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

A 48-year-old male enrollee has requested Rituxan for treatment of his multiple sclerosis.  Findings:  Three physician reviewers found that although additional studies are warranted, there is adequate literature supporting the use of Rituxan in the treatment of patients with MS to support its use in this case. In one study conducted by Bar-Or and colleagues, the safety, tolerability and effectiveness of Rituxan in patients with relapsing-remitting MS was observed. The authors reported An apparent reduction in relapsesover the 72 weeks compared with the year before therapy. Naismith and colleagues reported similar findings with Rituxan reducing the number of gadolinium-enhancing brain lesions in patients with MS. This patients progressive disease secondary to MS has been refractory to prior therapeutic attempts. It is known that if left untreated, MS can lead to severe disability. Given the literature referenced above, a trial of Rituxan is a reasonable therapeutic option for this particular patient and is likely to be superior to standard treatments.
Appeal type: Medical Necessity
Decision: Upheld

A 50-year-old male enrollee has requested monitored anesthesia care (MAC) services for treatment of his risk for colorectal cancer.  Findings:  The physician reviewer found that colonoscopy may be safely and effectively performed with conscious sedation of a benzodiazepine alone or with a narcotic in an office-based setting and without the need of monitored anesthesia care with Propofol, as required per American Society of Anesthesiologists (ASA) guidelines. McQuaid and Laine performed a systematic review of randomized controlled trials to compare the safety, efficacy, and efficiency of agents used for moderate sedation in EGD or colonoscopy. At the end of the review the authors concluded that, moderate sedation provides a high level of physician and patient satisfaction and low risk of serious adverse events with all currently available agents. Midazolam based regimens have longer sedation and recovery times than Propofol. All told, the MAC services provided on the date indicated were not medically necessary for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld

A 60-year-old female enrollee has requested reimbursement for PLIF at L5-S1 with microdiscectomy at L3-4 for the treatment of her spondylolisthesis and stenosis at L5-S1 and herniated disc at L3-4 on the left side. Findings:  The physician reviewer found that the definitive procedure in this setting is the anterior-posterior fusion which was offered by the Health Plan. The anterior-posterior fusion offers better success than the PLIF procedure. The anterior-posterior fusion does involve two separate incisions and is a larger and more morbid procedure. However, it does provide a greater probability of solid bony arthrodesis and therefore was more appropriate for this patient. As such, PLIF at L5-S1 with microdiscectomy at L3-4 was not medically necessary for this patient.
Appeal type: Experimental/Investigational
Decision: Overturned

A 31-year-old female enrollee has requested balloon sinuplasty of bilateral maxillary sinuses for treatment of her chronic sinusitis.  Findings:  Two physician reviewers found that the underlying principles of the technique of balloon sinuplasty of bilateral maxillary, which is the strategy of modifying and/or opening the pathways to facilitate presumably impaired sinus mucous drainage has been articulated and supported in the medical literature. The means of visualization and instrumentation has evolved over the years, but the concept and goals of many of the operations have not. Current imaging and visualization techniques using a balloon instead of a metal dilator, allow this more focused approach to the underlying strategy to be resumed. In this case, the absence of radiologic evidence of a (architecturally) blocked sinus opening only means that functionally, the patient had blockage. Thus, the procedure at issue provided the exact combination of probable success without exposing the patient to inappropriate risk. Therefore, the services at issue were likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for sinus surgery. Findings:  The physician reviewers found that the medical records fail to demonstrate the superior effectiveness of the services at issue.  The clinical notes document symptoms of recurrent acute rhinosinusitis with multiple episodes of the preceding six months. The physical examination and CT imaging confirmed evidence of nasal septal deviation, mucous membrane thickening within the maxillary sinus ostia and some hypertrophy of the inferior turbinates.  However, the patient had no evidence of frontal sinus disease based on the imaging studies or clinical examination and physical findings of the frontal sinus on the right side.  Of note, balloon sinus dilation was not mentioned preoperatively as a potential surgical intervention.  Balloon sinus dilation may be an effective method for limited sinus disease only.  The technique does not offer the ability to eradicate and remove extensive polyps.  At present, functional endoscopic sinus surgical techniques are considered the surgical treatment of choice for the management of chronic rhinosinusitis refractory to medical management. Thus, the services at issue were not likely to have been more efficacious than other treatment options. Final Result: 3 of 3 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. Credentials/Qualifications: All three physician reviewers are board certified in otolaryngology 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: Overturned

