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

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested GI effects comprehensive profile, immunoassay analyte complete gliadin sensitivity and food allergy panel total IgE and IgG. Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested services.  There is a lack of validated evidence indicating that the tests in question are more useful than standard testing in diagnosing any medical condition.  The actual utility of these tests, and their performance in comparison to the current gold standard celiac screening tools, has not been demonstrated.  Fecal calprotectin is a common and well accepted test for purposes of irritable bowel disease screening.  The additional testing in the panel tests for many elements of the stool microbiome whose health effects remain unknown, although they may be associated broadly with identified health conditions.  There is a lack of support for the services at issue in this clinical setting.  All told, the requested services are not medically indicated for the evaluation of this patient.Final Result: The reviewer determined that the requested services are not medically necessary for evaluation of the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is board certified in pediatrics with sub-specialty 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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for esophageal sphincter augmentation device (LINX procedure). Overall, there is a lack of randomized controlled trials with long-term follow-up demonstrating that LINX is safer or more effective than standard surgical anti-reflux procedures. One evidence review concluded that the long-term safety and efficacy of LINX - both alone and in comparison to current GERD therapies - remains to be determined. Another best-evidence review concluded that long-term comparative outcome data past one year are needed in order to further understand the efficacy of magnetic sphincter augmentation. Additionally, LINX more than surgical fundoplication is associated with severe dysphagia requiring endoscopic intervention. The currently available peer-reviewed literature does not support the conclusion that LINX is more likely to be beneficial in this case than standard treatment including surgical fundoplication. Further, the American College of Gastroenterology (ACG) guidelines for the management of reflux disease also state that more evidence is needed before LINX can be recommended. For these reasons, the requested esophageal sphincter augmentation device (LINX procedure) is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.One reviewer found that the requested esophageal sphincter augmentation device (LINX procedure) is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: Two of the three reviewers determined that the requested procedure 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:  One reviewer is board certified in internal medicine with sub-specialty certification in gastroenterology and is actively practicing. One Reviewer is board certified in internal medicine with sub-specialty certification in gastroenterology and is actively practicing.  One Reviewer is board certified in internal medicine with sub-specialty certification in gastroenterology 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: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for a power wheelchair, group 3 standard, captains chair. In this case, the medical documentation does not support that the requested equipment is medically necessary. The records do not establish that the enrollee has upper impairments that would preclude effective propulsion of an optimally configured manual wheelchair to accomplish her mobility-related activities of daily living. Poor subjective tolerance of propelling a manual wheelchair does not constitute an impairment or functional limitation with respect to this activity. The records do not establish that the enrollee has upper impairments that would preclude effective pressure relief maneuvers in conjunction with an appropriate pressure relieving seat cushion. Researchers have studied how movements such as sideward leans, for instance, can provide significant reduction in interface pressure at the ischial tuberosities. Poor subjective tolerance of or compliance with performing pressure relieving maneuvers does not constitute an impairment or functional limitation with respect to this activity. The records, notably, otherwise indicate that the enrollee is able to transfer independently, and a physical therapy evaluation indicated that the enrollee's pressure relief needs in a wheelchair can be met with an air villous cushion. These documented capabilities are largely not consistent with an inability to perform effective pressure relieving maneuvers independently without powered means. Researchers have noted that lack of compliance can result in pressure ulcer development with or without tools such as power tilt-in-space. A group 3 power wheelchair, therefore, is not medically necessary for the patient based on the available documentation. Accordingly, the requested equipment is not medically necessary to treat the enrollees medical condition at this time.Final Result: The reviewer determined that the requested equipment 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 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: An enrollee has requested reimbursement for buprenorphine HCL 2 mg (120 tablets in a 30-day period). The Health Plan has denied this request indicating that the medication at issue was not medically necessary. The buprenorphine HCL 2 mg (120 tablets in a 30-day period) provided was medically necessary for treatment of the patients medical condition. There is sufficient medical literature supporting the medication at issue in this clinical setting. A study concludes that buprenorphine is efficacious in detoxifying patient from opiates. In addition, another study found similar efficacy. In this case, the notes indicate the treatment plan is for detoxification using buprenorphine. The medication quantity as recommended by the patients provider will allow for a gradual weaning off opiates. Therefore, the medication at issue has been established as medically necessary for the treatment of the patients medical condition.Final Result: The reviewer determined that the medication at issue was 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 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: Overturned

