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

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for a stab phlebectomy. Findings:  The physician reviewer found that consistent with the guidelines from the Society for Vascular Surgery (SVS) and the American Venous Forum (AVF), the requested stab phlebectomy is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The patient has an accessory saphenous vein, which has demonstrated reflux. The patient meets all of the criteria for surgical treatment of an accessory varicose vein. She has been compliant with conservative measures and there is reflux in the accessory saphenous vein on ultrasound. All told, the requested stab phlebectomy is supported as likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Final Result: All three of the reviewers determined that the requested service is 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 reviewers 1, 2 & 3 are board certified in surgery with sub-specialty certification in vascular surgery 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: An enrollee has requested authorization and coverage for a lumbar/sacral interlaminar epidural injection for treatment of his low back pain.  Findings: The physician reviewer found that the submitted documentation supports the requested services in this clinical setting.  This patient has had trials of conservative therapy, including medication trials and chiropractic therapy.  He has evidence of radiculopathy on physical examination as well as positive MRI findings which support the diagnosis. The patient stated that the previous epidural helped him perform his activities of daily living.  Clinical practice guidelines support the performance of an epidural steroid injection for patients with spinal stenosis. The medical evidence supports the requested services in this patients case. All told, the requested lumbar/sacral interlaminar epidural injection is medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested services are 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 anesthesiology with sub-specialty certification in pain medicine and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a seven-year-old male enrollee has requested speech therapy for treatment of the enrollees articulation disorder.  Findings:  The physician reviewer found that based on the records provided, this patient has a serious articulation deficit that places him approximately two years behind his peers. He is intellectually normal or above normal, so his articulation defect is not due to a developmental delay, but is secondary to a neurological dysfunction of his brain/oral pharynx/tongue network.  Consistent with the publication from Tyler, this patients difficulties stem from this abnormality in his nervous system. Further, Sharp and Hillenbrand state that reviews of the literature indicate the necessity and effectiveness of speech therapy in children over the age of three-years of age with articulation defects. As such, this patient certainly has a specific congenital defect in his brain circuitry and qualifies for speech therapy as required by the Health Plan. Moreover, Pennington and colleagues offer an opinion of the effectiveness of therapy for children with articulation defects in a meta-analysis of the medical literature regarding the treatment of articulation defects in children. The authors concluded that there is limited evidence that demonstrates that speech therapy can alter the natural history of articulation abnormalities in children. As this controversy exists, it is recommended that this patient receive one hour of speech therapy per week for one year and continued if he has made significant improvement in his Goldman-Fristoe score (approximating low normal for age) by the end of the therapy year. All told, the requested speech and language therapy is clearly appropriate and medically indicated for treatment of this patients articulation disorder and should be approved. Moreover, Pennington and colleagues offer an opinion of the effectiveness of therapy for children with articulation defects in a meta-analysis of the medical literature regarding the treatment of articulation defects in children. The authors concluded that there is limited evidence that demonstrates that speech therapy can alter the natural history of articulation abnormalities in children. As this controversy exists, it is recommended that this patient receive one hour of speech therapy per week for one year and continued if he has made significant improvement in his Goldman-Fristoe score (approximating low normal for age) by the end of the therapy year. All told, the requested speech and language therapy is clearly appropriate and medically indicated for treatment of this patients articulation disorder and should be approved.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested authorization and coverage for once-per-week psychological therapy services. Researchers have noted that outpatient therapy is effective for childhood OCD and should be used when patients have not improved enough with medication treatment alone. Literature indicates that psychotherapy is typically used to help persons with depression, anxiety, and posttraumatic stress disorder, among other diagnoses. Researchers observe that there is a need for treatment planning as well as treatment goals in psychotherapy that would typically include symptom reduction of some type. In this case, it is apparent that the patient has anxiety symptoms that have continued over several months and years. While the patient has been receiving medication treatment, this alone has not been sufficient to treat the patients OCD and anxiety. Under these circumstances, once-per-week psychological therapy services are medically necessary for treatment of the patients medical condition.Final Result: The reviewer determined that the requested services are 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 psychiatry, with subspecialty certification in child and adolescent 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: Medical Necessity
Decision: Upheld

The patient is a 37-year-old male who suffered a brain injury resulting from his jumping out of a moving ambulance in January 2004. His wife reports his behavior has been altered and that he exhibits psychological problems. He was evaluated by the Centre for Neuro Skills and inpatient rehabilitation was recommended. The Health Plan has recommended a multidisciplinary evaluation as an alternative to inpatient care. A review of the information provided indicates the patient has some psychological problems. In addition, a review of the record indicates the patient is independent with gait, hygiene, grooming, and bathing. He is independent in all areas of basic self-care. Based upon this information, a multidisciplinary inpatient admission is not medically necessary. The recommended evaluations by the Health Plan are indicated and appropriate to create an appropriate treatment plan for this patient. Therefore, I have determined the requested services are not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld

