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

A 21-year-old female enrollee has requested for residential treatment for treatment of her eating disorder.  Findings:  The physician reviewer found that it appears that the enrollee has been making progress toward transitioning to a partial hospitalization program (PHP) level of care. However, at this time she is still in need of care at the residential treatment center (RTC) level in order to prevent relapse. Therefore, the RTC services provided have been shown to be medically necessary as well as coverage for additional services while the patient prepares to transition to a lower level of care.
Appeal type: Experimental/Investigational
Decision: Upheld

A 53-year-old male has requested a brain PET scan for evaluation of cognitive problems.  Findings:  Two physician reviewers found that PET scanning is not the standard of care in this setting as it has not been shown to have established benefit under these circumstances. At this time, there is inadequate data demonstrating that the use of PET in this context is likely to alter the care and management of this patient. The utility of PET as a diagnostic tool for evaluation of cognitive problems remains unproven.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for anesthesia services provided during a colonoscopy procedure. The Health Plan has denied this request indicating that the services at issue were not medically necessary for management of the enrollees pain during her colonoscopy. Findings: The documentation provided does not support the medical necessity of the services at issue in this clinical setting. The American Society of Anesthesiology (ASA) provides a preoperative physical status classification scoring system. In this case, the patients ASA preoperative physical status score was 2, which indicates a non-anesthesiologist or a non-certified registered nurse anesthetist could have provided intravenous sedation during the colonoscopy. Intravenous sedation performed by a non-anesthesiologist or non-certified registered nurse anesthetist is well supported in both clinical practice and in the research. Furthermore, it was noted that this patient had a successful colonoscopy performed in 2008 with intravenous sedation. The records did not indicate a failure of intravenous sedation with back pain. Given a low preoperative physical status classification score of 2 as well as a history of successful prior intravenous sedation, the anesthesia services provided during a colonoscopy procedure were not medically necessary for management of this patients medical condition.Final Result: The reviewer determined that the anesthesia services at issue were not medically necessary during the patients colonoscopy. Therefore, the Health Plans denial should be upheld.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: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for the LINX Reflux Management Procedure (CPT 43284).Findings: Two out of three physician reviewers found that the current medical evidence supports the requested service in this clinical setting. This patient has fulfilled eligibility criteria for the LINX Reflux Management Procedure since he has typical GERD symptoms, an abnormal pH study, intolerance to PPI therapy and absence of a large hiatal hernia. The requested service has been shown to be superior to twice-daily PPI therapy. Bell and colleagues compared the effectiveness of increased PPI dosing with laparoscopic magnetic sphincter augmentation in patients with moderate-to-severe regurgitation despite once-daily PPI therapy. The authors noted that the LINX Reflux Management Procedure normalized the total number of reflux episodes and acid exposure in 91 and 89 percent of patients, compared with 58 and 75 percent of those treated with twice-daily PPI therapy. The LINX Reflux Management Procedure has been compared with laparoscopic Nissen fundoplication in several meta-analyses. Clinical control of reflux was comparable after the two procedures. Aiolfi and colleagues noted that there was less gas bloat associated with the LINX Reflux Management Procedure than laparoscopic Nissen fundoplication. Ganz and colleagues evaluated the long-term safety and efficacy of the LINX prosthesis in a prospective single-group trial of 100 patients with long-standing GERD. The authors noted, Augmentation of the lower esophageal sphincter with a magnetic device provides significant and sustained control of reflux, with minimal side effects or complications. Therefore, the LINX Reflux Management Procedure (CPT 43284) is likely to be more beneficial than any other available standard therapy to treat the patients condition.Final Result: The reviewers determined that the requested services are likely to be more beneficial than any other available standard therapy to treat the patient's condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: Physician reviewers 1, 2 and 3 are board certified in internal medicine, with subspecialty 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: Upheld

