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

A 62-year-old female enrollee has requested Alimta in combination with Avastin therapy for treatment of her lung cancer.  Findings:  Two physician reviewers found that the standard of care for patients who have completed induction chemotherapy with carboplatin/Taxol/Avastin with responsive disease is continuation of maintenance Avastin, maintenance Alimta or observation. This is supported by the peer-reviewed literature, FDA criteria and compendium listing. Data from prospective, randomized, controlled studies is needed to be able to determine whether the combination of Alimta and Avastin has a clinical role in the treatment of patients with metastatic non-small cell lung cancer who have completed induction chemotherapy. The current medical evidence is not sufficient to support the contention that the combination of Alimta with Avastin is likely to be superior to the standard options noted above.  As such, Alimta in combination with Avastin therapy is not likely to be more beneficial for this patient than any other available standard therapy.
Appeal type: Urgent Care
Decision: Overturned

Nature of Statutory Criteria/Case Summary:  An enrollee has requested emergency room services on an emergent basis.  The physician reviewer found that review of the submitted clinical documentation demonstrates that a prudent layperson would have sought immediate medical attention on the date in question. In this case, the patient presented to the emergency room with sciatica and severe low back pain with a pain rating of 7/10. There are numerous serious possibilities that could have been causing these symptoms including disc herniation with compressive neuropathy, spinal cord compression, malignant tumor, paraspinal infection, and others. Undiagnosed pathology could lead to permanent weakness, foot drop, paralysis, and other serious medical problems. The severe nature of the patients symptoms, the failure of outpatient treatment, and the potential for serious complications were of sufficient severity that the absence of immediate medical attention could reasonably be expected to result in impairment to bodily functions. In sum, the services met prudent layperson criteria for emergency care.  Final Result:  The reviewer determined that the patients symptoms met prudent layperson criteria for emergency care. Therefore, the Health Plans denial should be overturned.  Credentials/Qualifications: The reviewer is board certified in emergency medicine is actively practicing. The reviewer is knowledgeable in the treatment of the enrollees medical condition, the proposed treatment, and familiar with guidelines and protocols in the area of the treatment under review.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for atherectomy. The documentation supports the medical necessity of the requested services in this case. The patient has a history of diabetes and tissue loss involving the right foot. Given that the patient is symptomatic, has a history of a diabetic foot ulcer and has significant bilateral evidence of flow limiting stenosis, he is an appropriate candidate for intervention. In a diabetic patient with even marginally abnormal ABIs, a foot ulcer, and known lower extremity arterial occlusive disease, atherectomy is medically appropriate. There is sufficient support for the requested services in this clinical setting. Therefore, the requested atherectomy 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 surgery with subspecialty certification in vascular 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: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for anesthesia services. Per the American Society of Anesthesiology (ASA) guidelines on monitored anesthesia care, indications for monitored anesthesia care include the nature of the procedure, the patients clinical condition and/or the need for deeper levels of analgesia and sedation than can be provided by moderate sedation. Unlike monitored anesthesia care, moderate sedation is a proceduralist-directed service that does not include a qualified anesthesia providers periprocedural assessment. Monitored anesthesia care includes all aspects of anesthesia care such as a pre-procedure assessment and optimization, intraprocedural care and post-procedure management that is inherently provided by a qualified anesthesia provider as part of the bundled specific service. According to the ASA, patient risk factors include significant medical conditions such as extremes of age, severe pulmonary, cardiac, renal, or hepatic disease, pregnancy, the abuse of drugs or alcohol, uncooperative patients, a potentially difficult airway for positive-pressure ventilation, and patients with anatomy that is associated with more difficult intubation. This patients second-degree atrioventricular block and hypertension are cardiac risk factors that can be exacerbated while receiving sedation, either by the anesthetic drugs themselves or hypoxic conditions created by providing sedation. Furthermore, the sedation required by this patient would be difficult to achieve and safely deliver by a non-anesthesia provider since all agents which can depress breathing function and exacerbate any pre-existing cardiopulmonary disease. For these reasons, the anesthesia services were medically necessary for 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 anesthesiology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a two-year-old male enrollee has requested speech therapy for treatment of the enrollees receptive and expressive language delays.  Findings:  The physician reviewer found that cerebral palsy is a non-progressive encephalopathy that occurs early in life, and results in numerous neurologic, motor, and postural deficits in the developing child. Children with cerebral palsy frequently have seizures, as well as speech and language delays, visual impairments, and cognitive delays. Secondary deficits in sensory and psychosocial skills may also result. Early intervention using a team approach optimizes each childs potential for development and prevention of secondary deficits.  Members of the team typically include a pediatrician, neurologist, occupational therapist, physical therapist, and speech and language pathologist.   Efficacy research is difficult in this patient population because of the numerous deficits represented.  This patient has choreoathetoid cerebral palsy, global developmental delay, and expressive and receptive language delay, and his skills fall significantly below those of other children his age. These deficits negatively impact his ability to communicate effectively.  In this patients case, the requested speech therapy is standard of care.  The submitted documentation has established the medical necessity of the requested therapy.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the oral appliance (E0486) provided.   Findings:  The physician reviewer found that given the body of evidence to support the use of oral appliance therapy, the device at issue was effective in the treatment of this patients OSA. While the guidelines recommend CPAP as the first line therapy for patients diagnosed with OSA, they acknowledge that not all patients are tolerant of CPAP.  In that setting, it is generally a standard practice to use alternative therapies to CPAP for patients with OSA who do not tolerate or respond to CPAP. According to recently published joint practice guidelines between the American Academy of Sleep Medicine (AASM) and the American Academy of Dental Sleep (AADSM) Medicine, the professional societies have stated: We recommend that sleep physicians consider prescription of oral appliances, rather than no treatment, for adult patients with obstructive sleep apnea who are intolerant of CPAP therapy or prefer alternate therapy. Other literature reviews have reached similar conclusions on the net utility/efficacy of oral appliance therapy.  A study performed a systematic review and meta-analysis of five studies assessing the effectiveness of an oral appliance for the treatment of obstructive sleep apnea. They found that an oral appliance decreased the apnea hypopnea index as compared with a sham device. Oral appliance therapy has been shown to have a higher degree of efficacy when compared to many surgical interventions for OSA .  Based on the published evidence available to date, the oral appliance (E0486) was likely to have been more beneficial than any available treatment method for the treatment of this patients medical condition.Final Result: All three reviewers determined that the device at issue was likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: Physician reviewer number one is board certified in internal medicine with sub-specialty certification in pulmonary disease with expertise in sleep medicine and is actively practicing. Physician reviewer number two is board certified in neurology with sub-specialty certification in sleep medicine and is actively practicing. Physician reviewer number three is board certified in oral facial and maxillary surgery with expertise in surgical treatment of obstructive sleep apnea and is 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

