported by the medical literature and is also the main conclusion of guidelines recently published by the American Society of Clinical Oncology. The American Society of Clinical Oncology (ASCO) recommendations are for premenopausal women to receive 5 years of adjuvant tamoxifen therapy. The ASCO guidelines cited above provide rigorous data in support of tamoxifen. A longer trial of tamoxifen is warranted in this patient and if the drug becomes absolutely intolerable, a switch to exemestane may be appropriate after oophorectomy. However, according to randomized clinical studies cited in the U.S. Food and Drug Administration approval history of exemestane, the rate of musculoskeletal complication in postmenopausal women was about the same with exemestane or tamoxifen. All told, the medical necessity of Aromasin (exemestane) has not been established in this case.  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 medical oncology and hematology 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.