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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for hydrogel spacer (CPT 55874). This patient presents with a history of prostate cancer. As part of his treatment regimen, the patients providers have recommended use of hydrogel spacers to decrease the toxicity to the rectum while the patient receives proton beam radiation therapy. As noted in the medical literature, hydrogel spacers can be utilized during radiation treatment of the prostate to increase the space between the rectum and prostate and decrease the amount of radiation that is delivered to the rectum (Hamstra, et al.). In a randomized phase 3 study in patients undergoing radiation for prostate cancer, the risk of late adverse events grade 2 or higher, declined from 5.7% to 0% in the control versus hydrogel spacer group. The spacer group also had a significant reduction in bowel quality of life decline. The National Comprehensive Cancer Network (NCCN) guidelines also endorse the use of hydrogel spacers in patients undergoing radiotherapy for prostate cancer. Therefore, requested hydrogel spacer (CPT 55874) is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Findings: Two of the three physician reviewers found the requested hydrogel spacer (CPT 55874) 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.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for power wheelchair accessories including sit to stand features. This patient presents with relapsing remitting multiple sclerosis. Per the provider, the patients condition has progressed, and she is unstable for transfers. The provider has recommended a power wheelchair with elevation seat system and power stander to enable her to safely perform activities of daily living and improve bilateral lower extremity swelling. There is a lack of evidence demonstrating that use of a power stander feature equipped on a power wheelchair provides clinically significant benefits with respect to health or functional outcomes in the setting of neurological weakness due to multiple sclerosis or other conditions impairing the active ability to stand. Overall, use of a power stander has not been demonstrated to improve muscle function, skin integrity, bony health, respiratory function, or digestive function in a significant manner in this patient population. With respect to wounds, the standing feature could mitigate risk in some areas, but would also introduce new areas that would be at higher-risk for pressure ulcer development. Power seat elevation can be an appropriate component for a power wheelchair in order to improve a patients independence with transfers. However, this patients records do not document that the patient is dependent on a mechanical transfer device for her transfers to support an indication for power seat elevation. Overall, there is a lack of documentation that the requested equipment will provide this patient with improved health or functional mobility. All told, the requested power wheelchair accessories, including sit to stand features, are not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Findings:  Two of the three physician reviewers found the requested power wheelchair accessories, including sit to stand features, 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 equipment is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: Physician reviewer 1 is board certified in physical medicine and rehabilitation and is actively practicing. Physician reviewer 2 is board certified in physical medicine and rehabilitation with subspecialty certification in neuromuscular medicine and is actively practicing. Physician reviewer 3 is board certified in physical medicine and rehabilitation and is actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned

The parent of a 15-year-old male enrollee has requested Remicade (infliximab) for treatment of the enrollees uveitis.  Findings:  Two physician reviewers found that in this patients case, the requested medication is likely to be more effective than other available treatment options.  Prior standard therapies, including steroids and methotrexate, have not resulted in improvement.  The patient has developed adverse sequelae to the long-term use of steroids.  There is sufficient support in the current medical literature for the requested medication in this clinical setting.  All told, Remicade is likely to be superior over other available treatment alternatives in this case.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patients parent has requested authorization and coverage for Omnitrope solution cartridge 10 mg/1.5 mL. In this case, the patient has mild central precocious puberty. The records document that the patients height is within the normal range for North American adult men. While a standard evaluation of pediatric short stature includes direct measurements of parental heights due to inaccuracy from self-reported heights, in this case, it is unlikely that direct measurements would change the mid-parental target height (MPTH) below the normal range for North American adult men. Given that the patients predicted adult height is within the normal range for North American adult men and also consistent with his family MPTH, the requested medication is not medically indicated. Therefore, Omnitrope solution cartridge 10 mg/1.5 mL is not medically necessary 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 pediatrics with sub-specialty certification in pediatric endocrinology 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 53-year-old male enrollee has requested Provigil for the treatment of his insomnia and daytime sleepiness secondary to congenital blindness. Findings:  The physician reviewer found that this patient has circadian rhythm disorder associated with blindness and excessive sleepiness as a consequence. The patient also has depression that appears to be better controlled with Provigil. Clinically, the benefits of Provigil are well documented in the records provided for review. Circadian rhythm disorder can be compared to shift-work sleep disorder, which is one of the indications for Provigil. The difference is the cause, but the outcome is the same (i.e., irregular sleep-wake cycle and insomnia with sleepiness as a consequence). Provigil has also been used in depression with good effect, and in several other conditions which are not FDA approved. As the patients diagnosis of irregular sleep-wake cycle closely corresponds to one of the approved indications for Provigil, and considering the severity of the patients disorder, the dual benefit from use of Provigil is strongly indicated for this patient.
Appeal type: Experimental/Investigational
Decision: Upheld

