Persius/imr-appeals huggingface dataset:
Appeal type: Medical Necessity
Decision: Upheld

A 62-year-old male enrollee has requested for cervical spinal fusion for treatment of his neck pain. Findings:  The physician reviewer found that the current medical evidence does not support the requested cervical spinal fusion in this clinical setting.  Fusion is indicated for the treatment of spinal instability, as the result of trauma, tumor, or infection, or following iatrogenic instability, such as following disc removal.  Degenerative cervical spine disease has become a common indication for surgical intervention, after failure of conservative management. All told, the requested cervical spinal fusion is not medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld

Findings:  The physician reviewer found that The patient has requested authorization and coverage for hydrocodone/acetaminophen 10 mg/325 mg (30 tablets/month). On determining when to initiate or continue opioids for chronic pain, Dowell and colleagues report, Nonpharmacologic therapy and nonopioid pharmacologic therapy are preferred for chronic pain. Clinicians should consider opioid therapy only if expected benefits for both pain and function are anticipated to outweigh risks to the patient. If opioids are used, they should be combined with nonpharmacologic therapy and nonopioid pharmacologic therapy, as appropriate.  The authors further note, Before starting opioid therapy for chronic pain, clinicians should establish treatment goals with all patients, including realistic goals for pain and function, and should consider how opioid therapy will be discontinued if benefits do not outweigh risks. Clinicians should continue opioid therapy only if there is clinically meaningful improvement in pain and function that outweighs risks to patient safety. The Federation of State Medical Boards (FSMB) strongly recommends prescribers use opioid therapy for chronic pain that is not cancer-related, or part of palliative care or end-of-life care, only when non-opioid and non-pharmacological options have not been effective and maintain opioid dosage as low as possible and continue only if clear and objective outcomes are being met. In this case, the patient has a diagnosis of lumbar facet and myofascial pain. The patient has reported past relief from lumbar radiofrequency lesioning (RFL). The patients pain management provider has recommended nonpharmacological modalities and does not note that opioid therapy is indicated at this time. While the guidelines are clear that opioid therapy may be initiated for patients for whom the benefit to risk ratio is favorable, in this case, the patient reports using alcohol for pain relief and the records document a history of post-traumatic stress disorder (PTSD) and major depressive disorder. Concurrent usage of alcohol with opioid therapy increases the risk of adverse reactions, and behavioral health disorders are also a known risk factor for opioid related complications. Given that this patient is being treated with non-pharmacological methodologies in a manner consistent with current medical literature, the requested medication is not medically indicated. Therefore, hydrocodone/acetaminophen 10 mg/325 mg (30 tablets/month) is not medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested service is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned

A 47-year-old female enrollee has requested residential treatment services for the treatment of her substance abuse. Findings:  The physician reviewer found that the patients motivation for change was not internal but still external (legal pressure).  She was at high risk for relapse due to many factors. In sum, the patient needed the structure of a residential treatment facility to counter these relapse issues.  This care was necessary before a lower level of care (i.e., outpatient treatment) could be attempted reasonably.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary:   An enrollee has requested Harvoni for eight weeks for treatment of her hepatitis C.   Findings:  The physician reviewer found that the submitted documentation supports the medical necessity of the requested medication.  The proposed treatment is considered the standard of care for the treatment of the patients with hepatitis C, genotype 1 infection.  As per the American Association for the Study of Liver Diseases and Infectious Diseases Society of America guidelines, all patients with chronic active hepatitis C should be treated regardless of fibrosis score.  Per the guidelines, the medical evidence supports treatment in all patients with chronic hepatitis C, except those with limited life expectancy less than 12 months due to non-liver-related comorbid conditions.  All told, Harvoni for eight weeks is medically indicated for the treatment of this patient.  Final Result: The reviewer determined that the requested medication is medically necessary for treatment of the enrollees medical condition.  Credentials/Qualifications: The reviewer is board certified in internal medicine with sub-specialty certification in gastroenterology 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 five-year-old female has requested individual (one-on-one) speech therapy, three to five times per week for treatment of the enrollees apraxia of speech.  Findings:  The physician reviewer found that apraxia of speech, also known as verbal apraxia or dyspraxia, is a speech disorder that affects a persons ability to organize the movements of the muscles used in speech. Individuals with this diagnosis have difficulty making speech sounds voluntarily and stringing these sounds together in the correct order to make words. The severity of both acquired and developmental apraxia of speech varies from person to person. In the most severe cases, a person may not be able to communicate effectively with speech, and may need the help of alternative or additional communication methods. Childhood apraxia of speech can continue into adult life. Research shows that children with developmental apraxia of speech have more success when they receive frequent (three to five times per week) and intensive treatment. Children seen alone for treatment tend to do better than children seen in groups. As the child improves, they may need treatment less often, and group therapy may be a better alternative. Children with developmental apraxia of speech will not outgrow the problem on their own. Speech therapy is often helpful for these individuals. Speech-language pathologists use different approaches to treat apraxia of speech, and no single approach has been proven to be the most effective.  Patients with apraxia of speech usually need frequent and intensive one-on-one therapy. In this patients case, intensive one-on-one speech therapy is standard of care. All told, the requested individual (one-on-one) speech therapy, three to five times per week, is medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Overturned

