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

Nature of Statutory Criteria/Case Summary:   An enrollee has requested AmniSure testing for evaluation of her pregnancy. Three physician reviewers found that the AmniSure test is used to aid in the detection of rupture of membranes when a patient reports signs, symptoms or complaints suggestive of rupture of membranes or premature rupture of membranes.  The diagnosis of rupture of membranes is typically confirmed by visualization of amniotic fluid passing from the cervical canal and pooling in the vagina, as well as a basic pH test of the vaginal fluid.  In this patients case, the records do not support that standard evaluation of possible rupture of membranes would have been insufficient.  Therefore, AmniSure testing was not likely to be of greater benefit than other methods of evaluation.  Final Result: Three 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 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: Overturned

A 19-year-old male enrollee has requested Avastin for the treatment of his progressive metastatic schwannomas with hearing loss. Findings:  The physician reviewer found that this patient has been diagnosed with recurrent schwannomas. There is a lack of compendium-listed treatment options for refractory schwannomas. The use of Avastin for treatment of this disease has been studied in a peer-reviewed, published, clinical trial and was found to be tolerable and effective. The study by Plotkin and colleagues concluded that Avastin was associated with a reduction in the volume of most growing vestibular schwannomas and improved hearing in some patients. Based on the rarity of the disease, the lack of other treatment options and the proven efficacy in a clinical trial, the use of Avastin is medically indicated for this patient.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for a percutaneous transcatheter closure of congenital interatrial communication (i.e., Fontan fenestration, atrial septal defect) with implant for treatment of the enrollees patent foramen ovale (PFO).Findings: Three physician reviewers found that based on the records provided, the patient with a cryptogenic stroke, patent foramen ovale and no documented contraindication to antiplatelet therapy. Although there is an association with patent foramen ovale and cryptogenic strokes, the medical literature does not consistently demonstrate improved outcomes with patent foramen ovale closure compared to medical therapy. For example, the CLOSURE 1 trial by Furlan and colleagues did not demonstrate relative benefit of patent foramen ovale closure using a Starflex device compared to medical therapy. Similarly, Carroll and colleagues showed no significant benefit of closure of a patent foramen ovale using the Amplatzer occluder compared to medical therapy alone in the intention-to-treat analysis. Therefore, the use of percutaneous closure devices for treatment of a patent foramen ovale in the setting of a documented transient ischemic attack or cryptogenic stroke is not indicated, except in specific circumstances where alternative therapies such as aspirin or warfarin are not tolerated, alternative therapies are contraindicated and alternative therapies have failed. In this case, there is no documented contraindication to antiplatelet therapy. Guidelines also do not recommend patent foramen ovale closure in this clinical setting (Messe, et al). For the reasons provided, the request for the percutaneous transcatheter closure of congenital interatrial communication (i.e., Fontan fenestration, atrial septal defect) with implant are 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 services are 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 certified in internal medicine with sub-specialty certification in cardiovascular disease 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

A female enrollee requested genetic testing for arrhythmogenic right ventricular cardiomyopathy for medical evaluation of her medical condition.  Findings:  The physician reviewer found that this patient has an established diagnosis of arrhythmic right ventricular dysplasia/cardiomyopathy.  In this circumstance, genetic testing would not be of benefit for the patient since the diagnosis is not in question and treatment would not change regardless of results.  All told, genetic testing for arrhythmogenic right ventricular cardiomyopathy was not medically indicated for the evaluation of this patient.
Appeal type: Medical Necessity
Decision: Overturned

A 27-year-old female has requested Nuvigil for treatment of her fibromyalgia and chronic fatigue.  Findings:  The physician reviewer found that in the medical literature, there is support for the use of the enantiomer of armodafinil, modafinil, in the treatment of fatigue due to multiple sclerosis (Rammohan, et al; Zifko, et al). However, there is sparse data on the use of armodafinil (Nuvigil) in the treatment of fatigue due to fibromyalgia. This patient has failed multiple treatments for her fatigue, yet has experienced a dramatic clinical response to Nuvigil. The records indicate that the patient is able to function in her work and within her home life without excessive fatigue secondary to medications and her medical condition with Nuvigil. As such, the request for authorization and coverage for Nuvigil has been demonstrated as medically necessary for this patient.
Appeal type: Medical Necessity
Decision: Upheld

