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

A 58-year-old female enrollee has requested authorization and coverage for radiofrequency neurolysis for treatment of the enrollees facet arthropathy and occipital neuralgia.  Findings:  Two physician reviewers found that the patient is requesting authorization and coverage for radiofrequency neurolysis. The patients provider diagnosed the patient with C2-3 facet joint pain on two occasions and C3-4 facet joint pain on one occasion. The patients MRI demonstrated multilevel spondylosis with facet disease, along with mild spinal stenosis, as well as multilevel foraminal stenosis. The patient has a history of alcohol abuse and is concerned about the long-term use of medications. The Health Plan has denied coverage for radiofrequency neurolysis on the basis that it is considered investigational in this setting.  Review of the submitted documentation demonstrates that the patient has facet joint pain and tested positive for diagnostic blocks, at least partially. The documentation of relief was vague. Dual blocks were performed at the C2-3 level with bupivacaine. At the C3-4 level, only one block was performed, with limited documentation provided regarding the efficacy of this block in relieving the patients pain. There is significant evidence that cervical radiofrequency neurolysis is an effective modality of treatment, however, the caveat is that diagnostic blocks must be controlled, either comparatively with two local anesthetics or placebo-controlled, which was not utilized in this case (Manchikanti, et al. (2009); Falco, et al.; and Lord, et al.). Generally, medial branch blocks must be performed on at least two occasions and re-evaluation of the response is essential prior to pursuing radiofrequency neurolysis. If a patient receives good pain relief at least for several weeks each time but fails to receive long-term relief, medial branch neurolysis may be appropriate. Given the absence of an adequate trial of medial branch blocks in this patients case, there is insufficient evidence that radiofrequency neurolysis is likely to be efficacious for treatment of her condition.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the partial hospitalization program (PHP) services for treatment of the enrollees polysubstance abuse, depression, and anxiety. Findings:  The physician reviewer found that the patient showed what appeared to be mild to moderate post-acute withdrawal symptoms. She was not suicidal or homicidal, and there were no emotional, behavioral, cognitive, or psychotic issues indicating a need for PHP level of care. She was medically stable to the extent that her hypertension did not require management in PHP. The standard of practice for hypertension management is in the outpatient setting. She was psychiatrically stable and she was motivated, completing assignments, and otherwise engaged in her treatment. She had coping skills and was aware of triggers. She was aware of relapse risk. She had multiple treatments in the recent past, and was familiar with the process. She no longer required the rigors of PHP level of care and could have been stepped down to IOP level of care to continue her recovery, along with the support of a 12-step home group and counseling. Thus, the PHP services provided 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: Experimental/Investigational
Decision: Overturned

A 57-year-old female enrollee has requested for retreatment with Rituxan for treatment of her rheumatoid arthritis. Findings:  Three physician reviewers found that Rituxan is effective in the treatment of rheumatoid arthritis due to the selective depletion of CD-20 positive B-lymphocytes. It is well recognized that those beneficial effects decrease as the B-cell population returns, typically six to 12 months after treatment. Schematically, this is parallel to the action of tumor necrosis factor (TNF) inhibitors. The effects of each agent last for a period of time based on the duration of TNF inhibition by that particular drug. Obviously, retreatment with TNF inhibitors is needed for long-term control of the disease process. Clinical experience demonstrates quite clearly that repeat treatment with Rituxan is also necessary to maintain benefit.
Appeal type: Medical Necessity
Decision: Overturned

The guardian of a 33-year-old male enrollee has requested the medication Banzel for the treatment of the enrollees seizure disorder secondary to isodicentric chromosome 15q duplication syndrome. Findings:  The physician reviewer found that this patient has refractory seizure disorder, and uncontrolled seizures pose a hazard. He has an underlying chromosomal abnormality, likely the etiology for his seizure disorder. Prior anticonvulsants have been ineffective for treatment of his condition. His current anticonvulsant regimen has been more beneficial than prior treatments. Per the literature, Banzel is the most recent antiepileptic drug to have shown efficacy in the treatment of Lennox-Gastaut syndrome (LGS). This patients condition is similar to LGS. Although the evidence supporting the use of available treatments for LGS is not robust, there is evidence demonstrating the efficacy of Banzel and the clinical evidence in this case demonstrates it has been effective for this patient. Topamax has an uncertain chance of success and a trial of such is not necessary. The current regimen is medically indicated and is more likely to be beneficial than Topamax or other treatments.
Appeal type: Medical Necessity
Decision: Overturned