Nature of Statutory Criteria/Case Summary: The patients parent has requested authorization and coverage for Nutropin AQ: growth hormone. The U.S. Food and Drug Administration (FDA) approves the use of Nutropin for the treatment of idiopathic short stature (ISS) in pediatric patients. Grimberg and colleagues note that ISS is defined by a height standard deviation score of 2.25. In this case, the patient is below the 1.2 percentile in growth with a poor interval growth velocity of five centimeters per year, which is low for a child starting puberty. The patients predicted final adult height is 150 cm, which is less than the mid-parental height of 63.75 inches and under 2.5 standard deviations of the mean for age and gender in growth. Given that the patient meets generally accepted diagnostic criteria for ISS, the requested medication is medically indicated. Therefore, Nutropin AQ: growth hormone is medically necessary for the treatment of this patient.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 sub-specialty certification in pediatric endocrinology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for residential treatment center services for treatment of the enrollees behavioral health condition. Findings:  The physician reviewer found that the submitted documentation demonstrates that the patient reported a high level of motivation and commitment. He had decreased panic and handwashing episodes.  He was using the tools he had learned to self-comfort his anxiety and he applied those towards recovery efforts as well.  He denied suicidal or homicidal ideation.  He was future oriented and planning to return to school to complete an advanced degree. The patients mood ranged from stable to depressed, with appropriate affect. His thoughts were linear and goal directed. The patient lived with family members. His family was involved in his recovery. There were no reported withdrawal symptoms.  He was medically and psychiatrically stable. The patient was not a danger to himself or others.  There were no emotional, behavioral, cognitive, or impulsive symptoms that would warrant residential treatment services.  He was motivated and was working the program.  The submitted documentation show that the patient had improved.  There was no evidence to indicate that returning him to his environment would lead to destabilization.  He had a sponsor. The patient was engaged in all aspects of his treatment plan. Although he continued to struggle with his emotions and OCD symptoms, and required treatment to further develop and solidify coping skills, these issues did not require the structured environment of a residential care treatment setting. The patient could have been stepped down to an ambulatory level of care. For these reasons, the residential treatment center services were not medically necessary for treatment of the patient. 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: Experimental/Investigational
Decision: Overturned

