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 capsule endoscopy for evaluation of bloating and constipation. Findings:  Two physician reviewers found that there is a lack of support for the requested services in this clinical setting. Community-accepted indications for capsule endoscopy include obscure gastrointestinal bleeding, small bowel Crohns disease, assessment of celiac disease, screening and surveillance for polyps in familial polyposis syndromes, and evaluation of the small bowel for tumors such as lymphoma, carcinomas or carcinoids. In this patients case, the records support possible irritable bowel syndrome. The results of her serology (even after dietary gluten challenge), HLA typing, and endoscopic biopsy do not warrant further studies for celiac disease. Final Result: The reviewers determined that the requested services are not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: Reviewers 1, 2 and 3 are board certified in internal medicine with sub-specialty certification in gastroenterology 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

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Lacosamide 450 mg/day. Findings:  The physician reviewer found that Lacosamide can be taken as monotherapy or adjunct therapy for focal-onset seizures in patients ages four years and up (Subbarao, et al). According to the practice guideline update summary from the American Epilepsy Society and subcommittee of the American Academy of Neurology (AAN), lacosamide is likely effective in treatment-resistant adult focal epilepsy and should be considered to decrease seizure frequency in this patient population (Kanner, et al.). Peer-reviewed medical literature includes publications comparing lacosamide to placebo in 1 Class I and 2 Class II studies. Kanner and colleagues reported that lacosamide at doses of 400 and 600 mg/day showed significantly higher responder rates and greater median reduction of seizures than placebo. Similarly, Chung and colleagues found that lacosamide 600 mg/day yielded a greater reduction in secondarily generalized tonic-clonic seizures. In this case, the patient has intractable epilepsy refractory to multiple medications. Based on the current medical literature and recommendations, lacosamide is appropriate for this patient to decrease seizure frequency in treatment-resistant epilepsy. In addition, lacosamide at doses up to 600 mg/day has been demonstrated to yield a greater reduction in seizures. Given this support, the requested lacosamide 450 mg/day is medically necessary for treatment of this patient.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 neurology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

A 67-year-old female enrollee has requested for minimally invasive parathyroidectomy surgery for treatment of her  hyperparathyroidism. Findings:  The physician reviewer found that a surgeon performing a selective parathyroidectomy may only have to explore the left side of the patients neck, thereby avoiding unnecessary potential complications. This approach offers clear advantages for this high-risk patient. Thus, in order to decrease the potential for morbidity in this patients case, minimally invasive parathyroidectomy surgery is medically appropriate and necessary.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement and prospective authorization and coverage for theta burst transcranial magnetic stimulation (TMS). Based on a review of the records provided, this patient has undergone a trial of two different agent classes at or above the minimum effective dose. Further, the duration of these trials included at least two evidence-based augmentation therapies or inability to tolerate pharmacologic agents. Specifically, the patient experienced severe insomnia and constipation with Nardil, a seizure with Wellbutrin, and nausea with vomiting with Brintellix. The patient has responded well to treatment with theta burst TMS without untoward side effects. The patients condition has improved with electroconvulsive therapy (ECT) and TMS. TMS treatment is a U.S. Food and Drug Administration (FDA) approved for treatment of major depressive disorder in a safe and effective manner. Based on the information provided, this patient does meet the clinical criteria for the use of TMS therapy. However, the current data do not support theta blast TMS in lieu of standard TMS. The patients Health Plan has providers available to render standard TMS services. Overall, theta burst TMS lacks adequate research to support its use in lieu of standard TMS. As this patient meets the criteria for treatment with TMS, the patient should obtain the standard of care TMS services from a provider within their Health Plans network. Therefore, the theta burst TMS services were not and are not medically necessary for treatment of this patient.Final Result: The reviewer determined that the services at issue were not and 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: Experimental/Investigational
Decision: Upheld

A 35-year-old female enrollee has requested for transcranial magnetic stimulation (TMS) for treatment of her major depression.  Findings:  Two physician reviewers found that there is a lack of peer reviewed literature supporting maintenance treatments with TMS. The current peer reviewed medical literature indicates that the value of TMS in the treatment of refractory depression is limited. The use of TMS for any indication other than the FDA approved criteria should be considered off label, as the current research does not show it to be more effective than pharmacotherapy in cases of refractory depression. TMS is FDA approved for patients who have failed a single trial of anti-depressants. This patient has shown only limited improvement on multiple anti-depressant medications. In sum, there is no evidence in the current literature to indicate that maintenance TMS or an additional course of TMS is likely to be more effective than any standard alternative treatment for major depressive disorder.
Appeal type: Medical Necessity
Decision: Upheld