A 59-year-old female enrollee has requested continued inpatient stay for treatment of her eating disorder and Crohns disease. Findings:  The physician reviewer found that based on review of the available records, this patient has anorexia nervosa and major depressive episode triggered due to the ongoing stressor of marital conflict. In addition, she experienced significant weight loss that needed medical attention. The records document that she was experiencing active suicidal ideations with a plan to overdose on admission. She continued to have suicidal ideations with a plan throughout the length of stay as well as homicidal ideations with plan as well through the date indicated. Applying the American Psychiatric Association (APA) treatment guidelines, this patients medical and psychiatric conditions support the medical necessity of continued inpatient services from the date indicated and forward. This patient was an imminent danger to self and others and thus inpatient hospitalization from the date indicated going forward is medical necessary for treatment of her medical condition.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a one-year-old female enrollee has requested for physical therapy, occupational therapy, and speech therapy for treatment of the enrollees Down syndrome.  Findings:  The physician reviewer found that the use of speech therapy significantly helps these patients communicate and learn to function since they have delays in their developmental attainment of milestones.  Speech and language therapy is often helpful for these children and for people with apraxia who do not spontaneously recover all of their speech abilities. Hypotonia, ligament laxity and motor alterations are all characteristic for patients with Down syndrome which oftentimes results in gross and fine motor skills as well as gait and coordination difficulties. Further, LaForme and colleagues examined whether participation in sensorimotor groups and individual intervention resulted in greater improvements in motor skill acquisition than solely individual intervention for young children with Down syndrome. The authors evaluated 10 children between 13-29 months and placed then in 2 groups. Children in both groups received individual intervention and children in the intervention group participated in 10 weekly sensorimotor groups. All children were assessed at 3 points using the Gross Motor Function Measure and Goal Attainment Scaling. Overall, they found that children in the intervention group demonstrated significant improvement compared with children in the control group in lying and rolling, crawling and kneeling, and total score domains of the Gross Motor Function Measure and in Goal Attainment Scaling. They concluded that participation in sensorimotor groups and individual intervention resulted in greater improvement in motor skill acquisition than solely individual intervention for young children with Down syndrome. Consistent with these findings, the requested speech therapy, OT and PT are medically necessary for this patient.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Entresto 97-103 mg twice a day. The current American College of Cardiology (ACC) and American Heart Association (AHA) guidelines support an indication for treatment with Entresto for this patient with reduced ejection fraction, as defined as 40% or less. The records document that this patient has class C, stage II congestive heart failure with a reduced ejection fraction. The patients ejection fraction on recent testing was 40%, which improved from 20-30% before starting optimal therapy with Entresto. Solomon and colleagues reported Entresto was effective at reducing heart failure in patients with an ejection fraction up to 40%. In addition, this patient has been on chronic Entresto therapy for years and has improved symptomatically and with an improved ejection fraction. All told, the requested Entresto 97-103 mg twice a 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 internal medicine with subspecialty 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: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested Forteo for treatment of her medical condition. Findings:  The physician reviewer found that current studies indicate that osteoporosis is an increasingly widespread condition, affecting 55% of Americans aged 50 and above. Of these, approximately 80% are women. Fractures are the most dangerous aspect of osteoporosis. They can lead to acute and chronic pain as well as increased mortality (Old and Calvert). Until recently, pharmacological options for the treatment of osteoporosis have been limited to antiresorptive agents, including the oral bisphosphonates. Newer treatment agents have become available over the past few years, including teriparatide (Forteo), which was initially approved for treatment of osteoporosis in 2002.  Forteo is a recombinant form of the biologically active component of parathyroid hormone which has been shown to increase bone mass and prevent fractures in osteoporotic bone (Drake et al).  In contrast to bisphosphonate medications, recent data also demonstrates that Forteo may aid in the healing of fractures and non-unions in osteoporotic patients (Babu et al).  Based on the submitted documentation and according to recent studies, Forteo is medically necessary in the treatment of this patients medical condition.  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 endocrinology and metabolism 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 male enrollee requested a medication course of three treatment cycles (up to six injections) of Xiaflex for medical treatment of his Peyronies disease.  Findings:  The physician reviewer found that Xiaflex has been shown to have modest efficacy in clinical trials and is U.S. Food and Drug Administration (FDA) approved for patients with Peyronies disease with at least 30 degrees of curvature and a palpable plaque. Xiaflex is the only FDA-approved drug for Peyronies disease. This patient has failed conservative therapy and is an appropriate candidate for Xiaflex. Therefore, the request for a medication course of three treatment cycles (up to six injections) of Xiaflex is medically necessary for treatment of the patients Peyronies disease.
Appeal type: Medical Necessity
Decision: Upheld

