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

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for occipital nerve injection (CPT code 64405). Greater occipital nerve blocks are an effective treatment alternative for patients who have headaches secondary to greater occipital neuralgia, which can be worsened secondary to myofascial neck pain. There are multiple studies demonstrating the benefits of greater occipital nerve blocks for patients with migraine who have failed standard therapies. Studies found that compared to control interventions, greater occipital nerve blocks provide substantial relief of pain and reduce the number of headache days and medication consumption. In this case, the patients migraines have been refractory to treatment with ibuprofen, Imitrex, Maxalt, and Zembrace SymTouch. The patients provider recommended treatment with greater occipital nerve blocks. Given the current support in the medical literature, the requested occipital nerve injection (CPT code 64405) is medically necessary for 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 neurology 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 54-year-old male enrollee has requested a Neuromuscular and Functional Electrical Stimulator (NMES) for treatment of his medical condition. Findings:  The physician reviewer found that Pomeroy and colleagues provide a comprehensive and thorough evaluation of recent medical literature evaluating the efficacy of neuromuscular electrical stimulation for the purposes of post-stroke motor recovery in the upper extremity. The authors concluded that electrical stimulation was felt to be better than no treatment, but felt this may be more an effect of the intensity of therapy, any form of therapy versus no therapy at all. However, when electrical stimulation was compared to conventional therapy, there was not a statistically significant difference between the two types of groups. Finally, there are no clear clinical guidelines as to which population of patients would benefit most from electrical stimulation, including amount of time elapsed from initial incident. While there appears to be some promise to the use of NMES in the treatment of post-stroke motor impairment, the authors concluded that there is insufficient robust data to inform clinical use of electrical stimulation for neuromuscular re-training.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for plastic/reconstructive surgery for treatment of the enrollees atrophic pitted scar of the face. Findings:  The physician reviewer found that the patient presents with an indented atrophic scar of the left chin that is 3 mm wide and less than 1 mm in depth after previous cryotherapy in March 2016. Based on the most recent evaluations, it does not appear that the scar is immature. Documentation from 10/25/16 noted that the scar is atrophic/indented and documentation from 11/10/16 reported that the scar is depressed. There was no mention of color of the facial scar or that it was hypertrophic. Although the recommendation was to wait at least one year following cryotherapy, there is no evidence of ongoing scar inflammation or immaturity and the scar is unlikely to significantly change with further elapse of time. In addition, a scar indentation after greater than eight months is unlikely to change significantly. At this point based on the above reasoning, the scar is likely fully mature and not likely to improve or change significantly. Final Result: The reviewer determined that the requested surgery 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 plastic 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: Experimental/Investigational
Decision: Upheld

A 55-year-old female enrollee has requested Rocephin IV for the treatment of her Lyme disease.  Findings:  Three physician reviewers found that the patient does not have a clear diagnosis of neuroborreliosis or past history of Lyme disease. She has no clear exam findings or laboratory/imaging confirmation of this diagnosis. She has already received multiple courses of antibiotics with no clear benefit. In cases of neuroborreliosis, the standard treatment is four weeks of antibiotic therapy. Therapy with repeated or extended courses has not proven efficacious and is associated with some risk. There are no double blind placebo controlled trials that demonstrate efficacy in treatments beyond 30 days for Lyme disease
Appeal type: Medical Necessity
Decision: Upheld

The representative of a 48-year-old female enrollee  requested authorization and coverage of the medication Actiq for treatment of the enrollees medical condition. The Health Plan denied the request indicating that the requested medication is not medically necessary for treatment of the enrollees chronic pain.One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer upheld the Health Plans denial on the basis that the requested medication is not medically necessary.
Appeal type: Medical Necessity
Decision: Overturned

A 56-year-old female enrollee has requested for bilateral upper lid blepharoplasty for treatment of her ptosis.  Findings:  The physician reviewer found that in the peer reviewed clinical literature, Rohrich and colleagues discuss the necessity of a preoperative work-up that may include a consultation with an ophthalmologist for documentation of visual field impairment to determine whether the obstruction is of visual significance. This criterion appears to be documented in the patients medical chart. Moreover, Trussler and Rohrich comment that with this patients condition, the function of vision can be affected. The authors stated that, Upper eyelid dermatochalasis is the loss of elasticity and support in the skin. This can create a fold of excess upper eyelid skin, which can impair the function of the eye, specifically, by superior and lateral visual field obstruction. Since this patients field of vision should be substantially improved with the requested procedure, it should be determined to be reconstructive in nature and medically indicated.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the DecisionDx-Melanoma Gene Assay testing. Cutaneous melanoma is initially treated by wide surgical excision and sampling of sentinel lymph nodes for those with high depth of invasion measuring 0.76-1.0 mm. Metastases to regional lymph nodes may be amenable to excision but they suggest a high risk for the development of metastatic disease in the future. Such patients may be observed or treated with interferon-alpha. However, the current data on the DecisionDx-Melanoma Gene Assay does not support its use as part of routine analysis after sentinel lymph node biopsy. Thus, the DecisionDx-Melanoma Gene Assay 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 DecisionDx-Melanoma Gene Assay 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 DecisionDx-Melanoma Gene Assay was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Credentials/Qualifications: Physician reviewers 1, 2 and 3 are board certified in internal medicine with sub-specialty certification in medical oncology 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