A 34-year-old female enrollee is requesting authorization and coverage for intravenous immunoglobulin (IVIG) therapy for treatment of her severe hyperimmunoglobulin E with chronic sinusitis and/or recurrent miscarriage.  Findings:  Two physician reviewers found that the use of IVIG to treat chronic pansinusitis and presumed asthma has not been established to be superior to standard treatments in this situation.
Appeal type: Medical Necessity
Decision: Upheld

The patient has requested reimbursement for monitored anesthesia care services provided during a colonoscopy. In this case, the patient underwent a colonoscopy. The patient did not have any heart, lung, kidney, or liver disease. There was no documentation of a history of alcohol or substance abuse. The patient was not morbidly obese and was unlikely to present as a difficult airway to manage. The literature does not support the use of monitored anesthesia care in a patient who does not have significant health conditions or airway concerns. Rather, the guidelines suggest there is high quality evidence to support the use of mild to moderate sedation in healthy uncomplicated endoscopy procedures, such as in this case. Based on the current medical evidence, the services at issue were not medically indicated. Therefore, monitored anesthesia care services provided during a colonoscopy were not medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested service was 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 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 55-year-old male enrollee has requested Sovaldi with Pegasys and ribavirin for treatment of his hepatitis C genotype 1B.  Findings:  The physician reviewer found that the use of Sovaldi in conjunction with Pegasys and ribavirin is supported by the medical literature. Lawitz and Gane demonstrated the safety and effectiveness of this medication combination in a Phase III study. The expected sustained viral response (SVR) for this patient is greater than 90% with this medication regimen. In addition, the requested medications are consistent with the standard of care according to the American Association for the Study of Liver Diseases (AASLD). All told, the requested Sovaldi with Pegasys and ribavirin is supported as medically necessary for treatment of this patients chronic hepatitis C virus.
Appeal type: Medical Necessity
Decision: Overturned