The parent of a 5-year-old female enrollee has requested Strattera for the treatment of the enrollees condition. Findings:  The physician reviewer found that an exception for the off-label use of a medication for this patient of 5 years of age would be appropriate if the proposed use is consistent with guidelines provided by national academies (such as the American Academy of Pediatrics or the American Academy of Child and Adolescent Psychiatry). These two academies indicate that a non-stimulant medication should not be used until traditional medications have been attempted and failed. The potential problems with a non-stimulant medication are felt to be increased compare to a stimulant medication. If the patient is placed on other medications and fails or has significant side-effects, then the off-label use of Strattera may be considered. The documentation provided does not support the use of Strattera at this time.
Appeal type: Medical Necessity
Decision: Upheld

A fifty-two year-old female with irritable bowel syndrome and chronic right buttock and lower extremity pain secondary to persistent sciatica is requesting authorization of Actiq.  Reviewers Findings:  The reviewing physician found that Actiq has not been approved for the management of chronic pain due to non-cancer related syndromes.  The reviewing physician found that the Health Plan denial should be upheld.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the advanced lipoprotein blood testing. This patients baseline basic lipid profile is within good range. In addition, the patient does not present with any risk factors or symptoms to suggest that she is at risk for early onset cardiovascular disease. For this patient, no current medical treatment of lipids is indicated aside from lifestyle modification. In the medical literature, measurement of advanced lipoproteins has not been shown to provide any information that would alter the treatment strategy in this low risk patient. Based on current recommendations, initial and repeat testing of advanced lipoprotein markers is not considered within the standard of care. In addition, measurement of methylenetetrahydrofolate reductase (MTHFR) polymorphisms has not been shown to be clinically useful in assessing cardiovascular risk. All told, the advanced lipoprotein blood testing was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Findings:  Three physician reviewers found the advanced lipoprotein blood testing was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the advanced lipoprotein blood testing was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Credentials/Qualifications: Physician reviewers 1 and 2 are board certified in internal medicine with subspecialty certification in cardiovascular disease and are actively practicing. Physician reviewer 3 is board certified in internal medicine with subspecialty certifications in cardiovascular disease and interventional cardiology 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 dopamine transporter (DaT) scan of the brain for evaluation of the enrollees tremors. Findings:  Two physician reviewers found that the diagnostic accuracy of DaT scans to detect abnormalities of dopamine metabolism in patients with Parkinsons disease is in excess of 95%. However, this test cannot distinguish between various parkinsonian syndromes. This modality can differentiate benign essential tremor from parkinsonian type tremor. In this patients case, she has already been treated for the presumed diagnosis of benign essential tremor, without a response. Therefore, the test is not supported for therapeutic decision making in this clinical setting. All told, the requested DaT scan of the brain is not likely to be more effective than other methods of evaluating this patient. 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 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: Upheld

Nature of Statutory Criteria/Case Summary:  An enrollee has requested the LINX procedure for treatment of his gastroesophageal reflux disease (GERD).  Findings:  Two physician reviewers found that overall, there is a lack of randomized controlled trials comparing LINX with Nissen fundoplication or other standard surgical anti-reflux procedures to suggest the LINX procedure would be more beneficial for treatment of this patients GERD than standard therapies. One evidence review concluded that the long-term safety and efficacy of LINX - both alone and in comparison to current GERD therapies - remains to be determined (Sheu and Rattner). Another evidence review concluded that, further studies are required to determine its long-term outcomes and its relative efficacy as compared to other established treatments (Loh, et al). In addition, adverse events, such as erosion through the esophagus, have been reported since U.S. Food and Drug Administration (FDA) approval (Bauer, et al). Moreover, LINX is associated with severe dysphagia requiring endoscopic intervention as compared to surgical fundoplication (Sheu, et al). The American College of Gastroenterology guidelines for the management of reflux disease also state that more evidence is needed before LINX can be recommended (Katz, et al). Based on current literature and clinical guidelines, the requested LINX procedure is not likely to be more beneficial for treatment of this patients medical condition than any available standard therapy. Final Result: Two reviewers determined that the requested procedure 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:   All three reviewers are board certified in internal medicine with sub-specialty certification in gastroenterology 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