The parent of a 27-year-old female enrollee has requested inpatient mental health services for treatment of the enrollees schizoaffective disorder. Findings:  The physician reviewer found that as evidenced by the submitted discharge summary, this patient required skilled observation in a structured setting.  She was not doing well prior to admission, but the cause of her decline was unclear.  The treatment team opined that she was overmedicated, but a reduction in medications led to an escalation of dangerous behaviors.  Therefore, it was medically necessary to titrate the patients medications at the inpatient level of care to be able to monitor her response in such a structured environment.  This level of care was necessary to decrease the risk of relapse upon discharge.  This patient required 24-hour monitoring, and she would have been at risk for relapse had she been prematurely discharged to a lower level of care.  All told, inpatient mental health services provided were medically indicated for this patient.
Appeal type: Urgent Care
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for psychiatric emergency medical services.Findings:  The physician reviewer found that the patient was admitted to detoxification. He was stepped down to residential treatment center level of care. Based on the documentation submitted for review, the patient did not receive psychiatric emergency medical services during the dates of service at issue. On admission the patients withdrawal symptoms were mild in nature. There was no Clinical Opiate Withdrawal Scale (COWS) on admission, or thereafter. The course of detoxification was not provided for review, and there is no documentation showing the patient was placed on a detoxification protocol. He was not a danger to himself or others. He was medically and psychiatrically stable. He reported that he was highly motivated, and staff reported that he was open and engaged in treatment. There was no evidence of emotional, behavioral, cognitive, impulsive issues. He was not manic or psychotic. There is no evidence showing that the patient had a psychiatric emergency medical condition that required emergency medical services, or that he received emergency medical services. Final Result: The reviewer determined that the patient did not receive psychiatric emergency medical services on the dates of service at issue. 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 authorization and coverage for Humatrope 12 mg, six cartridges per month. This patient had evidence of significant deterioration on linear growth, as shown on the growth chart, from the 50th to the 10th percentile, prior to initiation of growth hormone therapy. The patient demonstrated no growth. She did not have a bone age delay based on an average bone age. The estimated predicted adult height prior to therapy is significantly below the patients mid-parental target height of 64 inches and is the lowest cut-off value for normal height for an adult female. The patients growth rate and bone age prediction improved after starting treatment with growth hormone therapy. Given these findings, the requested Humatrope 12 mg, six cartridges per month is medically necessary for treatment of this 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 pediatrics with subspecialty 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: Upheld

The parent of a 12-year-old male enrollee has requested growth hormone (GH) therapy with Humatropey for the treatment of the enrollees idiopathic short stature. Findings:  The physician reviewer found that this patient has profound short stature, disordered growth velocity, and some psychosocial issues. GH therapy is appropriate in this instance. However, both Nutropin and Humatrope are FDA approved and known to be safe and effective for treatment of idiopathic short stature over the long term. Nutropin is therapeutically equivalent to pituitary-derived human GH. In vivo and in vitro pre-clinical and clinical testing of Nutropin in pediatric patients with GH deficiency, chronic renal insufficiency and Turners syndrome showed an increase in growth rate and an increase in IGF-1 levels. Nutropin is a formulary medication and no compelling reason for choosing Humatrope over Nutropin has been identified.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Tylenol 3. The Centers for Disease Control and Prevention (CDC) guidelines for use of opioids for chronic pain state that providers should evaluate the benefits and harms of continued therapy with patients every three months or more frequently. The CDC noted further, that when the benefits do not outweigh harms of continued opioid therapy, providers should optimize other therapies and work with patients to taper opioids to lower dosages or to taper and discontinue opioids. The 2017 Federation of State Medical Boards guidelines state that continuation, modification or termination of opioid therapy for pain is contingent on the clinicians evaluation of (1) evidence of the patients progress toward treatment objectives and (2) the absence of substantial risks or adverse events, such as signs of substance use disorder and/or diversion. In this case, the patient has been prescribed Tylenol 3 for chronic pain related to his Kaposi sarcoma and neuropathy. It is noted that he was informed that his recent urine drug screen was positive for methamphetamine. The providers assessment was that opioids were no longer a good option to treat the patients chronic pain due to the risks of treatment outweighing any potential benefits. His provider recommended Gabapentin and Motrin for his pain, and participation in a chemical dependency program. Based on the guidelines from the CDC and the Federation of State Medical Boards, the requested Tylenol 3 is not medically necessary for treatment of this patients chronic pain. 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 subspecialty certification in pain management 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: Upheld