A 55-year-old female enrollee has requested Actiq (fentanyl prescription 200mcg) for treatment of her pain.  Findings:  The physician reviewer found that Actiq is presently indicated for breakthrough cancer pain in patients who are opioid tolerant or otherwise with a limited life expectancy.  Current standard of care for chronic pain is treatment in a multidisciplinary practice to include physical therapy, massage therapy, behavioral therapy, and injections to help reduce pain. Opioids are considered adjunctive to this therapy. Short release/acting medication with a high-risk of dependence and tolerance, such as Actiq, is not recommended.   Baron and colleagues reported that high-dose opioids may 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 opioids for chronic pain reported a significant decrease in pain at the end of the study, further supporting the theory of opioid-induced hyperalgesia. High-dose opioids may cause adverse outcomes. Ballantyne and colleagues reported that prolonged use of high-dose opioids may induce tolerance, abnormal pain sensitivity, and hormonal effects. All told, in this patients case, Actiq (fentanyl prescription 200mcg) was not and is not medically indicated.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for DecisionDx-Melanoma genetic testing. While gene expression profile (GEP) testing has been shown to accurately identify risk of metastasis for patients with cutaneous melanoma, there is a lack of consensus on how this affects the treatment plan for patients. GEP testing is not considered routine standard of care and is not currently recommended under the National Comprehensive Cancer Network (NCCN) guidelines. There is a lack of medical literature supporting its use for the evaluation of patients with thin melanomas. In this case, the course of treatment for this patient would not change based on the results of the GEP testing. Therefore, DecisionDx-Melanoma genetic testing was not likely to have been more beneficial for evaluation of the patients condition than any available standard therapy.Findings:  Two of the three physician reviewers found the requested DecisionDx-Melanoma genetic testing was not likely to have been more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the requested services was not likely to have been more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: Physician reviewers 1, 2, and 3 are board certified in dermatology and are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for residential treatment center services provided for treatment of the enrollees behavioral health condition. Findings: The physician reviewer found that based on the documentation submitted for review, the residential treatment center services provided were not medically necessary for treatment of the patients medical condition. During the dates in dispute, the patient was no longer at risk for withdrawals, she was status post detoxification and treated with Naltrexone.  She was medically and psychiatrically stable, and she was highly motivated and participating in all factors of her treatment plan. In individual therapy she was dealing with issues such as self-esteem, improving boundaries, and guilt. In family sessions, she and her husband were working towards improving communication. These concerns could have been addressed at a lower level of care such as outpatient treatment. The patient no longer required the structure of the residential setting and could have been stepped down to a lower level of care. Thus, 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: Overturned

A 56-year-old female enrollee has requested a 12-month transition program to safely transition her to an in-network provider for the treatment of her behavioral health problems. Findings:  The physician reviewer found that articles in the psychiatric literature have shown positive relationships between continuity of care and health outcomes among persons with severe mental illness (Adair, et al.) and that strong clinician-patient relationships, relational continuity, and a caring, collaborative approach facilitate recovery from mental illness time and improved quality of life (Green, et al.).  Given the reported presence of improvement in function (such as returning to part-time work, decreased medications and decreased suicidal ideation), the patients apparent motivation and participation in treatment and the presence of medical literature indicating the positive effects of sustained continuity of care, the provision of services as requested would lead to improved outcomes, decrease the potential for clinical deterioration, and also enhance the other services being provided.
Appeal type: Experimental/Investigational
Decision: Upheld

A 70-year-old male enrollee has requested X-Stop Interspinous Process Decompression for the treatment of his lumbar spinal stenosis. Findings:  Two physician reviewers found that this patient has a history of chronic back pain and pain in his legs. There is no history of sciatic symptoms. He has stenosis by MRI scan with canal diameter down to 6 mm at L4-5. There are no large, scientific, long-term studies of X-Stop versus laminectomy versus conservative care. All available studies are of small numbers. No studies have been blinded. Given the paucity of evidence to date, the superiority of the X-Stop procedure remains unproven.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage of MRI of the left shoulder. Findings:  The physician reviewer found that correlative magnetic resonance images may be used in diagnosing the presence of three common shoulder pathologies, including rotator cuff pathology. In this case, the patient reported posterior shoulder pain, limitation of motion, and pain while sleeping. The provider suspected a rotator cuff tear and recommended an MRI scan and an orthopedic consultation. As the MRI may provide information that may aid in treating and managing the patients pain, the requested service is medically indicated. Therefore, MRI of the left shoulder is medically necessary for the evaluation 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 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: Overturned

A 34-year-old female enrollee has requested for a magnetic resonance imaging (MRI) of the lumbar spine and pelvis for evaluation of her lumbar back and leg pain.  Findings:  The physician reviewer found that the available clinical history indicates the patient has back pain, leg and hip pain, and weakness and atrophy of the leg. This history alone implies compression to a nerve, either in the lumbar spine or in the lumbosacral plexus in the pelvis. The possible causes include a disc herniation, lumbar spinal stenosis or lateral recess stenosis, an infection or a tumor involving the nerve root sheath in the spine or pelvis. The best available diagnostic test to rule out these possibilities is an MRI. This would avoid more indirect tests and it is non-invasive.