Nature of Statutory Criteria/Case Summary:  An enrollee has requested reimbursement for teeth implants (CDT-D6010) for teeth 4, 7, 10, and 12 provided on 12/18/20. Findings:  The physician reviewer found that many studies, support the use of complete dentures for rehabilitation of the edentulous maxilla. Placement of implants for an implant retained prosthesis can improve masticatory performance, reduce size of the prosthesis and improve phonetics and occlusion. High levels of patient satisfaction have been reported with implant supported prosthesis, especially for those patients who are dissatisfied with complete dentures. In this case, the patient does have an edentulous maxilla and it is known that this can result in decreased masticatory efficiency among other issues. On 12/23/20, the patient had his dentures relined. The patient underwent implant placement indicating a level of dissatisfaction with his conventional denture. Additionally, treating complete denture wearers with implants to support their denture has been shown to improve their chewing efficiency, increases maximum bite force and improves satisfaction. The placement of implants for a maxillary overdenture is consistent with the patients diagnosis of edentulous maxilla. Therefore, teeth implants (CDT-D6010) for teeth 4, 7, 10, and 12 provided on 12/18/20 were medically necessary for the treatment of the patients medical condition.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 oral and maxillofacial surgery and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

The patient is a 43-year-old male who was initially admitted for detoxification in January 2006 and was transferred to the residential treatment program in January 2006.  Notes from his admission assessment indicate he was in good health, was able to work with the problem (alcoholism), and had no physical disabilities. It was also noted that his family was supportive and he was motivated.  He had not developed a tolerance for alcohol and stated he was able to manage the problems of day-to-day life.  The patient had only one prior treatment for alcohol dependence dating back to 1994.  The patient is requesting reimbursement for residential treatment services provided in January 2006.  The Health Plan has denied his request based on a determination that those services were not medically necessary.Based on the ASAM criteria, services in either an Intensive Outpatient Program (IOP) or Partial Hospitalization Program (PHP) would have been most appropriate for this patient.  He had no significant symptoms of withdrawal, was motivated to receive treatment and had good family support.  The literature does not support the use of this level of care in preference to an IOP or PHP.  Further, the use of the IOP or PHP format would potentially have allowed the individual a longer episode of care and better facilitated his integration into a program of daily sobriety.  There were no indications that alternative approaches for the treatment of his alcoholism were tried, including the use of medications to treat the craving for alcohol that he described.  Based upon the information set forth above, I have determined the services at issue were not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/ Case Summary: This is male with hypertension, gastric reflux, degenerative arthritis of the spine, and irritable bowel syndrome. The patients primary care physician (PCP) reports he is being seen for ongoing back pain and medication management. Naproxen 375 mg twice a day for 15 days was ordered, as well as salicylate-menthol ointment for relief of back pain three times day. The PCP stated in the requests for diclofenac sodium 3% gel that the patient has persistent symptoms of back pain that have not responded to or been tolerated (stomach upset), with ibuprofen, aspirin, Tylenol, Bio Freeze topical and naproxen. At issue is whether Diclofenac Sodium 3% Gel is medically necessary to treat the patients medical condition. The patients medial records document one 15-day trial of naproxen for relief of back pain. The treating physician writes that ibuprofen and naproxen were not effective and/or resulted in stomach upset. No other NSAIDs were prescribed, prior to prescribing the requested Diclofenac Sodium 3% Gel. Literature reports that topical NSAIDs, including topical diclofenac sodium 3% gel used on patients with OA of the hands or knees, provide similar pain relief, improvement in physical function, and reduction of stiffness compared with oral NSAIDs in patients with OA of the hands or knees, and have fewer systemic adverse events. The FDA reports that diclofenac sodium 3% gel is indicated for the relief of osteoarthritis joint pain of the knees and hands. However, diclofenac sodium 3% gel has not been evaluated and approved for use on joints of the hip, shoulder or spine. The patient is being treated for arthritis of the spine, and therefore, diclofenac sodium 3% is not appropriate for his condition. Based on FDA recommendations and documentation in the medical records provided, the requested medication is not indicated for this patient for treatment of the spine. Final Result: The reviewer determined that the requested service is not medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The physician 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 similar medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested coverage for gene test (CPT 81545) Afirma performed for evaluation of the enrollees thyroid nodule. Findings:  Three physician reviewers found that the testing at issue was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The American Thyroid Associations guidelines indicate that for nodules with FLUS cytology, investigations such as repeat FNA or molecular testing may be used to supplement malignancy risk assessment in lieu of proceeding directly with a strategy of either surveillance or diagnostic surgery. Informed patient preference and feasibility should be considered in clinical decision-making.  In this case, the patient has a thyroid nodule with worrisome features and the cytopathology consistent with FLUS. The result of the Afirma GEC from the same specimen was benign. This information was important to determine the decision whether to perform a thyroidectomy and may prevent the need for a repeat biopsy or diagnostic hemithyroidectomy. In addition, there is sufficient support in the peer reviewed literature demonstrating the benefits of genetic testing in thyroid nodules. Final Result: Three reviewers determined that the testing 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 reviewers are board certified in internal medicine with sub-specialty certification in endocrinology, diabetes and metabolism 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 patient is a 71-year-old male who was diagnosed with localized prostate cancer. He consulted with a radiation oncologist within the Health Plan who recommended hormone therapy followed by external beam radiation treatment (EBRT). The patient then consulted a non-plan radiation oncologist who recommended proton beam radiation therapy.  The patient proceeded with proton beam radiation therapy and is now requesting reimbursement.  The Health Plan denied the request based upon a determination that the therapy was not medically necessary for the treatment of the patients prostate cancer.In general, proton beam therapy is more conformal than external beam radiation treatment. However, no randomized trials have been performed directly comparing proton beam to the Health Plans proposed EBRT.  As there is no clinical evidence that proton beam is more beneficial than the Health Plans proposed EBRT, I have determined the requested therapy is not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Experimental/Investigational
Decision: Overturned