A 46-year-old female enrollee has requested removal of right breast implant for treatment of her post status breast augmentation. Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested services.  If there is painful symptomatic grade IV capsular contracture and/or rupture of a silicone gel implant or infection/extrusion of a breast implant, its removal with capsulectomy would be medically necessary.  Removal of the capsule and implant with or without placement of a new implant should alleviate the pain and would prevent migration of the gel to adjacent areas where it could cause additional medical problems.  However, surgery for visible but non-painful capsular contracture (grade III) or palpable but not visible or painful capsules (grade II) is not medically necessary.  In this patients case, the capsular contracture grade is I-II so removal of the right breast implant is not medically necessary.  This patients condition does not constitute an abnormal structure of the body.  All told, the requested removal of right breast implant is not medically necessary and is not reconstructive in nature.
Appeal type: Medical Necessity
Decision: Upheld

The patient is a 41-year-old male with a long-term history of chronic back pain. An MRI revealed degenerative changes in the patients spine. The patient is seeking authorization for a vertebroplasty. There is no evidence the patient has a compression fracture.The patient suffers from chronic lumbar pain with apparent arthritis of the lumbosacral spine. The patient does not have an acute compression fracture. In the absence of such a fracture there is no clinical indication for a vertebroplasty. The patients condition does not meet accepted criteria for consideration of a vertebroplasty. Therefore, I have determined the requested procedure is not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a two-year-old female enrollee has requested for speech therapy for treatment of the enrollees speech delay.  Findings:  The physician reviewer found that the medical literature, one study from Schirmer and colleagues concluded that, Children born prematurely with low birth weight had an increased risk of language acquisition delay, and also had lower cognitive and behavior scores. As noted by Luu and colleagues, preterm infants showed catch-up gains in speech and language using the Peabody Picture Vocabulary Test-Revised. Given the support for the efficacy of speech therapy for young patients with language delays, this patient will most likely develop normal expressive language skills with speech and language therapy. Therefore, the requested speech therapy is medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned

A 59-year-old female enrollee has requested breast cancer gene (BRCA) testing for an evaluation of her condition. Findings:  The physician reviewer found that BRCA-1 and 2 genes are detected in only 5-10% of women with breast cancer. As this patient has no history of breast cancer, and from the submitted records does not have a relative with this known mutation, the probability of having the gene is likely the same as the general population. With that said, the status of the gene mutation in the blood relatives that have had breast cancer at an early age is unknown. This fact may put the patient at a slightly higher risk of having the mutation. In the submitted Health Plans Medical Policy for Genetic Testing for Cancer Susceptibility for BRCA-1 and 2 states, persons with a family history of three or more relatives with breast or ovarian cancer, at least one of which is a first or second degree relative. Thus, the patient appears to meet the Plans criteria for BRCA 1 and 2 testing. Given the patients significant family history of breast cancer, I find BRCA-1 and 2 testing should be performed. The guidelines for testing of BRCA-1 and 2 cite genetic counseling as a central feature. The submitted records do not document a consultation with a geneticist. The treatment implications for a positive or negative result should be discussed with a qualified genetic counselor. Therefore, the patient should see a genetic counselor prior to having the test performed.
Appeal type: Experimental/Investigational
Decision: Upheld

A 30-year-old female enrollee has requested extracorporeal shock wave therapy for the treatment of her plantar fasciitis. Findings:  Two physician reviewers found that the available medical literature shows there is some evidence that ESWT can provide a moderate degree of pain relief in selected patients with chronic plantar fasciitis who have failed appropriate conservative therapy. However, optimal treatment parameters have not been established, patient selection criteria have not been adequately defined, and there is a lack of information regarding the durability of treatment effect or any long-term adverse effects of ESWT. In addition, there have been conflicting results among the randomized controlled studies, raising doubts regarding the efficacy of ESWT for plantar fasciitis. Based on the scientific evidence available to date, there is insufficient evidence to indicate that ESWT was likely to be more beneficial for the treatment of the patients condition than any available standard therapy.
Appeal type: Medical Necessity
Decision: Upheld