The parent of a two-year-old male enrollee has requested  for Protopic (0.03%) for treatment of the enrollees atopic dermatitis. Findings:  The physician reviewer found that Atopic dermatitis (AD) is a chronic, highly pruritic inflammatory disorder of the skin. It is the most common chronic childhood skin disease. The disease may be associated with significant morbidity, particularly when complicated by a secondary infection. Frequent disruption of sleep is common, and emotional stress associated with the illness can have a significant impact on the quality of life for patients and their families. Much effort has recently been placed on the development of new treatment strategies for this increasingly common illness. Tacrolimus ointment is the first topical calcineurin inhibitor approved for clinical use and has been demonstrated to be safe and effective in the treatment of patients with AD. The FDA issued a recommendation for its topical use in children two-years-old or older that have moderate to serious atopic dermatitis, and that have not responded to other treatments. The use of topical Protopic (0.03%) is justifiable in this patient for the following reasons: he has moderate to severe AD which did not respond to long-term topical corticosteroids therapy, and Protopic (0.03%) has been safely and successfully used to treat immune-mediated skin lesions in patients younger than this patient.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for an echocardiogram performed at the Mayo Clinic Hospital in Rochester, MN. In this case, while the patient appeared at low risk for ischemic or arrhythmic cardiac disease due to her young age and a lack of significant risk factors or family history, she had a history of recurrent and severe chest discomforts resulting in admission to the emergency department and an episode associated with reported syncope. The provider recommended stress echocardiography to evaluate the patient for structural or valvular heart disease, exercise-induced ischemia, or ectopy as an etiology of her symptoms. Given the patients persistent and recurrent symptoms, a definitive non-invasive cardiac evaluation for exercise-induced ischemia, both microvascular and large vessel, exercise-induced arrhythmia, or structural heart disease was medically indicated. Therefore, the echocardiogram performed at the Mayo Clinic Hospital in Rochester, MN was medically necessary for the evaluation of this patient.Final Result: The reviewer determined that the service at issue was medically necessary for evaluation 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 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

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for substance abuse residential treatment center level of care services provided for treatment of the enrollees behavioral health condition. Findings:  The physician reviewer found that the substance abuse residential treatment center level of care services provided were not medically necessary for treatment of the patients medical condition. According to the documentation submitted for review, the patients post-acute withdrawal symptoms were not severe in nature. He was not a danger to himself or others, nor was he aggressive or violent. The patient was cognitively intact and not gravely disabled. There were no emotional, behavioral, cognitive, or impulsive symptoms that support treatment at the residential level of care. The patient was medically and psychiatrically stable. The patients medication management was extremely uncomplicated and there were no changes. The records note that medication assisted treatment was discussed during the course of treatment. There was no evidence of a high degree of impulsivity, agitation, depression, mania, hallucinations, or any other significant symptom that would interfere with his care. The patient was motivated and appeared to be working the program. The patient was cooperative and participating in his treatment plan. Although the patient continued to struggle with his emotions and required further treatment to help develop and solidify coping skills, this did not require the structured environment of a residential setting and could have been stepped down to a lower level of care. As such, the services at issue were not medically necessary for treatment of the patients medical condition. 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 psychiatry with sub-specialty certification in addiction 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

A 39-year-old female enrollee has requested Veramyst 27.5 mcg for the treatment of her allergic rhinitis. Findings:  The physician reviewer found that fluticasone furoate (Veramyst) is a synthetic trifluorinated corticosteroid with anti-inflammatory activity. The exact mechanism by which this corticosteroid exerts its effects in the treatment of allergic rhinitis is unknown. While Veramyst has been shown to be efficacious in this setting, the medications on the Health Plans formulary list are equally effective as Veramyst. In this patients case, there is no objective evidence of unsuccessful treatment with the nasal steroids that are on the Health Plans formulary list. The patients provider stated that the patient has not met criteria for the use of Veramyst. Thus, there is no documented need for Veramyst in this case as there are comparably effective medications available to this patient.
Appeal type: Medical Necessity
Decision: Overturned

A 59-year-old female enrollee has requested adult substance abuse sub-acute/residential treatment center (RTC) rehabilitation for treatment of her behavioral health condition. Findings:  The physician reviewer found that this patient had a long history of alcohol problems. At admission, her condition was well-documented.  However, as her stay continued, the documentation was sparser. It does appear that she was having some withdrawal symptoms upon presentation. However, these were minimal, as she was taking Ativan, which was likely decreasing or eliminating her symptoms.  There are several factors that would signify need for a more intensive level of care upon the patients admission: 1) she had a history of suicidal ideation and suicide attempts in the past while intoxicated; 2) depression; 3) her apparent denial of the severity of her illness; 4) lack of cooperation with AA; and 5) long history of alcohol dependency. With examination of the American Psychiatric Association guidelines for patient placement in an RTC, several of the criterion are applicable in this case: 1) the patient did not meet the clinical criteria for hospitalization, but her life and social interactions have come to focus predominantly on substance use; 2) lack of sufficient social and vocational skills and drug-free social supports to maintain abstinence in an outpatient setting; and 3) demonstrates denial that could respond to interpersonal and group confrontation. According to these guidelines, the patient met criteria for a RTC placement upon her admission. However, the documentation does not support the continued need for the patient to have remained at this level of care. After ten days of treatment, she was still having some withdrawal symptoms and mood swings. However, there is no documentation after this date of any such problems or indications that the patient could not be safely or effectively treated in a less restrictive setting. After ten days of treatment, the patient could have been treated safely and effectively at a less restrictive setting.
Appeal type: Medical Necessity
Decision: Overturned