The parent of a 17-year-old male enrollee has requested bilateral arthroereisis HyProCure implant surgery for the treatment of the enrollees talipes valgus. Findings:  Two physician reviewers found that because of the evidence provided, bilateral arthroereisis HyProCure implant surgery was likely to be more beneficial than standard aggressive debilitating rear-foot surgery for this patient. Scientific evidence demonstrates that the implant is non-aggressive, reversible and efficacious.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement and prospective authorization and coverage for Estrogel (estradiol gel). The records provided for review document that this patient presented with postmenopausal symptoms including hot flashes and night sweats, problems with sleep and libido, and vaginal dryness. The provider recommended treatment with Estrogel. As noted by Monteleone and colleagues, the signs and symptoms of menopause include central nervous system-related disorders, metabolic, weight, cardiovascular and musculoskeletal changes, urogenital and skin atrophy, and sexual dysfunction. Pinkerton noted that menopausal hormone therapy can provide relief for patients with hot flashes and night sweats, reduce bone loss and risk of fractures, and address genitourinary syndrome of menopause. Paciuc concluded that estrogen remains the most effective treatment for vasomotor symptoms and genitourinary symptoms, for osteoporosis prevention, symptom relief, and chronic disease prevention in female patients. Given this support, the Estrogel (estradiol gel) was and is medically necessary for treatment of this patient. 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 internal medicine with subspecialty certification in endocrinology, diabetes, and metabolism 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

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for transcatheter closure of atrial appendage for treatment of the enrollees paroxysmal atrial fibrillation. Findings:  The physician reviewer found that the transcatheter closure of atrial appendage was not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. According to the documentation submitted for review, the patient needed treatment to prevent embolic stroke due to atrial fibrillation and was not able to take anticoagulants due to prior bleeding side effects. In this circumstance, treatment options included the Watchman device, the AtriClip or surgical ligation. Surgical ligation is considered standard therapy in this clinical setting. Device-based therapy such as the Watchman and the AtriClip are not supported in established guidelines, since outcome data is still being accumulated. Given the lack of support in the peer-reviewed literature, the transcatheter closure of atrial appendage was not likely to be more beneficial than standard therapy. Final Result: The reviewers determined that the surgery at issue was 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: Reviewers 1, 2 and 3 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

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for transcranial magnetic stimulation services. Findings:  Three physician reviewers found the American Psychiatric Association has endorsed transcranial magnetic stimulation for the acute phase treatment of major depressive disorder. However, the recommendation does not yet extend to bipolar disorder or personality disorder. At the time of the disputed service, the patient had not exhausted standard available therapies, such as mood stabilizing medicines that work well for bipolar depression, like lithium, quetiapine and olanzapine-fluoxetine combination, or electroconvulsive therapy, which remains the most reliable, expeditious and efficacious neuromodulating intervention available today. The safety and appropriateness of transcranial magnetic stimulation in this setting remains unclear. All told, the superior efficacy of transcranial magnetic stimulation services has not been established.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 psychiatry 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

Nature of Statutory Criteria/Case Summary:  An enrollee has requested esomeprazole magnesium (Nexium) for treatment of her gastroesophageal reflux disease. The physician reviewer found that proton pump inhibitors are a class of therapeutically equivalent medications.  As a drug class, proton pump inhibitors are indicated for healing erosive esophagitis and peptic ulcer disease, as well as to manage symptomatic gastroesophageal reflux disease and acid hypersecretory states.  The duration of action and side effects characterize proton pump inhibitor variations.  No particular proton pump inhibitor is overall superior, such that as a class proton pump inhibitors are interchangeable.  In this patients case, the records do not support that her gastroesophageal reflux disease is advanced, nor has she demonstrated intolerance to a specific proton pump inhibitor.  The available records do not indicate that she maximized medical acid suppression treatment.  A therapeutic substitution in proton pump inhibitors would not be expected to place her health at undue risk.  There is a lack of support for the requested medication in this clinical setting.  All told, the requested esomeprazole magnesium (Nexium) is not medically indicated for the treatment of this patient.  Final Result: The reviewer determined that the requested medicine 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 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: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for Guardant360 test for evaluation of the enrollees non-small cell lung carcinoma. Findings:  Two physician reviewers found that the Guardant360 test is a liquid biopsy that analyzes patient plasma for mutations. Researchers performed a clinical study directly comparing the use of targeted agents with conventional chemotherapy approaches. The study involved 86 patients where the progression free survival on regimen selected by molecular profiling was compared to the progression free survival on the last chemotherapy regimen. The regimen selected by molecular profiling offered a 27% survival advantage. This trial has very significant results for patients with stage IV tumors. The results from molecular profiling offers a rational selection for this patients next regimen. Final Result: The reviewers determined that the services at issue were 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: 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.