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

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for the (1) telephone evaluation (CPT 99442) provided by Sheldon Jordan, M.D., (2) office visit (CPT 99214) provided by Sheldon Jordan, M.D., (3) advanced magnetic resonance imaging (MRI) (CPT 76498) provided by Sheldon Jordan, M.D., and (4) all or any of the repetitive transcranial magnetic stimulation (rTMS) (CPT 90868) received from Sheldon Jordan, M.D. Current medical literature supports the use of rTMS in the treatment of patients with fibromyalgia. Yang and Chang note that the results of a systematic narrative review suggest that TMS is beneficial for treating neuropathic pain of various origins, including from fibromyalgia. Lefaucheur and colleagues report that evidence suggest probable efficacy in the use of rTMS in improving the quality of life and decreasing pain in patients with fibromyalgia. Tanwar and colleagues found in a randomized controlled trial with follow-up at six months, average pain ratings and associated symptoms showed significant improvement post rTMS and the beneficial effects of rTMS lasted up to 6 months in the follow-up phase. In this case, the patient has a diagnosis of fibromyalgia. The patient has not responded to medications or physical therapy. Given that consultation with the provider and pre-procedure imaging were needed before initiating rTMS therapy, and that evidence shows that rTMS may be effective in treating fibromyalgia that is refractory to other treatment, the requested services were medically indicated. Therefore, the (1) telephone evaluation (CPT 99442) provided by Sheldon Jordan, M.D., (2) office visit (CPT 99214) provided by Sheldon Jordan, M.D., (3) advanced MRI (CPT 76498) provided by Sheldon Jordan, M.D., and (4) the rTMS (CPT 90868) received from Sheldon Jordan, M.D., were medically necessary for the evaluation and treatment of this patient.Final Result: The reviewer determined that the services at issue were medically necessary for evaluation and treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in physical medicine and rehabilitation 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: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary:  An enrollee has requested authorization and coverage for LINX surgical procedure. Findings:  Two of the three physician reviewers found that there is a lack of randomized controlled trials with long-term follow-up demonstrating that LINX is safer or more effective than Nissen fundoplication or other surgical anti-reflux procedures. LINX (more than surgical fundoplication) is associated with severe dysphagia requiring endoscopic intervention. The researchers concluded that the long-term safety and efficacy of LINX - both alone and in comparison to current GERD therapies - remains to be determined. The currently available peer-reviewed literature does not definitively support the conclusion that LINX is more likely to be beneficial in this case than standard treatment, surgical fundoplication. In sum, the requested LINX surgical procedure is not likely to be of greater benefit 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 with sub-specialty certification in gastroenterology 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

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for three-day electroencephalography (EEG) neurological testing in a hospital setting. This patients documentation indicates that the patient presents with complaints of spastic spells. The patient reports experiencing unprovoked recurring spontaneous episodes of altered consciousness and sensorium, which are concerning for a seizure diagnosis. As noted in the medical literature, EEG is an important tool in the diagnoses and management of patients with epilepsy. EEG monitoring is often used to help distinguish epileptic seizures from nonepileptic events. A routine EEG is typically less than an hour but can be enhanced with prolonged monitoring to obtain an extended EEG recording. EEG should be utilized for patients when seizure or epilepsy is a concern by the patients history and/or physical examination findings. Mikhaeil-Demo and colleagues noted that recordings taken over several days have been shown to increase sensitivity of seizure activity. This patient underwent evaluation with EEG in the outpatient setting that was inconclusive. In this clinical setting, the requested EEG is appropriate for further evaluation and potential diagnosis of this patients symptoms. Therefore, the requested three-day EEG neurological testing in a hospital setting is medically necessary for evaluation of this patient.  Final Result: The reviewer determined that the requested services are medically necessary for evaluation of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in neurology with subspecialty certification in vascular 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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for a computed tomography (CT) scan of the brain. In the continuing management of TBIs with intracranial hemorrhage, there are several modalities which can be employed. The primary modalities include CT and MRI. Obtaining imaging in the period post-TBI can play several important roles, including evaluation of underlying lesions, guiding rehabilitation and aiding in prognosis. MRI is considered a superior diagnostic imaging tool to CT brain imaging. It has been shown to better identify several abnormalities as compared with CT. In this case, the patient suffered a TBI. She had follow-up MRI which was reported as stable. Considering that MRI is generally accepted to be a more sensitive imaging modality, an additional CT scan would not be indicated at this time.Final Result: The reviewer determined that a CT scan of the brain is not medically necessary for evaluation of the enrollees medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications:  The physician 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: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for balloon sinus ostial dilation. Findings:  The physician reviewers found that nasal polyps cause nasal obstruction, discharge and reduction in or loss of sense of smell, but the etiology is unknown. The management of chronic rhinosinusitis with nasal polyps, aimed at improving these symptoms, includes both surgical and medical treatments, but there is no generally accepted management protocol. While sinus ostial dilation, with or without balloon sinuplasty, can be a therapeutic option for patients with chronic sinusitis, the criteria have not been met in this patient. The records do not include chronology of disease or treatment, and there is no documentation that the patient was treated with maximal medical therapy prior to the CT scan. Moreover, nasal polyposis was documented on endoscopy and imaging, which is not an indication for balloon sinuplasty. For these reasons, the requested balloon sinus ostial dilation is not supported as likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Final Result: 3 of 3 reviewers determined that the requested procedure is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: All three physician reviewers are board certified in otolaryngology 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 patients parent has requested authorization and coverage for first-omeprazole 5 ml twice a day at 2 mg/ml. Researchers reported that based on expert opinion, the working group recommends the use of proton pump inhibitors (PPIs) as first-line treatment of reflux-related erosive esophagitis in infants and children with GERD. However, PPI use is recommended in infants only when there are findings of erosive esophagitis. In this case, there was no indication the patient had an endoscopy or that the patient had been diagnosed with erosive esophagitis. She also does not have any identified abnormality of the esophageal anatomy, such as esophageal atresia. The medical evidence does not support the requested medication in this clinical setting. Therefore, first-omeprazole 5 ml twice a day at 2 mg/ml is not medically necessary for the treatment of this patient. 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 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