A 47-year-old female enrollee has requested sacroiliac joint steroid injections for treatment of her lumbar facet arthropathy, sacroiliac joint arthropathy, and myofascial pain syndrome.  Findings:  The physician reviewer found that the use of SI joint injections is very common in patients with low back pain due to SI joint or posterior capsular dysfunction, which account for about 20 to 25% of low back pain. The patient in this case has multiple findings on examination. The records indicate the patient has failed conservative therapy with medication, exercise therapy, and has had the pain for longer than three months. In this case, the role of a single appropriately performed bilateral diagnostic SI joint injection would be reasonable. Per the American Society of Interventional Pain Physicians (ASIPP) guidelines, a successful injection that provides relief would support possible therapeutic phase injections to be determined based on the degree and duration of relief. At this time, the patient should undergo one bilateral SI injection to help with the diagnostic work-up.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary:  An enrollee has requested authorization and coverage for narcotic pain medication (without having to cease using marijuana first) for treatment of his medical condition. Findings: The physician reviewer found that there is insufficient support for the requested medication in this clinical setting. The patient has non-malignant chronic pain, which will often worsen or recur as a result of opioid rebound. Additionally, the patient is using medical marijuana which is not indicated for concurrent use with opioids. The current standard of care for chronic pain is treatment in a multidisciplinary practice to include physical therapy, massage therapy, cognitive behavioral therapy, and injections to help reduce pain. Baron and McDonald reported that high dose and short acting opiates might contribute to pain sensitization via opioid-induced hyperalgesia, decreasing patient pain threshold and potentially masking resolution of a preexisting pain condition. In this retrospective study, the majority of patients undergoing detoxification of high dose opiates for chronic pain reported a significant decrease in pain at the end of the study, further supporting the theory of opioid-induced hyperalgesia. In sum, narcotic pain medication (without having to cease using marijuana first) is not medically indicated 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: The enrollee has requested authorization and coverage for platelet rich plasma injections. Findings:  The physician reviewer found that There is a paucity of high level literature regarding the application of PRP in the management of patellar and Achilles tendinopathy. Dupley and colleagues concluded that there is a paucity of randomized controlled trials evaluating the role of PRP in patellar tendinosis. Their results suggest that, based on limited evidence, PRP is superior over other established nonsurgical treatments (dry needling and extracorporeal shockwave therapy) for refractory patellar tendinosis. However, larger randomized controlled trials may allow better characterization of the role of PRP in this condition. This patient presents with a six month history of chronic right knee pain with no history of trauma or injury. Clinical examination findings and imaging evidence are consistent with patellar tendinitis. It is noted that he has attended physical therapy without benefit. However, there are no details regarding the type or duration of physical therapy. There is no documentation of additional conservative treatment, including medications, activity modification, or strapping/taping. There is a lack of large volume, long term, peer reviewed outcome studies to support the use of PRP in the treatment of patellar tendinopathy as discussed above. Additionally, there is limited support for PRP in refractory patellar tendinosis in patients who have not responded to comprehensive treatment for at least 12 months, which is not the case in this situation. Therefore, in this patients case, the request for PRP injections are not medically necessary for the patients knee pain. 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 orthopedic surgery and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

Findings:  The physician reviewer found that The patients parent has requested authorization and coverage for anterior lumbar interbody fusion (ALIF) procedure to L5-S1 (CPT 22558 and 22853). Bydon and colleagues concluded that a trial of conservative therapy may be considered for patients with low-grade spondylolisthesis presenting with radiculopathy. These treatment options may include physical therapy, epidural steroid injections, and pain medications. If unresolved, surgical options may include decompression alone or decompression and fusion. Resnick and colleagues noted that as a result of decompression, the inherent instability associated with the spondylolisthesis may progress and lead to further misalignment that results in pain or recurrence of neurological complaints. Under these circumstances, lumbar fusion is considered appropriate to stabilize the spine and prevent delayed deterioration. This patient is being treated for degenerative disc disease at L5-S1, stenosis at L5-S1, left lumbar radiculopathy, and lumbago. The patients records document presentations of chronic low back and bilateral leg pain. The patients provider has recommended ALIF to L5-S1. However, detailed documentation is not evident regarding trial and failure of recent, reasonable and comprehensive less invasive conservative care measures. The records include documentation of a recent bilateral transforaminal epidural steroid injection at L5 on 9/29/21 and right L5-S1 interlaminar epidural steroid injection on 8/31/21. Although the records document that the patient has undergone treatment with physical therapy, the available note was dated 9/24/20, without report of completion of recent physical therapy. Moreover, dynamic flexion and extension imaging studies were not provided for review to potentially assess the amount of instability at the requested surgical level. For these reasons, the requested ALIF procedure to L5-S1 (CPT 22558 and 22853) 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.