A 38-year-old female enrollee has requested a PET scan for an evaluation of her gastrointestinal stromal tumor. Findings:  Two physician reviewers found that gastrointestinal stromal tumors are rare malignancies, but recent literature indicates a vital role of PET imaging in the staging and evaluation of treatment for recurrence. There is peer-reviewed literature concerning this particular tumor and the use of PET imaging. The American Cancer Society has stated that PET imaging is the most promising tool to date for the detection of such a tumor. In this patients case, CT of the liver was equivocal. The use of PET scan would not only allow for the evaluation of possible hepatic metastasis, but also allow for a way to evaluate the response to therapy given to date.
Appeal type: Medical Necessity
Decision: Overturned

The patient is an 18-year-old female who underwent surgery to correct a malocclusion. Post surgery the patient developed a tongue thrust. The patients oral surgeon has recommended myofunctional intervention (speech therapy) to improve the thrust and to prevent recurrence of the malocclusion post surgery. The Health Plan has denied authorization and coverage for the requested therapy on the basis it is not medically necessary.Review of the scientific literature demonstrates myofunctional therapy is supported by the American Speech and Hearing Association. In addition, although there is no literature specifically involving post surgical cases, a report by Piyapattamin, et al. documented post-surgical tongue thrust improvement by correction of applied forces. Given that the requested therapy is considered an appropriate treatment for tongue thrust, and there is concern malocclusion may occur in this patient, the requested therapy is medically reasonable and appropriate and should be authorized. Accordingly, I have determined the requested therapy is medically necessary for treatment of the patients medical condition. The Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Upheld

 Nature of Statutory Criteria/Case Summary:   An enrollee has requested Juvederm injections for treatment of her medical condition.  Findings:  The physician reviewer found that in this patients case, the condition constitutes an abnormal structure of the body.  The patient has evidence of lesions/changes that are consistent with chronic biting.  The patient also has some evidence of facial soft tissue atrophy.  This would be considered abnormal.  The chronic biting provides a form of trauma that has led to the lesions/condition.  However, the requested services will not be performed to improve function.  The use of Juvederm as a functional treatment of her chronic biting is not a standard therapy.  In addition, conservative management and other treatment choices have not been adequately documented.  Juvederm can be used to create a more normal appearance, if there is evidence of significant soft tissue loss of the face, which is not present in this case.  Additionally, the services are not likely to provide more than a minimal improvement in the appearance of the patient.  In this case, her facial abnormality is not well-defined to be significant enough to warrant soft-tissue augmentation and thus, one cannot determine if more than a minimal improvement would be likely.  Although the patient states that the Juvederm is being performed for functional reasons, it is not clear that soft tissue augmentation would be the treatment of choice in preventing chronic mucosal injury.  All told, the requested Juvederm injections are not reconstructive in nature and are not medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested services are not reconstructive in nature and are not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.  Credentials/Qualifications: The reviewer is board certified in 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: Medical Necessity
Decision: Upheld

A 61-year-old female enrollee requested authorization and coverage of Botox injections for the treatment of tension headaches.  The enrollees health plan denied the request indicating that the requested treatment is 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 Botox injections are not medically necessary.
Appeal type: Medical Necessity
Decision: Upheld

A 52-year-old female enrollee requested authorization and coverage of Miacalcin nasal spray. The Health Plan denied the request indicating that the requested medication is not medically necessary for treatment of the enrollees osteopenia.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: Upheld

A male enrollee requested Aranesp 300 mcg subcutaneous (SQ) every three weeks, or in the alternative, Procrit 40,000 units SQ daily for two weeks for medical treatment of his anemia in end stage renal disease with chronic kidney disease.  Findings:  The physician reviewer found that erythropoiesis stimulating agents are generally not recommended for patients with hemoglobin levels above 10, since they can increase the risk of thromboses. In addition, there is a lack of documentation that this patient has any significant angina that requires maintaining hemoglobin or has chemotherapy exposure or cancer. All told, the requested Aranesp 300 mcg subcutaneous (SQ) every three weeks, or Procrit 40,000 units SQ daily for two weeks, is not medically indicated and necessary.