A 51-year-old female enrollee has requested lateral displacement of calcaneal step osteotomy surgery for treatment of her ankle pain. Findings:  The physician reviewer found that although there may be value in procedures to correct hindfoot alignment in the treatment of early osteoarthritis of the ankle joint, this is generally done in association with other indicated measures, such as ligament reconstruction, or procedures such as drilling. There is a lack of data demonstrating the efficacy of the requested procedure in this patients case. The outcome of realignment of valgus problems has indicated that it is contraindicated in cases with significant cartilage degeneration.  In this case, the patients arthritis is more advanced.  There was evidence of osteophytes in the x-ray performed a few weeks following the injury. Additionally, the subsequent studies continued to report evidence of significant cartilage loss and joint narrowing.  All told, the submitted documentation fails to establish the medical necessity of the requested lateral displacement of calcaneal step osteotomy surgery in this patients case.
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 (HCPCS K0856).In this case, the patient has a history of traumatic spinal cord injury with chronic residual motor impairments that preclude ambulation and independent propulsion of a manual wheelchair. Moreover, the patients functional deficits are consistent with his level of injury (Chay, W. and Kirshblum, S.). He has been independently operating a power wheelchair, as well as driving an adapted van while seated in his power wheelchair which is locked via a pin system into the driver's seat area. The use of assistive devices for mobility by persons with the patients condition, in general, is considered crucial (Florio J, et al.). The records in the present case indicate that the patient has more than one power wheelchair, at least one of which was found to be operational and in good condition. The patient has elected not to outfit this power wheelchair with lockdown pins due to concerns of future obsolescence. However, any new power wheelchair model is also at risk for discontinuation at any time and future obsolescence. Under these circumstances, the requested power wheelchair, group 3 standard (HCPCS K0856) is not medically necessary to perform one or more mobility-related activities of daily living or instrumental activities of daily living in or out of the home, including access to the community.Final Result: The reviewer determined that the requested durable medical equipment is not medically necessary to perform one or more mobility-related activities of daily living or instrumental activities of daily living in or out of the home, including access to the community. 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: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for immediate surgery to remove a left ovarian cyst. Findings:  The physician reviewer found that the submitted documentation does not support the medical necessity of the requested procedure in this clinical setting. This patient describes pain over the last year, and a cyst that has decreased in size. These symptoms are more consistent with a functional ovarian cyst, which arises from the normal functioning of ovaries, as opposed to a pathologic cyst, such as a chocolate cyst. Pathologic cysts are often related to endometriosis and do not get smaller. The patient's provider noted an interval decrease in the size of the lesion. In a review on adnexal/ovarian masses,  A study noted A cyst may also become hemorrhagic without rupture. Immediate surgical intervention is required only if there is concern that brisk bleeding from the cyst may cause anemia or hemodynamic instability. Other patients may be managed with pain management and follow-up for resolution of the pain and the mass.  If this patients pain is related to a hemorrhagic cyst, it should resolve with conservative management.  There can be many other causes of abdominal and pelvic pain, most of which do not require surgical intervention. The provided documentation do not indicate that conservative management have been assessed for treatment of this patient. The medical studies show that hemorrhagic cysts are common and transient and often resolves over time. Moreover, this patient had prior surgeries with unsatisfactory results. As such, it would not be clinically prudent to proceed with surgery when there are no clear indications to do so.  There is no clinical indication for surgery at this time.  Therefore, immediate surgery to remove a left ovarian cyst is not medically necessary for treatment of this patient. Final Result: The reviewer determined that the requested procedure 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 obstetrics and gynecology 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 67-year-old male enrollee has requested Mekinist (trametinib) for treatment of his metastatic melanoma with metastases to the brain, lungs and colon. Findings:  The physician reviewer found the submitted documentation and relevant literature fails to demonstrate the medical necessity of the requested medication. The medical literature does not support the use of Mekinist (trametinib) in this clinical setting. The patients melanoma was found to harbor a B-RAF V600E mutation, such mutation does qualify him for treatment with B-RAF inhibitor. The patient did receive such treatment, vemurafenib, for quite some time and his cancer is resistant to it. Mekinist is a kinase inhibitor that works by a different mechanism than vemurafenib, with the hope that it can overcome resistance to the B-RAF inhibitor. Mekinist has been demonstrated to have clinical activity either alone or in combination with B-RAF inhibitor and it has been U.S. Food and Drug Administration (FDA) approved for use in metastatic melanoma. However, there is a limitation in that it is not approved for use in patients resistant to B-RAF inhibitors, such as vemurafenib, nor in patients who have received ipilimumab. Both of these apply to this patient. These limitations are established by the FDA as well as Mekinists prescribing manufacturer. For the reasons set forth above, Mekinist is not approved in this clinical setting and not medically necessary for treatment of the patients medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Acthar Gel for treatment of the enrollees rapidly progressive glomerulonephritis. Findings:  Two physician reviewers found that there is a lack of data supporting treatment of crescentic glomerulonephritis with Acthar Gel. Overall, Acthar Gel has been primarily used in the treatment of nephrotic syndrome and not crescentic glomerulonephritis. If the patient shows clinically active progression, she may be a candidate for plasma exchange and cyclophosphamide. If her serum creatinine is stable, she should be observed while not on methimazole. Currently, azathioprine, if she does not have deficiency of thiopurine methyltransferase, mycophenolate or methotrexate as maintenance therapy for two years remains the standard of care. Given these findings, the requested Acthar Gel is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Final Result: The reviewers determined that the requested medication 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 nephrology 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 Xeljanz XR tablets. Findings: According to guidelines, for patients with continued disease activity despite treatment with disease modifying anti-rheumatic drug (DMARD) monotherapy, combination of traditional DMARD agents, addition of a tumor necrosis factor (TNF) inhibitor or non-TNF biologic, are supported rather than continuing DMARD monotherapy. In this case, the patient was previously treated with the DMARD methotrexate. Subsequently, this patient received Xeljanz to optimize disease control. Based on the ACR recommendations, the use of Xeljanz for treatment of this patients rheumatoid arthritis is medically appropriate after DMARD therapy with methotrexate was unsuccessful. Furthermore, the guideline specifically stipulates that there is no particular order of preference when choosing the next agent to optimize rheumatoid arthritis disease control after attempting use of a DMARD. Given this support, the requested Xeljanz XR 11 mg tablets are medically necessary for 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: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested authorization and coverage for oral nutritional supplement, Neocate Junior. Findings:  The physician reviewer found that the submitted documentation does not support the medical necessity for requested nutritional supplement in this clinical setting. EoE is an atopic disorder leading to inflammation of the esophagus and associated symptoms of dysphagia, nausea, and abdominal pain with associated poor weight gain.  Although there is some support in the medical literature that an elemental diet can be an effective management of EoE, more focused elimination diets lead to remission in up to 45 percent of cases. In this patients case, the documentation indicates that his dysphagia and esophageal eosinophilia have resolved with avoidance of peanut, soy, and wheat.  Although, this patient continues to have slow growth and evidence of mild malnutrition based on his growth charts, he is able to take food with dairy and is noted to consume milk daily. He does not have dysphagia to solids. As such, the patient should be able to tolerate high-calorie dairy foods as well as other high-calorie foods that do not contain peanut, soy, or wheat.  Additionally, the provider describes early satiety and so a trial of an appetite stimulant may be indicated.  Furthermore, it may be reasonable to consider an avoidant restrictive food intake disorder or other contributing factors for the patients inadequate caloric intake. Final Result: The reviewer determined that the nutritional supplement 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 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: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for gallbladder removal surgery. Findings: The physician reviewer found that the submitted documentation supports the requested services in this patients case. Cholecystectomy can be effective for management of biliary colic associated with gallbladder disease, regardless of the presence of gallstones. It can resolve biliary colic, even when the gallbladder ejection fraction is normal on hepatobiliary scan. In this case, the patient has symptoms consistent with biliary colic or gallbladder-associated pain, and there is a good possibility that cholecystectomy may result in resolution of her abdominal pain. All told, the requested gallbladder removal surgery 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 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: Medical Necessity
Decision: Upheld