The parent of a 17-year-old female enrollee has requested residential treatment for treatment of the enrollees anorexia nervosa.  Findings:  The physician reviewer found that although this patient required ongoing intense treatment, the submitted documentation does not demonstrate the medical necessity of residential treatment provided from on the dates in question. During the dates of service at issue, partial hospitalization level of care was medically indicated. Per American Psychiatric Association guidelines, the patient could have been safely and effectively treated at the partial hospitalization level of care. All told, residential treatment provided on the said dates was not medically indicated.
Appeal type: Urgent Care
Decision: Overturned

A 42-year-old female enrollee has requested emergency services for the treatment of her leg pain.  Findings:  The physician reviewer found that the patients symptoms met prudent layperson criteria for emergency care. A prudent layperson with an average knowledge of medicine and 10/10 hip and leg pain developing over the course of a few hours would reasonably expect the absence of emergency care to jeopardize their health. The patients symptoms were clearly severe, based on her 10/10 pain scale rating and her requirement of narcotic medications for pain control.
Appeal type: Medical Necessity
Decision: Upheld

A female enrollee requested in-home occupational therapy and in-home physical therapy for medical treatment of her medical condition.  Findings:  The physician reviewer found that for those with diabetic neuropathy and gait disorders, aerobic exercise training can provide some benefit in function.  In this case, the patient has undergone significant home physical therapy and she has progressed to ambulating short distances at stand by assistance.  She was discharged from her treating home physical therapist and is independent with self-care.  Further improvements in endurance can be achieved as tolerated with custodial level supervision and assistance from caregivers.  No marginally significant improvements in outcomes or clinical course would be expected with further home therapies beyond an independent exercise program with custodial level supervision and assistance.  All told, the requested in-home occupational therapy and in-home physical therapy are not medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for magnetic resonance imaging (MRI) of the cervical spine. Findings:  The physician reviewer found that records document that this patient presents with right upper extremity and facial paresthesias, headaches, and nausea. The patients provider has recommended further evaluation with MRI of the cervical spine. According to the American College of Radiology (ACR) appropriateness criteria for the evaluation of patients with cervical neck pain or cervical radiculopathy, MRI of the cervical spine is indicated for further evaluation of concerning signs and/or symptoms including neck pain or radiculopathy in the setting of trauma, malignancy, prior neck surgery, spinal cord injury, certain systemic diseases, suspected infection, and intractable pain despite therapy. The records provided for review do not include documentation of any concerning signs or symptoms as described by the ACR recommendations. Moreover, the patient does not have any new reported neurological symptoms since previous MRI. The patient underwent a recent MRI of the cervical spine approximately one month ago, which demonstrated no significant findings. In the absence of any new symptoms or indication for the examination, the requested MRI of the cervical spine is not medically necessary for 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. Credentials/Qualifications: The reviewer is board certified in radiology with subspecialty certification in diagnostic radiology 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

Nature of Statutory Criteria/Case Summary:  An enrollee has requested Fetal Aneuploidy Trisomy Risk testing for evaluation of her medical condition.  Findings:  Three physician reviewers found that the American College of Obstetricians and Gynecologists has recommended that cell-free fetal DNA can be used as a primary screening test in women at increased risk of aneuploidy.  This includes women aged 35 years or older, women with a positive first-trimester or second-trimester screening test result, fetuses with ultrasonographic findings that indicate an increased risk of aneuploidy, women with a history of a child affected with a trisomy, or a parent carrying a balanced robertsonian translocation with increased risk of trisomy 13 or trisomy 21.  This patient did not meet any of these criteria.  Thus, Fetal Aneuploidy Trisomy Risk testing was not likely to have been superior over other methods of evaluating this patient.  Final Result: Three physician reviewers determined that the services at issue were not likely to be more beneficial for evaluation 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 obstetrics and gynecology 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: Upheld

Nature of Statutory Criteria/Case Summary: The parent of an eight-year-old male enrollee has requested authorization and coverage for 100 hours of direct one-on-one applied behavioral analysis (ABA) therapy (CPT code H2019), and 20 hours of supervision by Board Certified Behavior Analyst (BCBA) (CPT code H0032) for treatment of the autism spectrum disorder. Findings:  The physician reviewer found that the documentation submitted for review does not support the need for additional hours of ABA therapy. The Health Plan had approved a block of ABA therapy that included provide 43.3 hours per month of direct one-on-one ABA therapy, 8.7 hours per month of BCBA supervision, and 4.3 hours of caregiver training. The ABA hours authorized by the Health Plan are medically reasonable in this clinical setting. According to the documentation submitted for review, the patients behavior does not pose significant threat of harm to the recipient or others. In addition, the gains made toward developmental norms and behavior goals can be maintained if care is reduced. Based on the clinical documentation submitted for review, the request for 100 hours of direct one-on-one ABA therapy (CPT code H2019), and 20 hours of supervision by BCBA (CPT code H0032) provided are not medically necessary for treatment of the patients medical condition. Final Result: The reviewer determined that 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 pediatrics with sub-specialty certification in developmental-behavioral pediatrics 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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for transoral incisionless fundoplication (TIF) utilizing the EsophyX device. The efficacy of TIF has been studied in randomized controlled trials. However, the conclusions are contradictory. An American College of Gastroenterology (ACG) guidelines for treatment of GERD report that the usage of current endoscopic therapy or TIF cannot be recommended as an alternative to medical or traditional surgical therapy. further studies are required to define optimal techniques and most appropriate patient selection criteria, and to further evaluate device and technique safety.` Guidelines from the American Society for Gastrointestinal Endoscopy (ASGE) do not recommend endoscopic procedures for patients with complicated GERD which the guideline defines as dysphagia or Barretts esophagus and report that the long-term follow-up data for TIF is limited. For these reasons, the requested TIF with the EsophyX device is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.One reviewer found that the requested TIF with the EsophyX device is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: Two of the three reviewers determined that the requested procedure is not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld.
Appeal type: Experimental/Investigational
Decision: Upheld