A 49-year-old male enrollee has requested human growth hormone therapy for treatment of his myopathy.  Findings:  Three physician reviewers found that the superior efficacy of the requested human growth hormone has not been established in this patients case.  He has demonstrated drug-induced mitochondrial myopathy secondary to antiretroviral drug therapy.  In this clinical setting, standard treatment includes physical therapy.  There is a lack of double-blind, placebo-controlled trials demonstrating the efficacy of human growth hormone therapy in this case.  There is a lack of support in the medical literature demonstrating the effectiveness of the requested therapy for drug-induced myopathy.  Therefore, the requested therapy is not likely to be more effective than other options for the treatment of this patient.
Appeal type: Experimental/Investigational
Decision: Upheld

A 20-year-old male enrollee has requested electrical muscle treatment (NESS L300) functional electrical stimulation (FES)for treatment of his quadriplegia at C5-7 incomplete.  Findings:  Two physician reviewers found that although a FES device can be beneficial in select cases with isolated foot drop secondary to an upper motor neuron lesion, it is not indicated for patients with profound bilateral lower extremity weakness across the ankle, knee, and hip, as noted in this patients case. Further, some literature documents use of FES devices for patients with stroke and multiple sclerosis, but there is a paucity of studies for patients with low cervical injuries with diffuse and extensive lower limb dysfunction. All told, the requested device is not supported as likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.
Appeal type: Medical Necessity
Decision: Upheld

A 37-year-old female enrollee has requested a consultation for breast reduction/implant removal for an evaluation of her macromastia. Findings:  The physician reviewer found that the patients condition does not constitute an abnormal structure of the body. There is no loss of functioning documented and the patient has the normal appearance of a patient who has undergone breast augmentation surgery. The preferred procedure would offer no more than minimal improvement in appearance and the additional scars could worsen her appearance. The patient lacks physical findings in the record and the photographs do not support her requests. The removal of breast implants is not reconstructive in this case nor medically necessary under general concepts of medical necessity as there are no functional issues documented.  She does not have grade IV Baker capsular contractures, no rupture of implants, no diagnosis of cancer or other tumors or systemic conditions to warrant removal of the implants. Therefore, there is no medical necessity of a plastic surgery consultation.
Appeal type: Medical Necessity
Decision: Overturned

The parents of a seven-month-old female born at 33-6/7-weeks gestation with a birth weight of 1910 grams with mild respiratory distress and mild hyperbilirubinemia are requesting Synagis for the remainder of the RSV season.Reviewers Findings:  The reviewing physician found that the patients birth weight and gestational age place the patient at risk for severe RSV disease, similar to the risk faced by extremely premature infants.  The reviewing physician found that the Health Plan denial should be overturned.
Appeal type: Medical Necessity
Decision: Overturned

A 49-year-old male enrollee requested continued authorization and coverage for Lamisil. The health plan has denied this request indicating that the requested medication is not medically necessary for treatment of the enrollees onychonycosis.One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer overturned the health plans denial on the basis that the requested medication is medically necessary.
Appeal type: Experimental/Investigational
Decision: Upheld

A 38-year-old female enrollee has requested authorization of a continuous passive motion (CPM) machine for treatment of her right knee cartilage defect.  Findings:  Two physician reviewers found that while the benefit of continuous passive motion has been established and accepted following total knee arthroplasty, there is a lack of evidence showing improved results with continuous passive motion following knee chondroplasty as compared to standard rehabilitation with physical therapy.
Appeal type: Urgent Care
Decision: Upheld