A 56-year-old female enrollee has requested cardiac evaluation and more frequent cardiology evaluations for the treatment of her heart condition. Findings:  The physician reviewer found that studies performed have demonstrated that more effective care is given to patients for the treatment of cardiac disease when performed by a cardiologist compared to care performed by an internist. Thus, annual follow-up visits with a cardiologist are medically necessary, unless recurrent symptoms develop that are of concern for an exacerbation of her underlying heart disease, thereby requiring more frequent evaluation. That said, there is no evidence that the patient needs to continue to be followed by her doctor specifically. A referral to a board certified cardiologist would be medically reasonable and appropriate in this setting.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/ Case Summary:  The enrollees parent requested authorization and coverage for the injectable medication, Aimovig, for treatment of chronic migraine headaches.According to the medical record, the enrollee has chronic migraine headaches, status migrainosus, and tectal glioma (a benign lesion in his brain). He underwent endoscopic third ventriculostomy (ETV) surgery for hydrocephalus. He is followed by a neurologist for symptoms of daily headaches with pain spikes. He also gets nausea, lightheadedness, light sensitivity, movement sensitivity, and noise sensitivity associated with the migraines. He has missed a lot of time at school.  For his symptoms, he has tried treatment with Propranolol, amitriptyline, Venlafaxine, riboflavin, Melatonin, Sumatriptan, Rizatriptan, Vicodin, Norco, Diclofenac, Compazine, Zofran, Naproxen, and vaping THC. He also had right occipital trigger point injection and admission for intravenous dihydroergotamine (DHE), but neither had any benefit. He also tried Cognitive Behavioral Therapy (CBT), but after 4 sessions there was no benefit. Amitriptyline was started with some benefit. His neurologist states that his PedMIDAS score is 38, which is indicative of severe disability from headaches. He was hospitalized for 3 days for a Depacon infusion. He continued to have daily headaches and his neurologist increased his dose of amitriptyline and recommended re-trialing CBT. He was 4 weeks into a long stretch of high intensity migraine and his neurologist has determined he needs more aggressive therapy. She recommended an admission for intravenous Thorazine followed by initiation of treatment with monthly subcutaneous injections of Aimovig. The medical literature notes that Aimovig is a calcitonin gene-related peptide receptor antagonist indicated for the preventive treatment of migraine in adults. The safety and effectiveness in pediatric patients has not been established. Future studies are needed to provide additional evidence for both safety and efficacy of migraine-specific agents already in use for treating adults. There is a current clinical trial to evaluate the efficacy and safety of erenumab (Aimovig) in migraine prevention in children (6 to <12 years) and adolescents (12 to <18 years) with episodic migraine.Final Result: Two of the three reviewers determined that the requested service is not likely to be more beneficial than any available standard therapy for treatment of the enrollees medical condition. Credentials/Qualifications: Three reviewers are board certified in Pediatric Neurology. All 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 33-year-old male enrollee requested inpatient treatment for medical treatment of the enrollees medical condition.  Findings:  The physician reviewer found that the submitted documentation supports the medical necessity of a portion of the services.  This patient was hospitalized with septic shock.  He was treated appropriately and stabilized.  The patient remained tachycardic despite fluid resuscitation.  He was noted to have decreasing hemoglobin and was transfused blood.  Imaging of the lungs was negative for a pulmonary embolism, and he was transferred to the general floor.   The patient continued to require hemodialysis, antibiotics and therapy.  He had a fever with an increasing white blood cell count and was again transfused due to continued anemia with sinus tachycardia.  He remained otherwise hemodynamically stable and could have been transferred to a lower level of care.  At this juncture, the patient was ambulating with assistance and was tolerating an oral diet.  All told, it was determined that a portion of the services was medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld

A 52-year-old female enrollee has requested  a muscle biopsy for evaluation of her myalgia. Findings:  The physician reviewer found that review of the submitted documentation and relevant literature fails to demonstrate the medical necessity of the requested services. In this case, the patient has chronic myalgia and complaints of leg weakness and has had an extensive work-up including neurology and rheumatology consultations. Muscle weakness on examination has not been documented in the medical records submitted for review and laboratory studies have been normal with the exception of an elevated ESR, a non-specific finding. There is no laboratory evidence of muscle injury, with both CK and aldolase reported as normal on multiple occasions. The requested muscle biopsy is not indicated given non-invasive investigations have been normal or negative. The diagnostic yield of muscle biopsy is dependent on selection of a muscle that is weak on exam, but in this case there appears to be no objectively weak muscles. For the reasons provided, the requested services are not medically necessary for evaluation of the patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned

A female enrollee requested admission to a tertiary center, such as University of California at Irvine, for diagnostic pelvic magnetic resonance imaging (MRI) or computed tomography (CT) scan and hysterectomy for medical evaluation and treatment of her anemia and menorrhagia. Findings:  The physician reviewer found that for patients with bleeding significant enough to require transfusion, a work-up for the underlying pathology is indicated, especially given the high risk of uterine and/or endometrial cancer. In this case, the patient will likely require surgery to help control her bleeding because of the size of her uterus, known large fibroid, and degree of menorrhagia that has led to anemia and transfusion. In addition, her ongoing risks of hyperplasia and malignancy related to her morbid obesity as well as her overall medical history makes her a poor candidate for conservative treatments. Thus, the patient requires work-up that includes a facility that can accommodate her weight issues, such as imaging capabilities, operating room table and equipment. Therefore, the medical necessity of the requested admission to a tertiary center for diagnostic pelvic MRI or CT scan and hysterectomy has been established in this clinical setting.
Appeal type: Medical Necessity
Decision: Upheld