A 69-year-old male enrollee has requested the X-Stop interspinous distraction device for treatment of his lumbar spinal stenosis. Findings:  Three physician reviewers found that the Food and Drug Administration (FDA) indicates that X-Stop should not be used with significant instability, and this patients records mention Grade I or Grade II spondylolisthesis, which is suspicious for instability. In addition, X-Stop is not appropriate when a neurogenic bowel or bladder is present. This patients recent urinary retention may be a manifestation of that condition. Moreover, the use of X-Stop remains investigational because it is still being researched in patients to determine the long-term (greater than two years) efficacy and safety. To that end, the FDA has required a five-year study to determine the long-term safety and effectiveness of the device, which is still ongoing.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Norco. As noted by the Centers for Disease Control (CDC) guidelines, the use of opiates for chronic non-malignant pain is not recommended. When using long-term opioid therapy, providers must document assessment of pain and function compared to baseline, evaluate risk of harm or misuse, and check that non-opioid therapies have been optimized. In this case, there is no evidence of a screening urine toxicology. This is a requirement of chronic opiate maintenance, and is necessary to evaluate the risk of harm or misuse. Therefore, the requested Norco is not medically necessary for treatment of this 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 anesthesiology with sub-specialty certification in pain management and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Vemlidy 25 mg tablets. Findings:  The physician reviewer found that : Guidelines for the treatment of hepatitis B from the American Association for the Study of Liver Disease (AASLD) recommend entecavir and tenofovir (Viread and Vemlidy) compared to the alternatives for the treatment of chronic hepatitis B. In comparison with tenofovir disoproxil fumarate (Viread), which the patient takes, the Vemlidy formulation of tenofovir is effective for hepatitis B, but is associated with fewer side effects, including decreased risk of osteopenia and renal disease. For this reason, the request for Vemlidy 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 male enrollee requested speech therapy for medical treatment of his medical condition status post ischemic stroke. Findings:  Two physician reviewers found that there is adequate support for speech therapy in treating cognitive/linguistic deficits after cerebrovascular accidents. This patients documentation describes a cognitive deficit secondary to an ischemic stroke which bled, which is known as an acquired brain injury. The records noted that the patient had potential for measurable improvement within a reasonable time. Further, there is no other treatment that would be considered the standard of care over this type of therapy for this particular type of cognitive deficit. Thus, speech therapy services were likely to have provided this patient with greater benefit than any available intervention.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for intraoperative radiotherapy (IORT) (CPT 77424, 77425, and 77469). Based on the available documentation, this patient has a history of left breast invasive ductal carcinoma in situ (DCIS). Pathology revealed the patients breast cancer to be estrogen receptor (ER) positive, progesterone receptor (PR) positive, and HER2Neu non amplified. The patients provider has recommended treatment with a course of radiation therapy using IORT. On review of the medical literature, there are sufficient outcomes data published demonstrating the safety and efficacy of IORT for patients with breast cancer who are suitable candidates for partial breast irradiation (Correa, et al.). Specifically, the TARGIT-IORT study is a high quality trial which supports the use of IORT as within the standard of care in this patients clinical setting. Vaidya and colleagues found that, For patients with early breast cancer who met our trial selection criteria, risk adapted immediate single dose TARGIT-IORT during lumpectomy was an effective alternative to EBRT [external beam radiotherapy], with comparable long term efficacy for cancer control. Given this support, the requested IORT (CPT 77424, 77425, and 77469) is 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 requested IORT (CPT 77424, 77425, and 77469) is 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 services are likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: Physician reviewer 1 is board certified in radiation oncology and is actively practicing. Physician reviewer 2 is board certified in radiation oncology and is actively practicing. Physician reviewer 3 is board certified in radiation oncology 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.