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

A 66-year-old female enrollee has requested X-STOP procedure for the treatment of her lumbar spinal stenosis. Findings:  Two physician reviewers found that there is level I evidence that the X-STOP procedure is effective in treating lumbar spinal stenosis. It has been approved by multiple societies and proven effective and safe in several studies. Kuchta and colleagues concluded that, The interspinous device does not replace microsurgical decompression in patients with massive stenosis and continuous claudication, but offers a safe, effective and less invasive alternative in selected patients with spinal stenosis. The authors noted that their single center results indicated satisfactory short and long-term effect during a follow-up period of two years. Zucherman and colleagues suggested that, The X-STOP provides a conservative yet effective treatment for patients suffering from lumbar spinal stenosis. In the continuum of treatment options, the X-STOP offers an attractive alternative to both conservative care and decompressive surgery. All told, there is adequate evidence to support the use of the X-STOP procedure in this setting.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a 14-year-old female enrollee has requested inpatient psychiatric hospitalization for treatment of the enrollees major depressive disorder. Findings:  The physician reviewer found the submitted documentation supports the medical necessity of the services at issue.  This patient continued to report suicidal ideation with plan.  For the duration of her hospitalization, she remained on 15-minute monitoring.  The records do not indicate that progress was made in terms of response to treatment, as she was described daily as having poor insight into appropriate management of emotional regulation with poor judgment and impulse control.  The current medical evidence supports inpatient psychiatric hospitalization in this clinical setting.  All told, inpatient psychiatric hospitalization was medically indicated for the treatment of this patient.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested reimbursement for outdoor behavioral health therapy services (wilderness program).Findings: Two out of three physician reviewers found that the outdoor behavioral health therapy (wilderness program) services at issue were not likely to have been more beneficial than any other available standard therapy for the patients condition.Despite the reported positive benefits of outdoor behavioral health programs, the literature does not support claims that outdoor behavioral health programs are more effective than other therapies. Very few studies directly compare outcomes of outdoor behavioral health programs to other therapeutic interventions. A scoping review conducted by Dobud and Harper found only 13 such studies and concluded that few significant differences were found to pinpoint specific ingredients required to produce significant change. Little to no differences were found to isolate specific therapeutic factors. Although outdoor behavioral health programs can be an effective treatment intervention for adolescent substance use and mental health disorders, there is no evidence to support the claim that it is more beneficial than any other available standard therapy. Although the outdoor behavioral health program literature contains a number of studies that suggest that participants show some level of improvement on behavioral health outcomes, there are considerable limitations in the research methodology used to examine these programs and the results are not conclusive. Most notably, there is a lack of randomized controlled trials or well-designed cohort studies that would allow causal conclusions about the impact of outdoor behavioral health programs to be drawn. Accordingly, the outdoor behavioral health therapy (wilderness program) services at issue were not likely to have been more beneficial than any other available standard therapy for the patients condition.Final Result: The reviewers determined that the services at issue were not likely to have been more beneficial than any other available standard therapy for the patients condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: Physician reviewers 1, 2 and 3 are board certified in psychiatry, with subspecialty certification in child and adolescent psychiatry, and are actively practicing. All three reviewers are experts in the treatment of the enrollees medical condition and are 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 Synvisc One injections to the left hip for treatment of the enrollees degenerative arthritis of the left hip.  Findings: Three physician reviewers found that although viscosupplementation has been used for many years as non-operative treatment for osteoarthritis of the knees, mixed results have been reported in the literature. With respect to viscosupplementation of the hip joint, the medical literature demonstrates that results have been generally disappointing in hip osteoarthritis. In addition, the American Academy of Orthopedic Surgeons (AAOS) guidelines for treatment of osteoarthritis of the knee does not support the use of viscosupplementation. In sum, there is a lack of medical literature supporting viscosupplementation as effective for osteoarthritis of the hip. As such, the requests for Synvisc One injections to the left hip joint are not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: Three reviewers determined that the requested medication 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 physician reviewers are board certified in orthopedic 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: Experimental/Investigational
Decision: Upheld

