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

A 49-year-old female enrollee has requested Botox injections for the bladder for the treatment of her refractory overactive bladder. Findings:  Three physician reviewers found that there is preliminary interest in the multitude of conditions that may respond well to Botox injections. At this time, the use of Botox for treatment of urinary urgency, frequency, and urge incontinence remains under study. The current FDA recommendations for Botox do not include this patients symptoms and the medical literature does not support this proposed off label use. A number of variables are involved in Botox administration including the amount, dilution volume, location, quantity, and depth of injections. The optimal amount, dilution and injection sites have not been well established. While most of the studies performed to date have shown that Botox resulted in some improvement in patient symptoms with relatively few reported side effects, the studies do indicate that further research is necessary to determine the above variables as well as the positive effect and the appropriate interval between injections.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary:  An enrollee has requested Xeljanz for treatment of her alopecia areata.  The physician reviewer found that the submitted documentation supports the requested medication in this clinical setting.  This patient has had numerous topical and systemic therapies with minimal sustained improvement.  This patients condition is a challenging condition to treat with few effective options.  The identification of tofacitinib (Xeljanz) as an effective therapy for alopecia areata, particularly of the universalis type, is significant as there is a lack of other effective treatment options.  Given that the patient has benefitted from a trial of this medication, when all other treatments have failed, there is support for the Xeljanz in this clinical setting.  All told, the requested medication Xeljanz 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 patients medical condition. Therefore, the Health Plans denial should be overturned.  Credentials/Qualifications: The reviewer is board certified in dermatology 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: The enrollee has requested reimbursement for the Guardant360 testing for evaluation of the enrollees stage 1 adenocarcinoma of the right upper lung.  Findings:  Two physician reviewers found that there are non-randomized studies exploring the value of molecular profiling, however the results have not demonstrated the efficacy of such an approach to treatment. One randomized trial did not demonstrate a significant clinical benefit from choosing therapy based on molecular targets versus by the providers clinical judgment. Currently, the data suggests that finding a mutation does not support treatment directed at that target to produce a clinically meaningful response. Final Result: The reviewers determined that the testing at issue was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld.  Credentials/Qualifications: Reviewers 1, 2 and 3 are board certified in 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: Upheld

Nature of Statutory Criteria/Case Summary:  An enrollee has requested residential mental health treatment for the treatment of his behavioral health conditions. Findings:  The physician reviewer found that the submitted documentation does not support the medical necessity of the treatment intervention, as the record fails to demonstrate that less restrictive interventions targeting his substance use during the episode of illness had either been unsuccessful or would have been inappropriate.  Upon admission, he had stable vital signs and an unremarkable mental status examination.  There was no evidence of significant medical or psychiatric comorbidity, and the patient was motivated.  Further, the record did not include critical documents from the treatment facility.  In the absence of such clinical documentation, there is no evidence to suggest that comprehensive specialty services provided at a lower level of care, such as partial hospitalization or intensive outpatient programming in a sober living environment, would have been unreasonable or consistent with inadequate care.  Thus, residential treatment center services were not medically necessary for the treatment of this 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: Medical Necessity
Decision: Overturned

The parent of an enrollee has requested reimbursement for Xifaxan 200 mg tablet, three (3) times a day (42 tablets for a 14-day supply). Small intestinal bacterial overgrowth (SIBO) is a recognized cause of gastrointestinal distress and is also thought to be one of the contributing factors to irritable bowel syndrome (IBS). Although SIBO is typically treated with antibiotics, there are not any antibiotics which are specifically approved for this indication by the U.S. Food and Drug Administration (FDA). Xifaxan (rifaximin), which has been FDA approved for treatment of IBS-D, is one of the antibiotics which has been found to be most effective in treatment of SIBO in adults. The low-FODMAP diet is another treatment for SIBO which is often recommended but which also does not have double-blind randomized controlled trial evidence to support its use. In this case, given the absence of safer alternatives and of other medications with stronger evidence of efficacy, Xifaxan (rifaximin) was the most appropriate treatment for the patients small intestinal bacterial overgrowth (SIBO). Therefore, the medication Xifaxan 200 mg tablet, three (3) times a day (42 tablets for a 14-day supply), was medically necessary to treat the patients medical condition.Final Result: The reviewer determined that the medication at issue was medically necessary to treat 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 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: Upheld