A 54-year-old female has requested nipple AlloDerm insertion for treatment of her medical condition status post bilateral mastectomy.  Findings:  The physician reviewer found that the patient underwent bilateral skin sparing mastectomy for breast cancer four years agowith removal of the nipples.  She now has bilateral silicone breast implants under the muscle.  Multiple attempts at nipple reconstruction have been made.  The submitted photographs show symmastia, joining of the inframammary folds across the midline, horizontal scars in the outer half of each reconstruction with the right one being indented, a small barely protruding right nipple, and a left nipple that is only visible because of its difference in color versus the surrounding skin.  The submitted photographs support the medical necessity of the requested nipple AlloDerm insertion.  This patients condition constitutes an abnormal structure of the body caused by the surgical treatment of cancer.  Per the photographs, the nipples have not been adequately reconstructed.  A number of reconstructive techniques have been described for nipple reconstruction, including skin grafts, composite grafts, and various local flaps.  As noted in the current literature, the use of AlloDerm in nipple reconstruction can lessen or prevent flattening of reconstructed nipples and produce projection.  Of note, the medical literature supports the use of AlloDerm to bolster skin flap reconstruction.  As long as this patients surrounding tissue will sustain a local flap, then the requested services are indicated.  There is a lack of support for the use of AlloDerm to create or preserve nipple projection in the absence of such a local flap.  All told, the requested nipple AlloDerm insertion is reconstructive in nature and is medically necessary for the treatment of this patient
Appeal type: Medical Necessity
Decision: Overturned

A 23-year-old female enrollee has requested for residential treatment for treatment of her eating disorder. Findings:  The physician reviewer found that she was not appropriate for transition to a less intensive level of care as she continued to pursue antisocial and eating disordered behaviors. The patient continued to drink alcohol and violated her treatment contract, and still requires the level of supervision provided in a 24-hour care residential treatment setting.
Appeal type: Experimental/Investigational
Decision: Upheld