A 47-year-old female enrollee requested capsule endoscopy (CPT 91110) for medical evaluation of her medical condition.  Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the superior effectiveness of the requested services in this patients case.  Both push endoscopy and capsule endoscopy would be appropriate for evaluation of the small bowel.  The records do not establish that the requested capsule endoscopy is likely to be of greater benefit than push endoscopy in this clinical setting.  All told, the requested capsule endoscopy is not likely to be more efficacious than other modalities for the evaluation of this patient.
Appeal type: Urgent Care
Decision: Upheld

A 22-year-old female enrollee has requested for emergency services required on an emergent basis. Findings:  The physician reviewer found that there is no documentation in the medical record to support that the patient was at risk of losing her vision or that she was in moderate or severe distress. The patient rated her discomfort as 2 out of 10 at triage. The patients symptoms did not meet prudent layperson criteria for emergency care.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested digital breast tomosynthesis for evaluation of the enrollees breast cancer screening.  Findings: Three physician reviewers found that there is sufficient support in the peer-reviewed literature for the diagnostic procedure at issue in this clinical setting. Skaane and colleagues performed a large prospective screening trial To assess cancer detection rates, false-positive rates before arbitration, positive predictive values for women recalled after arbitration, and the type of cancers detected with use of digital mammography alone and combined with tomosynthesis. The authors concluded that The use of mammography plus tomosynthesis in a screening environment resulted in a significantly higher cancer detection rate and enabled the detection of more invasive cancers. Given the support in the medical literature, the use of breast tomosynthesis was likely to be more beneficial for evaluation of the patients breast exam than conventional mammogram and is due to improved cancer detection rate.   Final Result: Three reviewers determined that the diagnostic procedure at issue was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: All three physician reviewers are board certified in diagnostic radiology and are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

The parent of a 17-year-old male enrollee has requested mental health outpatient psychotherapy visits for treatment of the enrollees psychotic disorder and rule out chronic schizophrenia, paranoid type.  Findings: The physician reviewer found that the medical literature is clear that the primary treatment for both positive and negative symptoms of schizophrenia is medication. From the records provided for review, it appears that the patient has not had an adequate trial of medication.  This treatment would include consistent administration over a period of months of an anti-psychotic medication in therapeutic dosages.  This plan would also include trials of several different medications if the initial choice had unacceptable side effects or failed to be efficacious. Additionally, a mood stabilizer is often added to enhance the efficacy of treatment. Although the parent indicates the patient has been or is being treated with a mood stabilizer, the records do not describe the length of the trial or the dosage prescribed. As described in the published clinical trials, psychosocial interventions should be given as adjunctive treatment. To date, no definitive psychosocial intervention has sufficient evidence-based data to support it, but there is anecdotal information to show that such treatment is beneficial. Thus, while medication, information, and support groups can be helpful to improve compliance, the literature does not provide support for chronic, intensive individual psychotherapy such as that being requested.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested a wireless pressure sensor for evaluation of her medical condition.  Findings: Two physician reviewers found that the submitted documentation fails to demonstrate the superior efficacy of the requested device.  Per the medical evidence, the efficacy of the requested device is uncertain at this time and is not recommended in current guidelines for the treatment of heart failure.  In this patients case, the requested wireless pressure sensor is not likely to be of greater benefit to this benefit than standard modalities. Final Result: Two reviewers determined that the requested device is not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld.  Credentials/Qualifications: All three physician reviewers are board certified in internal medicine with sub-specialty certification in cardiovascular disease 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: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollees representative has requested reimbursement for intensity modulated radiation therapy (IMRT) services (CPT 77014 and G6015). Standard treatment for rectal cancer is with three-dimensional (3D) conformal radiation therapy. Currently, there is a lack of clinical data in the medical literature to suggest that treatment with IMRT offers a clinical benefit compared to conventional radiation therapy techniques for tumors of the rectum. The National Comprehensive Cancer Network (NCCN) guidelines do not support the use of IMRT in this clinical setting. A phase II study, which examined the use of IMRT in patients with rectal cancer, found no benefit when compared to historical controls (Hong, et al.). In this patients case, the dose-volume histogram showed no clinically significant benefit with the use of IMRT over standard 3D conformal radiation therapy. Therefore, IMRT services (CPT 77014 and G6015) were 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 IMRT services (CPT 77014 and G6015) were 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 services at issue were not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: Physician reviewers 1, 2, and 3 are board certified in radiation oncology 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.