An enrollee has requested authorization and coverage for alternative medicine office consultation and integrative medicine follow-up visit. Findings:  Three physician reviewers found when treating insomnia, patients should receive therapy for any medical condition, psychiatric illness, substance abuse or sleep disorder that may be precipitating or exacerbating the insomnia. If symptoms are severe enough to require intervention, cognitive behavioral therapy is the initial therapy that is recommended.  If a combination of behavioral therapy and medication is required, the medical evidence supports a short acting medication for six to eight weeks. If symptoms continue, evaluation in a sleep disorder center prior to the institution of long-term medications may be indicated.  In this case, the documentation does not support that the patient has received optimal therapy for medical and psychiatric conditions or that non-pharmacologic treatment for insomnia has failed. The records do not document evaluation with a sleep study. Additionally, the documentation does not support that she has adhered to standard sleep hygiene or had a trial of cognitive behavioral therapy. All told, the requested alternative medicine office consultation and integrative medicine follow-up visit are not likely to be more efficacious than other treatment options. Final Result: The reviewers determined that the requested services are 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 internal medicine 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

A 44-year-old female enrollee requested authorization and coverage of a DEXA scan and a full-body DEXA scan for the treatment of osteoarthritis.  The health plan denied the enrollees request indicating that the requested DEXA scans are not medically necessary.One physician reviewer performed a medical necessity Independent Medical Review.  The physician reviewer upheld the health plans denial on the basis that the requested DEXA scans are not medically necessary.
Appeal type: Medical Necessity
Decision: Upheld

A 65-year-old male enrollee has requested air transportation for treatment of his symptoms concerning for myocardial infarction.   Findings:  The physician reviewer found that the submitted documentation demonstrates the patient was experiencing chest pain, symptoms similar to a heart attack he had suffered in the past. Providers on the scene recommended he be transported to the closest facility. The patient refused such transport so that he could be transported to a further facility to be treated by his cardiology group. The patient stated that the closest facility did not have cardiac catheterization capability. However, it was not known at the time of transfer whether the patient was suffering an acute myocardial infarction. In practice, it is the standard of care to transport a patient to the closest facility for an initial assessment and stabilization prior to air transport. Transfer to a specialized cardiology unit could safely have been undertaken from another facility while other medical measures were conducted. This patient could safely have been transported by ground ambulance to the closest facility. Therefore, the air transportation services at issue were not medically necessary for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary:  An enrollee has requested an intensive inpatient pain management program for treatment of her fibromyalgia, fatigue and chronic headaches.  The physician reviewer found that the request for an intensive inpatient pain management program is medically necessary for treatment of the patients medical condition. There is support for the requested services in the medical literature. The study by Angst and colleagues states Intensive interdisciplinary rehabilitation with more behavioral therapies was accompanied by a greater improvement in patients who were severely affected by pain, compared with standard rehabilitation by the end of the stay. Angst and colleagues also stated that Inpatient, structured interdisciplinary rehabilitation covering elements of cognitive and operant behavioral therapy, graded activity exercise, and adapted drug therapy revealed moderate to large short-term and mid-term improvements in physical and mental health and in the major coping dimensions as captured by comprehensive and specific assessment. In this case, the medical records submitted for review indicate a condition of chronic pain that has not responded to multidisciplinary care that includes medication management and psychological therapy and biofeedback. The medical records support that the patient is currently on chronic opioids.  Inpatient pain rehabilitation is the preferred course of therapy for patients who have chronic pain that has failed other conservative care. As such, the requested intensive inpatient pain management program is supported as consistent with guidelines for chronic pain management and medically necessary in this clinical setting. 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 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