A 38-year-old female enrollee has requested radiofrequency ablation of uterine fibroids for treatment of her symptomatic uterine fibroids. Findings:  Two physician reviewers found that the patient appears to have symptoms of dysmenorrhea and less frequently pelvic pain unrelated to her menstrual cycle. The medical record documents uterine fibroids by a clinical pelvic exam, but these findings are not confirmed on ultrasound. Thus, the location of the fibroids and the individual size of the largest fibroids are not known. In addition, there is no documentation as to whether these fibroids are intramural, subserosal, or submucsoal. In the peer-reviewed medical literature, many of the studies evaluating RFA had selection criteria that defined the overall size of the uterus and the largest fibroid. This patients uterus was documented by clinical exam at 16-week size. However, many of the studies were performed on a fibroid uterus of smaller size and volume. Chudnoff and colleagues excluded patients where the uterine size was greater than 14-week size. The most definitive therapy is a hysterectomy and other minimally invasive approaches include uterine artery embolization and magnetic resonance imaging (MRI) guided high frequency ultrasound ablation. Currently, there are several case reports in the literature on RFA, but more data is needed. Conventional myomectomy procedures are still considered the standard of care for patients who want to maintain the option of future childbearing. For these reasons, the requested services are not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for a 28 day supply (240 pills) of Norco. Findings:  The physician reviewer found that there is a lack of support for the medical necessity of the requested medication in this clinical setting. Chronic pain that has no hope for a cure is considered palliative in nature and treatment. The stepwise World Health Organization (WHO) ladder for pain relief is considered the reasonable approach to pain control in the palliative setting. In the documentation available for review, not all non-opioid treatment options have been utilized. There was no mention of behavior therapy despite much research to support its use. The medical literature recommends consideration of alternatives to opioids as well as to be weaned to a lower dose of opioids or weaned off the medications entirely. In this patients case, there is a lack of objective treatment goals for pain and function for the requested medication. The records indicate that tolerance has taken place since the start of the narcotics. The medical evidence shows that dose escalation is not a long term plan but a short term plan for the treatment of tolerance. Simply adding more pure mu agonists will, for a short while, take care of the symptoms of mu agonist saturation. However, down regulation will transpire and then the patient is back to where they started in terms of their perception in pain. Moreover, not all non-opioid medications classes have been optimized or tried. Finally, continuation of opioid medications, prescribed at higher doses without proper treatment for the opioid use sets this patient up for higher morbidity and mortality. For all these reasons, 28 day supply (240 pills) of Norco is not medically necessary for treatment of the patients medical condition. 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 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: Upheld

Nature of Statutory Criteria/Case Summary: A male enrollee has requested reimbursement and prospective authorization and coverage for mental health and substance abuse residential treatment center (RTC) services. Findings:  The physician reviewer found that records provided for review document that this patient continued to experience cravings, mainly in the moderate range. He was not a danger to himself or others, nor was he aggressive or violent. He was cognitively intact and he was not gravely disabled. There were no emotional, behavioral, cognitive, or impulsive symptoms that would warrant the RTC level of care. He was medically and psychiatrically stable. There was no evidence of a high degree of impulsivity, agitation, mania, hallucinations, or any other significant symptom that would interfere with his care. Although remaining depressed and anxious, and reporting sleep disturbance at three to four hours, these issues did not require the RTC setting for monitoring. Naltrexone was not started until after the date of service in question. He was not on a complicated medication regimen. His doses of trazodone and Vistaril remained unchanged. He was cooperative, motivated and was noted to be working the program. Although the patient had a potential for relapse, he has a history of a long period of sobriety, and extensive experience with 12 step programs. He planned to discharge to sober living. Although he continued to report feelings of guilt, remorse, and repetitive thoughts of his sisters death, he could have received further treatment on an ambulatory level of care such as PHP. He no longer met clinical guidelines for RTC level of care. For these reasons, the RTC services provided from the date of service in question, forward were not and are not medically necessary for treatment of this patients behavioral health issues. Final Result: The reviewer 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 reviewer is board certified in psychiatry with sub-specialty certification in addiction medicine and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patients parent has requested reimbursement for air ambulance transfer. The records provided for review document that this patient sustained a displaced Salter III fracture of the right ankle as well as and IV fracture of the distal tibia, spiral fracture of the distal fibula, and non-displaced fractures of all metatarsals. Based on current medical literature, this type of injury is treated with closed reduction, which is successful in most cases. The provider recommended transfer for treatment, and closed reduction was not performed prior to transfer. This patients displaced ankle fracture with deformity required immediate closed reduction and possible open reduction. Since treatment was not available at the initial facility, transportation to the receiving facility in an emergent fashion was appropriate. In reviewing the medical records, the transfer was not a request of the patients family. Given these findings, the air ambulance transfer was medically necessary for treatment of this patient.Final Result: The reviewer determined that the services at issue were 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 79-year-old male enrollee has requested Sonata (zaleplon)for the treatment of his insomnia. Findings:  The physician reviewer found that the concerns expressed regarding the safety of zolpidem are not supported in the literature. Both zaleplon and zolpidem are FDA approved and have an identical mechanism of action. These medications have a similar side effect profile, including amnesia and sporadic reports of parasomnias. There is nothing in the report of zolpidem-related car accidents to suggest that the drivers did not take the medication and operate a motor vehicle purposefully. Furthermore, as zolpidem is more commonly prescribed than zaleplon, there is selection bias in side-effect reporting. In summary, both zaleplon and zolpidem are likely to be effective in treating this patients symptoms, and there is no convincing argument that zaleplon is safer than zolpidem. The Health Plans requirement that the patient undergo a trial of zolpidem prior to authorization of zaleplon is not unreasonable.
Appeal type: Experimental/Investigational
Decision: Overturned