Nature of Statutory Criteria/Case Summary:  An enrollee has requested emergency department services on an emergent or urgent basis. The physician reviewer found that review of the submitted documentation demonstrates that a prudent layperson would not have sought immediate medical attention on the date in question. The patient states he sought immediate medical attention because he was concerned about the abnormal shape and appearance of his penis. Based upon the submitted medical records, the patient had not sustained any trauma and was not in any pain. He was not taking any medication associated with priapism. Based on the patients presenting complaints and symptoms, a prudent layperson in this circumstance would not reasonably believe he was suffering from a serious medical condition that required medical attention on an immediate basis.  In sum, the patient was not suffering from a serious medical condition that was likely to place the patients health in serious jeopardy, cause serious impairment to body functions or cause serious dysfunction to a body organ or part. Thus, the services did not meet prudent layperson criteria for emergency care.  Further, it has not been established that criteria for urgently needed services were met on the date in dispute. In this case, the patient presented with a partial erection with no reported trauma or pain. On physical examination the findings were minimal with a slight enlargement of the base of the penis compared to the shaft. The documentation does not support that a prudent layperson would seek immediate medical attention for swelling at the base of the penis. Based on the documentation submitted for review a prudent layperson in a similar situation would not have believed immediate medical attention was necessary to prevent serious deterioration of ones health. In sum, based on the patients clinical presentation, the patient did not meet prudent layperson criteria for urgently needed services. As such, the Health Plans denial should be upheld.   Final Result:  The reviewer determined that the patients symptoms did not meet prudent layperson criteria for emergency care or urgently needed services. Therefore, the Health Plans denial should be upheld.  Credentials/Qualifications:  The reviewer is board certified in emergency 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 patient has requested authorization and coverage for Aimovig 70 mg/mL autoinjector. Calcitonin gene-related peptide receptor antagonists (CGRP) are biologic agents with demonstrated efficacy, safety, and tolerability for the preventive treatment of episodic and chronic migraine that do not require dose titration, may achieve rapid treatment effects, and are effective in patients who have failed prior preventive treatment and in patients on concurrent oral preventive treatments. Aimovig (erenumab) is a CGRP approved by the U.S. Food and Drug Administration (FDA) for the preventive treatment of migraine in adults.  The American Headache Society (AHS) notes that treatment with monoclonal antibodies to CGRP may be indicated for patients with chronic migraines with an inadequate response to topiramate, beta-blockers, and nortriptyline. Researchers found that in patients with chronic migraines, erenumab 70 mg and 140 mg reduced the number of monthly migraine days with a safety profile similar to placebo. In this case, the patient has a history of chronic headaches and is unable to tolerate oral preventative medications. The records noted that topiramate and beta-blockers were contraindicated. Given that the patient fits AHS criteria for treatment with CGRP monoclonal antibody therapy, the requested medication is medically indicated. Therefore, Aimovig 70 mg/mL autoinjector 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 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: Overturned

Nature of Statutory Criteria/Case Summary: A patient with a diagnosis of alopecia universalis has requested authorization and coverage for bimatoprost. The records document that he has failed topical treatments, including Xeljanz and intralesional steroid injections. In this patient, proven treatments with intralesional steroids and Xeljanz cream for his alopecia universalis have not been substantially beneficial. However, the patient reports improvement with bimatoprost. There is evidence in limited trials demonstrating that the use of prostaglandin agents such as bimatoprost may be effective in this patient population . Studies suggest that complete regrowth may occur in up to 24% of patients. Further, the U.S. Food and Drug Administration (FDA) has approved 0.03% bimatoprost solution for the treatment of eyelash hypotrichosis. Since standard treatments have failed, it is reasonable for the patient to be treated with an FDA approved therapy for increasing eyelash length, thickness, and darkness. Therefore, the use of bimatoprost is medically necessary for the 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 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: Overturned

Nature of Statutory Criteria/Case Summary:  An enrollee has requested reimbursement for sacroiliac joint fusion procedure (right sided sacroiliac instrumented fusion, allograft, fluoroscopy, robotic assisted) rendered at MemorialCare Long Beach Medical Center in December of 2019.Findings: Three out of three physician reviewers found that sacroiliac joint fusion procedure (right sided sacroiliac instrumented fusion, allograft, fluoroscopy, robotic assisted) rendered at MemorialCare Long Beach Medical Center in December of 2019 was likely to have been more beneficial for the enrollee than any available standard therapy.Current peer-reviewed medical literature states that sacroiliac fusion may be indicated for patients with severe chronic pain localized to sacroiliac joint causing significant functional impairment when other sources of pain have been excluded. There are sufficient quality studies showing sacroiliac fusions superiority over non-surgical management. Minimally invasive sacroiliac joint fusion has also shown to be relatively safe. In this case, the patient had sacroiliac joint pain that caused functional impairment. The patient had persistent symptoms despite conservative treatment. Therefore, sacroiliac joint fusion procedure (right sided sacroiliac instrumented fusion, allograft, fluoroscopy, robotic assisted) rendered at MemorialCare Long Beach Medical Center in December of 2019 was likely to have been more beneficial for the patient than any available standard therapy.Final Result: The reviewers determined that the service at issue was likely to have been more beneficial than any available standard treatment for the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer 1, reviewer 2, and reviewer 3 are board certified in board certified in orthopedic surgery. All reviewers 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.