The patient is an 18-year-old obese female with low exercise participation. The patients physician has prescribed Zetia for this patient with cholesterol of 252 and LDL of 145. It does not appear that the patient has primary relatives with premature coronary artery disease. The Health Plan has denied authorization for Zetia indicating that it is not medically indicated for treatment of the patients condition.The Health Plans denial is medically appropriate. There are no recommendations for cholesterol lowering agents for anyone under the age of 35, especially females, with a lipid profile in the range the patient has (LDL less than 190). In addition, the submitted information does not demonstrate that the patient has a family history of a first degree relative with premature coronary artery disease. Furthermore, no other risk factors are noted. Therefore, I have determined that the requested medication is not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a 22-month-old male enrollee has requested for speech therapy for treatment of the enrollees cerebral palsy. Findings:  The physician reviewer found that the plasticity in the developing brain still exists, even in patients with underlying neurological disease such as cerebral palsy. This brain plasticity can be utilized to improve overall neurological health. Specific treatment, including speech therapy, can be used to help induce brain plasticity, with the ultimate goal of retraining neural circuitry not compromised by the underlying pathogenic processes that give rise to expressive and receptive speech delay. Given this patients diagnoses of cerebral palsy and speech and language delay and the consensus in the available peer reviewed literature, speech therapy is medically appropriate and necessary for treatment of this patient.
Appeal type: Medical Necessity
Decision: Overturned

The patient has requested authorization and coverage for a Synvisc-One injection for the right knee. Review of the current medical literature pertaining to viscosupplementation reveals mixed results. Although viscosupplementation may relieve knee pain in some patients with osteoarthritis, it is unknown which patients will benefit. Considering the foregoing, viscosupplementation can only be recommended for patients with a history of lasting benefit from prior injections and in carefully selected cases when everything else has been tried and the options are limited. In this case, the patient has a history of pain relief from prior viscosupplementation injections. Furthermore, the patients options are limited. The patient has tried and failed other conservative treatments, with the alternative being a total knee arthroplasty. The medical evidence supports the requested service in this clinical setting. Therefore, a Synvisc-One injection for the right knee is medically necessary for treatment of this patient. Final Result: The reviewer determined that the requested service 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 orthopedic 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.