A 55-year-old male enrollee has requested Remicade, 300mg every two weeks for the treatment of his rheumatoid arthritis of the spine (ankylosing spondylitis). Findings:  The physician reviewer found that the medical literature failed to find support for a maintenance dose of infliximab (Remicade) at intervals of 2 weeks in ankylosing spondylitis. In one clinical trial published by van der Heijde and colleagues, the dose of Remicade was pushed to 7.5 mg/kg in patients who met defined criteria for disease activity, but the dosing interval was not shortened. The standard textbook of Rheumatology does not recommend a dose interval of less than 6 weeks for maintenance therapy in ankylosing spondylitis. Nor do the submitted medical records provide any insight into the rationale for giving a dose of Remicade which greatly exceeds the usual recommended dose, particularly when multiple upper respiratory infections have been documented.
Appeal type: Medical Necessity
Decision: Upheld

A 24-year-old female enrollee has requested additional substance abuse intensive outpatient program (IOP) services for treatment of her polysubstance dependence. Findings:  The physician reviewer found that based on the medical literature and the documentation submitted for review, the services at issue are not and were not medically necessary for treatment of the patients medical condition. In this patients case, she is not experiencing withdrawals and there is no evidence of suicidal ideation, intent, or plan.  She is cooperative with staff and respectful of others in groups. There are no comorbid medical or psychiatric conditions complicating her recovery. She is willingly engaged in treatment and demonstrates readiness to change. She participated in the group process and has been sober since the date indicated. She is gaining understanding and learning coping skills to self-manage. Although she is not engaged in 12 step recovery, there is nothing to preclude her from doing so. Moreover, the patient is fully functioning and does not require observation by and interaction with staff at this level of care. Thus, the patient can safely continue her treatment at a lower level of care such as an office based setting and/or a 12 step program. All told, the requested additional IOP services from the date indicated forward are not and were not medically necessary.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a 17-year-old male enrollee requested intensive outpatient program services for medical treatment of the enrollees behavioral health conditions.  Findings:  The physician reviewer found that this patient struggles with cannabis use disorder and co-occurring mood and trauma-based syndromes, in addition strained parental dynamics.  The literature supports aggressive treatment of appropriate duration in this clinical setting.  Based upon the submitted records, this patient has not consolidated the treatment gains necessary to maintain affective harmony and abstinence outside of the intensive outpatient program setting.  The services provided at the intensive outpatient program level of care are consistent with good medical practice and are reasonably expected to improve the patients condition while preventing a more serious episode of illness.  All told, intensive outpatient program services were and are medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a two-year-old female enrollee has requested  for speech therapy for treatment of the enrollees childhood apraxia of speech. Findings:  The physician reviewer found that speech therapy is indicated with any delay greater than 25%. An extensive review of the literature including a meta-analysis by Law, et al. noted the positive effect of speech and language therapy interventions for children with expressive phonological and expressive vocabulary difficulty. Feldman and Messick note that treatment for language disorders is predicated primarily on the childs language profile and level of communication skills. Childhood apraxia of speech is a condition in which children have difficulty with the controlled production of speech sounds. The etiology is thought to be neurologic in origin. Affected children make errors in producing vowels and consonants, and show enormous variability in terms of phonemes, loudness, and related features. This inconsistency in their production makes interpretation of their speech very challenging. Intensive levels of treatment are needed to help children with childhood apraxia of speech. Research suggests that these children require intensive therapy and a large number of sessions to move from 50% of their speech being understood by unfamiliar listeners to 75% of their speech being understood (Campbell, T.F.). Children who participate in speech-language treatment show better improvement than those children who receive no treatment (Feldman and Messick).
Appeal type: Medical Necessity
Decision: Overturned