An enrollee has requested reimbursement for the OncotypeDX Prostate Cancer genetic testing provided by Genomic Health, Inc. This patient underwent genomic and protein biomarker testing with the OncotypeDX to aid in clinical decision-making with regard to his prostate cancer. Current peer-reviewed medical literature supports an indication for molecular and genomic testing for patients with low risk disease to make decisions regarding observation versus treatment. Drawbacks include heterogeneity of prostate cancer and uncertainty of potential clinical benefit. Researchers concluded that further understanding is needed to appreciate the potential benefits and limitations of these novel tests. All told, the OncotypeDX Prostate Cancer genetic testing provided by Genomic Health, Inc. 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 services at issue were 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 reviewers 1, 2, and 3 are board certified in urology 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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Nalu Neurostimulation System (peripheral nerve stimulation). This patient presents with chronic intractable pain of peripheral nerve origin. There is documentation that the patient has been treated with standard therapies including medications, physical therapy, behavior modification, chiropractic care, and psychiatric services for more than six months. The patient reportedly obtained at least 50% of pain relief with a diagnostic nerve block and a three to seven day trial of percutaneous peripheral nerve stimulation. The provider has recommended implantation of the Nalu Neurostimulation System. Peripheral nerve stimulation has been used in the treatment of several chronic pain conditions including pain due to peripheral nerve dysfunctions, complex regional pain syndrome, and cranial neuralgias. Current data supports that peripheral nerve stimulation can be effective for chronic, intractable pain that is refractory to conventional therapies such as physical therapy, medications, and nerve blocks. Multiple studies have shown that peripheral nerve stimulation can be helpful to decrease pain in patients with severe pain in the distribution of a peripheral nerve (Walsh, et al.). Therefore, the requested Nalu Neurostimulation System (peripheral nerve stimulation) 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 Nalu Neurostimulation System (peripheral nerve stimulation) 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 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

The parent of a 16-year-old female enrollee has requested  for the enrollees participation in a wilderness program for treatment of the enrollees behavioral health problems. Findings:  Three physician reviewers found that wilderness programs are considered experimental at this time. There is inadequate evidence documenting their efficacy. There were other available treatments that were likely to be more effective for this patient, including medication.  There is no evidence the patient received an adequate trial of standard therapy prior to entering the wilderness program.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Euflexxa injections for the left knee.Current medical literature pertaining to viscosupplementation reveals mixed results. Evidence from eight systematic reviews and six randomized controlled trials indicate that although viscosupplementation may relieve knee pain in some individuals with osteoarthritis, it is not known which individuals will benefit. Different studies have tried mixing hyaluronic acid with corticosteroids, platelet rich plasma, and other agents to make it more effective. The current evidence is limited and guidelines from organizations such as the American Academy of Orthopedic Surgeons indicate that the evidence is not conclusive. As such, the Academy does not currently support viscosupplementation as standard treatment for osteoarthritis of the knees. In light of the foregoing, viscosupplementation can only be recommended in individuals with a history of lasting benefit from prior injections and in carefully selected cases when everything else has been tried and the options are limited. In this case, the patients options are clearly limited. The patient has tried and failed other conservative treatments, with the alternative being a total knee arthroplasty in the presence of mild osteoarthritis. Under these circumstances, Euflexxa injections for the left knee are medically necessary to treat 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 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: Upheld

A 56-year-old female enrollee has requested anesthesia services provided during a colonoscopy for treatment of her medical condition. Findings:  The physician reviewer found that the monitored anesthesia care (MAC) provided on the date indicated was not medically necessary for the patients colonoscopy. The patient did not present with a medical history that would require monitored anesthesia care. The standard of care for monitored anesthesia care for a minimally invasive procedure is airway difficulty, large fluid shifts and co-morbid conditions that would put the patient at risk during the procedure. There is no evidence within the documentation submitted for review of co-morbid conditions that would place the patient at risk for complications requiring the need for monitored anesthesia care. Moreover, a colonoscopy may be safely and effectively performed with conscious sedation of a benzodiazepine alone or with a narcotic in an office-based setting and without the need of monitored anesthesia care with propofol, as required per the American Society of Anesthesiologists (ASA) guidelines. McQuaid and Laine performed a systematic review of randomized controlled trials to compare efficacy, safety, and efficiency of agents used for moderate sedation in esophagogastroduodenoscopy (EGD) or colonoscopy. The authors concluded that moderate sedation provides a high level of physician and patient satisfaction and low risk of serious adverse events with all currently available agents. Midazolam-based regimens have longer sedation and recovery times than propofol. Based on the documentation submitted for review and the peer-reviewed literature cited above, the services at issue were not medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld

The parents of a 14-year-old female have requested growth hormone therapy for treatment of short stature.  Findings:  The physician reviewer found that there is no medical documentation to support the necessity of growth hormone therapy in this case. In fact, administration of growth hormone at the patients current bone age maturation can be detrimental.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for inpatient residential treatment services. Findings:  The physician reviewer found that The American Society of Addiction Medicine (ASAM) supports individualized, person-centered treatment that is responsive to specific needs and patient progress rather than focusing on placement in a program with a fixed length of stay, moving from program-driven to clinically driven and outcomes-driven treatment. The ASAM criteria is a set of objective guidelines used by clinicians to assist with treatment planning and advocates for service intensity provided in the least intensive but safe treatment setting.In this case, on admission, the patient had no symptoms of withdrawal and was not at imminent risk for withdrawal. He was not a danger to himself or others. There were no emotional, behavioral, or cognitive barriers to providing this patient with the treatment at a lower level of care. The patient reported that his pattern of use was not daily. He was ordered no medications except for ibuprofen and acetaminophen as needed. There was no evidence of a high degree of impulsivity, aggression, agitation, depression, mania, hallucinations, or any other significant symptom that would interfere with his care.The patient was motivated and appeared to be compliant with the program. He was accepting the principles of treatment and involving himself in his recovery. His parents were supportive and involved in his recovery. Psychiatrically, the patient did not require the containment of a 24-hour/seven days per week environment with 24-hour/seven days per week medical and nursing monitoring. The patient recognized his triggers and the negative consequences of his behavior and was progressing well in working the steps outlined in Alcoholics Anonymous. He was receptive to learning new coping skills for relapse prevention.Relapse risk is inherent in this population and is not a reason to keep a patient in this setting. There was nothing to suggest that the patient could not have been treated in an ambulatory setting at a lower level of care in conjunction with community-based supports, such as the 12-step program with a sponsor. Therefore, the inpatient residential treatment services provided to the patient were not medically necessary for the 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 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

A 69-year-old male enrollee has requested the medication Levaquin (500 mg daily) for the treatment of his pulmonary infections. Findings:  The physician reviewer found that continuous daily antibiotic treatment with Levaquin 500 mg is not medically necessary for this patient. The recommended dose for exacerbation of chronic bronchitis is 500 mg daily, but not on a continuous basis. The recommended duration of antibiotic therapy for respiratory infections is 5 to 14 days. Furthermore, there is evidence that longer durations (seven days versus five days) of antibiotic therapy are not more efficacious in treating exacerbations of chronic obstructive pulmonary disease (COPD) (Falagas). All told, there is no convincing peer-reviewed evidence that continuous daily antibiotic therapy reduces the frequency or severity of respiratory infections, prevents exacerbations of COPD or is effective for any other respiratory condition such as restrictive lung disease, interstitial lung disease, or bronchiectasis.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a six-year-old male enrollee has requested speech therapy services for treatment of the enrollees speech delay.  Findings:  The physician reviewer found that review of the submitted documentation supports the medical necessity of the requested speech therapy in this patients case. The patient has an identified delay in expressive speech with articulation deficits and pragmatic speech delays. His speech delays are approximately 40% of normal speech. Speech therapy is indicated with any delay greater than 25% (Feldman and Messick). 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. Additionally, speech therapy plays a key role in the management of speech sound disorders, with which this patient also presents. Speech therapy is particularly useful in helping affected children to identify and practice the mature patterns of speech. The goal is to attain improvements in functional communication. Feldman and Messick note that children who participate in speech-language treatment show better improvement than children who receive no treatment. Based upon this patients documented expressive and pragmatic speech delays, speech therapy is medically appropriate and necessary.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested coverage for residential treatment center services for treatment of the enrollees behavior health condition.  Findings: The physician reviewers found that in this clinical setting, the services at issue were not and are not medically necessary for the treatment of the patient. There were no post-acute withdrawal symptoms. The patient was not a danger to himself or to others.  There were no emotional, behavioral, cognitive, or impulsive symptoms that would warrant this level of care. He was medically and psychiatrically stable. He was motivated and appeared to be working the program. No new problems had arisen and there was no evidence to indicate that returning him to his environment would lead to destabilization. The patient had just completed a residential treatment. Moreover, there was no indication that additional residential treatment would have provided significant improvement. The provided records demonstrated that he could have safely been treated at an ambulatory level of care in conjunction with a 12-step program and a sponsor. Residential treatment was not medically indicated as he did not require 24-hour supervision.  As such, the services at issue were not and are not medically necessary for the treatment of this patient.Final Result: The reviewers determined that the services at issue were not and are not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The physician reviewer is board certified in psychiatry and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.