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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage laparoscopic anti-reflux surgery utilizing LINX Reflux Management System (CPT 43284) for the enrollees gastroesophageal reflux disease (GERD). Findings:  The 3 physician reviewers found that according to the documentation submitted for review, the patient has GERD based on pH recording. However, it appears the patient has benefited to a significant degree from acid suppression treatment, and as such cannot be considered medically refractory to acid blocker drugs. Also, implantation of LINX in this clinical setting must be approached with caution given the patients lack of endoscopically-advanced esophageal inflammation. LINX implantation, with its inherent surgical risks and post-operative complications is not likely to be more beneficial than conventional medical therapy in combination with lifestyle modification aimed at reducing GERD symptoms and manifestations. All told, the request for laparoscopic anti-reflux surgery utilizing LINX Reflux Management System (CPT 43284) is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Final Result: The 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: Physician reviewer number one 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.Physician reviewer number two 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.Physician reviewer number three is board certified in internal medicine with sub-specialty certification in gastroenterology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for functional electrical stimulation (FES) for treatment of the enrollees spinal cord injury.  Fulfills Findings:  The physician reviewer found that there is a lack of sufficient peer-reviewed literature supporting definitive physiological responses of a spinal cord injured individual to FES devices. Moreover, there is a lack of literature support demonstrate that FES provides a clinically meaningful benefit beyond that of standard exercise recommendations for an individual with T6 paraplegia, including aquatic exercise, upper body ergometry, and passive stretching. For the reasons provided, the request for FES 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 equipment 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: Physician reviewer number one 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.Physician reviewer number two 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.Physician reviewer number three 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

A 51-year-old female enrollee requested authorization and coverage of removal of a Greenfield filter from the inferior vena cava for relief of back and abdominal pain.  The Health Plan denied the enrollees 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 services are not medically necessary for treatment of the patients medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned

A 36-year-old male enrollee has requested a computed tomographic angiography (CTA) of the heart for evaluation of his trace triscupid regurgitation (TR), trace mitral regurgitation (MR), and mild right ventricular (RV) enlargement and moderate biatrial enlargement.   Findings:  Two physician reviewers found that CT angiography (CTA) is a mature and accurate technology that is capable of imaging the coronary arteries and other cardiac structures in a completely non-invasive manner (Hendel, et al.). No other non-invasive technology is capable of performing this feat with the clarity, speed and accuracy of CTA. In addition, CTA has been shown to have lower doses of radiation than other commonly used cardiac tests such as thallium and technetium nuclear stress tests, invasive coronary angiography and percutaneous coronary angioplasty. CTA has been shown to provide not only excellent clinical performance potential but also relevant and incremental prognostic information (Mark, et al.). The ACC/AHA has recommended the use of CTA in patients with inconclusive or equivocal stress tests, as was detected in this patient (Hendel, et al.). This is due to the fact that CTA is non-invasive and prevents the complications from invasive coronary angiography such as bleeding, arterial perforation, arteriovenous fistulas, stroke and death. It also provides equal if not better information on the 3D geometry of coronary anatomy, coronary course in relation to other structures, plaque extent, plaque severity as well as plaque composition or morphology of calcified versus soft, which has prognostic value. This all translates into a robust technique which contains multiple important levels of clinical information in a safe, accurate and non-invasive manner. CTA was useful for this patient, as it avoided an unnecessary invasive procedure with all the associated risks and complications thereof; it reassured the treating and referring physician and patient regarding the absence of coronary artery disease and it imparted an excellent prognosis that will allow the patient to avoid the use of lifelong statin, aspirin and other anti-atherosclerotic medications.
Appeal type: Experimental/Investigational
Decision: Upheld

A 63-year-old female enrollee has requested for lumbar artificial disc replacement and hospitalization for treatment of her degenerative disc disease.  Findings:  Three physician reviewers found that currently there is a paucity of reliable and reproducible scientific data demonstrating that artificial disc replacement is an appropriate treatment in patients with more than one level of degenerative disc disease. Further, the performance and durability of the procedure remains uncertain. Specifically, there is inadequate evidence that disc replacement reliably, reproducibly, and over long periods of time fulfills the three primary aims of clinical efficacy, continued motion, and few adjacent segment degenerative problems. Total disc replacement has been associated with a high rate of re-operations, and the potential problems that may occur with longer follow-up have not been fully documented. Therefore, total disc replacements should only be used within the context of strict clinical trials. This patient presents status post two-level artificial disc replacement surgery. All told, the surgery at issue was not likely to be more beneficial for treatment of this patients medical condition than standard alternatives.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested intensive outpatient program services for treatment of his behavioral health condition. Findings: The physician reviewers found that based on the submitted records, IOP level of care was not medically necessary. The patient was not a danger to himself or others; he was cognitively intact; he showed no violent tendencies; he was no longer psychotic; and he was not manic. Moreover, the records indicate that the patient was medically stable and capable of caring for his activities of daily activities.  For these reasons, the services at issue were not and are not medically necessary for the treatment of this patients medical condition.Final Result: The reviewer determined that the services at issue were not and are not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The physician 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 patient has requested authorization and coverage for ZTlido 1.8% topical system. The U.S. Food and Drug Administration (FDA) has approved the ZTlido 1.8% topical system for the treatment of post-herpetic neuralgia. A review reported that there is a lack of evidence to support the use of lidocaine patches, such as ZTlido, for musculoskeletal pain. In this case, the patient has a known diagnosis of lumbar radiculopathy and lumbar stenosis. She was also diagnosed with arthritis, which is a musculoskeletal disease. The provider recommended treatment with ZTlido patches. However, the records do not document an indication for this medication. Based on the available medical records for review and the current medical literature, the requested ZTlido 1.8% topical system is not medically necessary for 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 anesthesiology with subspecialty certification in pain management 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 Synthroid. The Health Plan has denied this request indicating that the requested medication is not medically necessary for treatment of the enrollees hypothyroidism. The submitted documentation supports the medical necessity of the requested medication. The patient has successfully treated her hypothyroidism in the past with Synthroid brand preparation. It is possible that the patient had a reaction to one of the inactive components of the generic levothyroxine preparation.  According to the American Thyroid Association guidelines, this issue has been controversial and no studies or recommendations have been conclusive. If a patient could be prescribed the same generic formulation from refill to refill, there would be no reason to be concerned about distinction between branded and generic products. However, if prescribing a generic product exposes the patient to switching between generic products, then a potential concern remains. In this patients case, it is not good medical practice to change to a generic preparation or a different brand. She may experience the side effects she had when she tried a generic in the past, and she will require additional testing and office visits that would not be necessary if she were to continue her proven effective therapy with Synthroid. Since the patient has been stable and done well for several years with Synthroid, it is appropriate to stay on Synthroid. Therefore, Synthroid 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 endocrinology, diabetes and metabolism and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