The patient is a 68-year-old female with bronchiectasis. According to the information provided the patient was diagnosed with bronchiectasis with mucoid pseudomonas infection by her pulmonologist. Thereafter, the patient was started on inhaled tobramycin after a hospitalization in December 2003. The patients condition improved after home treatment with inhaled tobramycin. The patient was also started on daily azithromycin as well as bronchodilators. Since starting inhaled tobramycin the patient has improved symptoms and quality of life.Pulmonary function tests performed in May 2004 indicate moderate to severe obstructive lung disease with an FVC of 58%, FEV1 of 56% and FEV1/FVC ratio of 70%. It appears the Health Plan has denied further coverage for inhaled tobramycin on the basis that there is no scientific evidence supporting its use in patients with non-cystic fibrosis induced bronchiectasis.The inability of patients with bronchiectasis to effectively clear secretions results in frequent pulmonary infections. One of the more difficult organisms to treat is pseudomonas. Mucoid pseudomonas is usually seen in patients with bronchiectasis resulting from cystic fibrosis. In those patients inhaled tobramycin has been beneficial in decreasing symptoms and hospitalizations. Regarding non-cystic fibrosis patients, Barker, et al. reported a decrease of sputum pseudomonas density in bronchiectasis with inhaled tobramycin. In addition, Drobnic, et al. reported a decrease in risk for hospitalization in patients treated with inhaled tobramycin in non-cystic fibrosis bronchiectasis. Furthermore, Orriols, et al. suggests that long-term inhaled tobramycin may be safe and lessen disease severity in non-cystic fibrosis patients with bronchiectasis and chronic bronchial infection with pseudomonas. Moreover, it is evident tobramycin has been beneficial for this patient.Based upon the information set forth above, I have determined the requested therapy is medically necessary for treatment of the patients medical condition. Therefore, the Heath Plans denial should be overturned.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: A patient has requested reimbursement for the occipital nerve block injection that was received and/or authorization and coverage for future injections. The Health Plan has denied the services at issue as investigational. Findings:  Two out of three physician reviewers found that greater occipital nerve blocks are a simple, safe and effective method, with mild side effects and can be used in patients with inadequate pain relief in spite of medical prophylaxis, or in those who have not tolerated medical treatment. Compared to control intervention, GONB intervention can significantly alleviate pain, reduce the number of headache days and medication consumption, but have no significant influence on the duration of a headache per four weeks for migraine patients. In this case, the record indicates the patients migraines were relatively well-controlled with Cymbalta and the use of Reglan and Benadryl for acute therapy. There is no mention of status migrainosis, failure to respond to triptans, non-steroidal anti-inflammatory drugs or other standard treatments for acute migraine. While occipital nerve block is frequently used to treat refractory migraine in order to break a migraine cycle, and sometimes for migraine prevention, there is no documentation that this was the issue in this case. One physician reviewer found that Nerve blocks, including occipital and trigeminal blocks, are widely accepted in headache medicine. They are commonly used in headache centers for the treatment of acutely severe migraines, as well as preventive treatment.Final Result: The reviewers determined that the services at issue was 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: Physician reviewers 1, 2 and 3 are board certified in neurology 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: Experimental/Investigational
Decision: Overturned

A 60-year-old female enrollee has requested for Botox injections for treatment of her low back pain.   Findings:  Two physician reviewers found that a variety of studies of Botox treatment have shown pain relief due to anti-nociceptive effects directly as well as by reducing muscle spasm. Clinical study results have shown that injecting Botox into trigger points is not a very effective strategy. However, treatment of muscle groups to correct abnormal tone, dystonic contractions, or biomechanical dysfunction, can be beneficial. The safety of Botox treatment is well established through the medical literature. Studies of treatment of back pain have found benefit with doses in the range of 200-300 U. Standard treatment for myofascial back pain includes trigger injections. Trigger injections were performed in this patient with transient relief. Botox therapy provided more sustained relief. Thus, the use of Botox in this case was medically reasonable and appropriate in light of the scientific data available.