The patients parent has requested reimbursement and prospective authorization and coverage for Hizentra 8 grams weekly infusions with supplies. This patient present with many recurrent infections and low immunoglobulin levels. The standard of care in this clinical setting includes treatment with intravenous immunoglobulin (IVIG) such as Hizentra. The records provided for review document that since starting treatment with Hizentra, the patient has experienced an improved quality of life. In this particular patient, with six months of treatment, there has been a significant benefit with decrease in provider office visits and he has been able to return to activities of daily living. Researchers described the use of IVIG for primary immunodeficiencies as being definitely beneficial. The authors noted that IVIG is increasingly recognized as a treatment of a variety of medical condition, not only for its ability to fight infection as a replacement therapy but also for its anti-inflammatory and immunomodulating effects. All told, Hizentra 8 grams weekly infusions with supplies were and are medically necessary for treatment of this patients medical condition.Final Result: The reviewer determined that the medication at issue was and 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 pediatrics with subspecialty certification in pediatric oncology 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 47-year-old male has requested past and future coverage for transcranial magnetic stimulation (TMS) therapy for treatment of his depression.  Findings:  Two physician reviewers found that the patient has been diagnosed with major depressive disorder, recurrent, severe. The patients symptoms included irritability, anhedonia, cognitive impairment, sleep disturbance, weight gain, fatigue and thoughts of death. He was noted to have impaired functioning, both socially and occupationally. He has been tried on and failed to achieve significant improvement or remission on multiple antidepressants and augmentation strategies, including: Prozac, Zoloft, Wellbutrin, Effexor, trazodone, Depakote, Parnate, Lamictal, Abilify, Zyprexa, and Seroquel. All of these medications have been either ineffective or produced intolerable side effects. Psychotherapeutic approaches have also yielded inadequate therapeutic effect. The patient was previously treated with transcranial magnetic stimulation (TMS) therapy and has benefitted from the treatment. According to the records provided for review, this patients depression was treatment resistant since multiple antidepressants and augmentation strategies had not successfully brought on remission. In the peer-reviewed studies, Schutter reported that TMS had a moderate effect on patients with treatment resistant depression. Similarly, George and colleagues showed that TMS was significantly more likely than sham treatment to produce remission in patients with treatment resistant depression. With regard to this patients diagnosis, Avery and colleagues demonstrated that TMS is a safe and effective treatment for major depressive disorder. Moreover, the American Psychiatric Association (APA) practice guidelines for treatment of depression suggest that acute phase treatment may include TMS.Thus, TMS is an effective treatment supported by the evidence-based literature. Further, TMS has been granted a category I CPT code by the American Medical Association (AMA), and is FDA approved for patients with treatment-resistant major depressive disorders.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Entresto. Findings:  The physician reviewer found that  (FDA) has approved Entresto for the treatment of patients with heart failure with preserved or mildly depressed ejection fraction. The FDA label also indicates that left ventricular ejection fraction is a variable measure, and clinical judgment should be used in deciding whom to treat. In the study by Solomon and colleagues, the subgroup of patients with an ejection fraction less than 57% showed significant benefit with Entresto treatment. This led the FDA to recently approve Entresto in this patient subgroup. In this case, the patient has a possible familial dilated cardiomyopathy. Her LV is dilated, and her EF is mildly depressed. She is being started on medical therapy as part of a genetic cardiomyopathy evaluation. Although minimal symptoms are present, she is at risk for more severe symptomatic congestive heart failure. Based on prior published data, treatment can affect outcomes, even in the absence of clinical symptoms. Thus, Entresto is medically necessary for the treatment of the 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 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: Experimental/Investigational
Decision: Overturned

A 46-year-old male has requested reimbursement treatment with oxaliplatin in combination with gemcitabine for the treatment of malignant mesothelioma.  Findings:  Three physician reviewers found that there is sufficient literature data to support the use of oxaliplatin and Gemzar in malignant mesothelioma, and to indicate that these drugs are more likely to be efficacious than any other possible chemotherapy drugs.
Appeal type: Medical Necessity
Decision: Upheld

The patient is a 15-year-old female with a diagnosis of idiopathic scoliosis, which has progressed to 50 degrees. In 2000, the patients curve was 34 degrees and she was placed in a full-time thoracolumbosacral orthosis brace. Despite bracing, the patients curve progressed to 50 degrees. A request has been made for an idiopathic Copes Dynamic brace. The Health Plan has denied the request indicating that the requested equipment is not medically necessary for treatment of the patients scoliosis.Review of the current literature reveals no scientific evidence regarding the efficacy of the requested brace. Additionally, there is evidence indicating that if an idiopathic scoliosis progresses to greater than 50 degrees while in an acceptable brace, continued bracing will not prevent further curvature in a premenarchal patient. Also, the primary recommendation of the patients providers is surgical intervention. Given the lack of scientific evidence supporting the requested brace and the degree of curvature experienced by the patient, I have determined that the requested equipment is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.