An enrollee has requested reimbursement for mitral valve replacement by transvenous procedure provided . Findings:  The physician reviewer found that the patient has multiple co-morbid conditions including CAD, hypertension, acute on chronic CHF with acute decompensation, obesity as well as the requirement for a revision mitral valve replacement if this procedure were performed via open procedure. The cardiovascular surgical pre-operative evaluation found the patient was at a high surgical risk for a revision open heart procedure. Based on his multiple co-morbidities in the setting of prior mitral valve replacement surgery, the transcutaneous mitral valve-in-valve replacement provided this patient with the greatest chance of survival with the fewest post-operative complications. The current peer-reviewed medical literature provides support for the feasibility and efficacy of transcutaneous mitral valve replacement in selected circumstances as well as noting greater peri-operative risk in the setting of surgical revision mitral valve replacement. Based on these findings and the patients assessment, the mitral valve replacement by transvenous procedure provided was likely to be more beneficial to this patient than a revision open mitral valve replacement.  Final Result: The reviewers determined that the services at issue were 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: the physician reviewers are board 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: Experimental/Investigational
Decision: Upheld

A 43-year-old male enrollee has requested ultrafast computed tomography (CT) of the heart for an evaluation of his potential coronary artery disease. Findings:  The physician reviewer found that this patient has severe hyperlipidemia. He had an ultrafast CT of the heart performed for coronary artery disease screening.  The patient had risk factors for coronary artery disease (CAD), which included a family history of CAD and hyperlipidemia.  At present, ultrafast CT scans are considered experimental. For screening asymptomatic patients such as this patient, there is limited data regarding the tests sensitivity and specificity. These factors, coupled with relatively high radiation doses, argue against use of the ultrafast CT scan in patients such as this patient.  Furthermore, there are other proven modalities for assessing this patients cardiac risk.
Appeal type: Experimental/Investigational
Decision: Overturned

A 54-year-old male enrollee has requested tumor treatment fields therapy (TTF) with NovoTTF-100A system for treatment of the enrollees recurrent glioblastoma. Findings:  Three physician reviewers found that the requested services are likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Following progression of disease in patients with glioblastoma multiforme, who have already received optimal initial therapy with surgery followed by radiation with temozolomide, there is a lack of reliably effective options for further therapy. The National Comprehensive Cancer Network (NCCN) guidelines list several chemotherapy agents that have been shown to have some activity as second-line therapies, but also indicate that palliative care alone is an acceptable option.  In this context, the NCCN guidelines propose use of NovoTTF as a treatment option, with a grade 2B level of evidence. This is in recognition of results of a Phase III trial that showed this therapy to be as efficacious as chemotherapy, in terms of survival parameters, but less toxic. Based on the above considerations, most notably the paucity of effective treatment options in this context, the requested services are likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.
Appeal type: Medical Necessity
Decision: Upheld

A 58-year-old male enrollee has requested a liver transplant for treatment of his multifocal hepatocellular carcinoma (HCC).  Findings:  The physician reviewer found that there has been documented interval response with decreased enhancement in the treated lesions. In addition, there has been detection of new lesions as per the latest contrasted liver imaging. The new lesions suggest advancing disease, which predicts worse outcomes with liver transplantation. Therefore, without evidence of downstaging to meet the UCSF or Milan criteria, liver transplantation is not supported as medically necessary for this patient.