A 28-year-old female enrollee has requested coverage for excision of skin of the abdomen, hips, thighs, buttocks and lipectomy of the lower extremities for treatment of her excess skin condition. Findings:  The physician reviewer found that correction of skin laxity following massive weight loss is generally considered cosmetic in the absence of clear and compelling documentation of specific signs and symptoms that 1) are clearly related to the excess skin 2) are health threatening or cause significant functional disability and 3) have failed to improve despite reasonable attempts at conservative therapy.  The submitted records do not include convincing and confirmatory evidence of a chronic functional problem that has not responded to reasonable attempts at conservative therapy.Surgical lipectomies or body contouring for medically necessary indications should be reserved for patients that have failed optimal medical management for intertrigo, which has not been shown to be the case for this patient.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Injectafer 750 mg/15 mL vial. Findings: The U.S. Food and Drug Administration (FDA) approves the use of Injectafer as an iron replacement for the treatment of iron deficiency anemia in adult patients who have an intolerance to or unsatisfactory response to oral iron. In this case, the patient has a history of persistent anemia and iron deficiency. The records noted that with oral iron replacement and Venofer, the patients ferritin was 32 ng/mL. Given that the records show that the patient has achieved normal hemoglobin and ferritin levels on Injectafer, the requested medication is medically indicated. Therefore, Injectafer 750 mg/15 mL vial 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 obstetrics and gynecology with sub-specialty certification in reproductive endocrinology and infertility 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 authorization and coverage for alprazolam (Xanax) 2 mg tablets. Findings:  The physician reviewer found that in the early 1960s, the newly synthesized benzodiazepine class of medication effectively supplanted barbiturates as the mainstay of psychopharmacologic treatment of anxiety.  Although safer than their predecessor, the benzodiazepines possess an array of potential side effects.  Disinhibition, cognitive dulling, perceptual disturbances and exacerbation of depression are common, while a connection with Alzheimers disease later in life has been suggested in the peer-reviewed literature. In this patients case, the risks of benzodiazepine therapy outweigh the potential benefits. The patient has a history of addiction. Benzodiazepines should be avoided in patients with history of addictive illness. In terms of medication alternatives, the patient has not failed an adequate trial of pro-serotonergic medicines, which represent first-line interventions for depression and anxiety. The record illustrates that the patient has been presented with reasonable somatic alternatives, but he declined those treatments. Further, it does not appear that the patient has pursued trusted non-pharmacologic interventions, such as chemical dependency counseling or cognitive behavioral therapy for anxiety and/or depression. In this patients case, the plan for alprazolam tapering was consistent with contemporary practice standards. The current medical evidence does not support the requested medication in this clinical setting. All told, alprazolam (Xanax) 2 mg tablets are not medically necessary for the treatment of this patient. Final Review: 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 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

Nature of Statutory Criteria/Case Summary: The child of an enrollee has requested reimbursement and authorization and coverage for skilled nursing facility care.Functional impairments due to a cerebral stroke can be severe to profound. While functional recovery may be amenable to natural recovery processes and rehabilitative measures, the extent of initial injury is a major determinant of functional outcomes as it defines the residual neuronal reservoir that is capable of engaging in recovery. Half of the variance seen at six months post stroke can be accounted for by the initial motor impairment. Notably, most of the significant neurological and functional recovery following a stroke occurs in the early stages after stroke, i.e., in the first 30 days, and gains are slower to come in the subsequent stages. There is a general consensus that initiating intensive rehabilitative measures earlier in the post-stroke course enhances outcomes (i.e., within the first few days and weeks post-stroke), but there are generally poor data guiding optimal practices regarding dose, manner, and venue of stroke rehabilitation in the more subacute and chronic stages.In this case, the patient was noted to have sustained multiple strokes and she has had minimal function as well as severe encephalopathy since that time. The patient has undergone extensive formal rehabilitation, but she has made minimal to no meaningful progress. Records indicate that the patient remains dependent for all care and mobility, that she is not following commands, and that she does not even recognize her family members. There is no realistic community disposition identified in the available documentation. Records reflect that the patient has been at a custodial level of care. Under these circumstances, the requested continued skilled nursing facility care services were not, and are not, medically necessary to treat the patients medical condition.Final Result: The reviewer determined that the requested services were not, and are not, medically necessary to treat the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is board certified in physical medicine and rehabilitation 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 parent of an enrollee has requested an anesthesia procedure on the mouth for treatment of the enrollees medical condition.   Findings:  The physician reviewer found that the submitted documentation supports the requested services in this clinical setting.  General anesthesia for pediatric dental procedures is generally considered to be a safe and effective practice.  General anesthesia is often employed to facilitate extensive dental treatment particularly in younger pediatric patients who do not have the psychological or emotional maturity required to cooperate in an office setting.  The combination of an inability to cooperate and a need for an extensive dental procedure makes general anesthesia an appropriate treatment modality for pediatric patients.  This patent has situational anxiety, requires extensive dental treatment and is uncooperative.  There is sufficient support for the requested services in this clinical setting.  Therefore, the requested anesthesia procedure on the mouth is medically indicated for the treatment of this patient.   Final Result: The reviewer determined that the requested services are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.   Credentials/Qualifications: The reviewer is board certified in anesthesiology with sub-specialty certification in pediatric 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: Upheld

Findings:  The physician reviewer found that The patient has requested reimbursement for hyperbaric oxygen therapy (HBOT) treatments. HBOT has been used for and is indicated for the treatment of compromised skin grafts and skin flaps. In this case, the records and a physical examination did not indicate there were any failed hypoxic skin grafts. Vyas and colleagues report that autologous fat grafts may be used for wound healing due to their abundance in progenitor cells. However, there is a lack of data and insufficient evidence in current medical literature supporting HBOT and fat grafting. Gandhi and colleagues report that multicenter studies must be conducted to determine HBOT's true efficacy, mechanism of action, risks, and advantages over conventional treatments. Therefore, HBOT treatments were not medically necessary for the treatment of this 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.