The parent of a four-month-old male enrollee has requested skilled nursing services for treatment of the enrollees congenital dislocation of the right knee. Findings:  The physician reviewer found that a congenital dislocation of the knee is a rare medical condition. There is a lack of support in the medical literature documenting a requirement for skilled nursing services during preoperative or postoperative care in these patients.  Based on the medical documentation provided, the services at issue were not medically indicated. During the orthopedic visits, an assessment was provided by the clinic nurse. During the time of serial casting, prior to surgery, the patient was taking ibuprofen for pain.  Postoperatively, the patient was taking Tylenol with codeine. There are no other specific nursing procedures prescribed by the physician. The submitted nursing notes document custodial care and standard cast care for this patient.  The patient did not require documentation of vital signs.  Standard cast care, both with serial casting and postoperative care, typically does not require the services of a skilled nurse.  Pain management with the medications prescribed in this patients case does not typically require nursing supervision.  Therefore, the care provided by the nurse would be considered custodial in nature.  All told, skilled nursing services were not medically indicated.
Appeal type: Medical Necessity
Decision: Overturned

A 64-year-old female enrollee requested Serevent Diskus and ProAir albuterol inhaler, one inhaler per month, for medical treatment of her  medical condition.  Findings:  The physician reviewer found that long-acting beta agonists such as Serevent Diskus may be used for long-term control for persistent asthma.  However, they should not be used as a monotherapy for long-term control of asthma, but rather used in combination with corticosteroids for the long-term control and prevention of symptoms.  Thus, the current medical evidence does not support Serevent Diskus in this clinical setting, as the records indicate that the patient does not desire to utilize inhaled corticosteroid medication.  However, short-acting beta-2 agonists such as the requested ProAir albuterol inhaler are considered a first-line treatment option for acute exacerbation of asthma events.  Therefore, there is sufficient support for the requested ProAir albuterol inhaler for the treatment of this patient.  In sum, the submitted documentation fails to demonstrate the medical necessity of Serevent Diskus in this case.  However, the requested ProAir albuterol inhaler, one inhaler per month, is medically indicated.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a four-year-old female enrollee has requested for speech therapy and occupational therapy for treatment of the enrollees autism. Findings:  The physician reviewer found that OT combined with speech and language therapy can focus on oral-motor intervention to reduce tactile sensitivity and increase muscle tone to enhance language development. The goal of early identification of speech and language problems is to initiate early intervention, which has been shown to improve outcomes for children who have ASD. Eikeseth concluded of his study that patients who received behavioral treatment gained an average of 17 IQ points, 13 points in language comprehension, 23 points in expressive language, and 11 points in adaptive behaviors. In comparison, the eclectic treatment group obtained an average of 4 points in IQ with no additional improvements noted. Finally, the American Academy of Neurology (AAN) guidelines for autism developed in 2000 states, The immediate and long-term evaluation and monitoring of autistic individuals requires a comprehensive multidisciplinary approach, and can include one or more of the following professionals: psychologists, neurologists, speechlanguage pathologists and audiologists, pediatricians, child psychiatrists, occupational therapists, and physical therapists, as well as educators and special educators.
Appeal type: Medical Necessity
Decision: Upheld

A 34-year-old male enrollee has requested Lexapro 10mg for treatment of his anxiety.   Findings:  The physician reviewer found that the patient reports that he has had negative side effects to the recommended formulary alternatives. However, the details were not noted. Additionally, the patients contention is not corroborated by the medical records submitted. The only documentation of an alternative medication is Ativan, with no details regarding dose, length of the trial, side effects or response. All told, the documentation fails to establish the medical necessity of the requested medication in this patients case.