The parent of a 15-year-old female enrollee requested residential treatment center services for medical treatment of the enrollees bipolar disorder.   Findings:  The physician reviewer found that the patients medications were at the target levels and she was compliant with them. In addition, she was not exhibiting any aggression or suicidal ideation. The provider noted the patient did exhibit insight into her problems, especially her manipulative behaviors.   Moreover, she was able to discuss her warning signs with the provider. Thus, the patient could have been safely and adequately treated in a less restrictive treatment setting than residential treatment center level of care. The patient was medically stable and no further medication changes were contemplated. She was compliant, was not aggressive or a danger to herself or others, and she demonstrated insight into her behaviors and knowledge of coping skills. All told, the residential treatment center services were not medically necessary for treatment of this patients medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/ Case Summary:  The enrollee requested authorization and coverage for gastric peroral endoscopic myotomy (G-POEM). The enrollee has a history of gastroesophageal reflux disease, gastroparesis and repaired paraesophageal hiatal hernia. He underwent Linx band placement and his gastroesophageal reflux disease improved, but he subsequently developed belching and bloating. Testing revealed delayed gastric emptying. He underwent balloon dilation of the pylorus with Botox to the pylorus, but his symptoms did not improve. He was treated for Helicobacter pylori and the Linx band was removed without improvement. The gastroenterologists impression was gastroparesis. This procedure is not approved by governmental bodies and it is not included in any society guidelines.  Despite literature showing improved outcomes in nausea and vomiting, the studies are short-term and involve small numbers of enrollees. More investigation is needed to identify optimal candidates, a standardized approach to pre-operative and post-operative testing, and a standard endoscopic approach. This enrollee may have pyloric dysfunction as a mechanism for delayed gastric emptying, but he failed pyloric dilation.  It is not clear if this enrollee would benefit from another pyloric interventional procedure. There are no validated criteria defining a distinct subset of individuals with decreased pyloric distensibility. Large, prospective, randomized trials are needed. There are several limitations that exist because a gold standard does not exist to which the effectiveness of G-POEM can be compared.Final Result: Three of the three reviewers determined that the requested services are not likely to be more beneficial than any available standard therapy for treatment of the enrollees medical condition. Credentials/Qualifications: Three reviewers are board certified in gastroenterology and are 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

The mother of a 26-year-old female enrollee requested authorization and coverage of licensed vocational nursing (LVN) services at home for treatment of the enrollees medical condition. The Health Plan denied the request indicating that the requested services are not medically necessary for treatment of the enrollees Rett syndrome.One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer upheld the Health Plans denial on the basis that the requested services are not medically necessary.
Appeal type: Experimental/Investigational
Decision: Upheld

The parents of a four-year-old male enrollee have requested an intrapulmonary percussive ventilation (IPV) system for treatment of the enrollees spinal muscular atrophy (SMA).  Findings:  Two physician reviewers found that although the IPV system has been FDA approved since 1993, a survey of the peer-reviewed literature reveals only a few studies; most with small sample sizes and dealing with the use of IPV for cystic fibrosis. Cystic fibrosis is not a neuromuscular disease and is a very different entity than spinal muscle atrophy (SMA), Type II. The studies that did show a significant positive effect often involved a subject who was refractory to the standard modalities of chest physiotherapy. In general, there is a paucity of IPV studies in the pediatric and neurological literature. While IPV is thought to be of some benefit in this instance, the patient already has a therapy vest and a cough-assist device and manual chest physiotherapy is also an effective method of airway clearance.
Appeal type: Medical Necessity
Decision: Overturned

A transgender female enrollee has requested facial feminization surgery for medical treatment of her gender identity disorder.  In this patients case, the submitted documentation supports a diagnosis of gender identity disorder. Photographs of the patient demonstrate the presence of masculine facial features. Moreover, the patients therapist notes the patient suffer[s] from significant dysphoria in relation to her facial features. In fact, anxiety and depression related to the patients masculine facial features is well documented in the records provided. Therefore, based upon the above cited evidence and the patients clinical history and current presentation, rhinoplasty (30410), frontal bossing and orbital reshaping (21209), jaw/chin contouring (21198) and tracheoplasty (31750) are medically necessary for treatment of the patients gender identity disorder. These procedures also meet reconstructive surgery criteria, as the presence of the patients masculine facial features represent an abnormal structure of the body as a result of her gender identity disorder and these procedures would be expected to create a normal appearance as well as provide more than minimal improvement in the patients appearance.  With regard to the requested septoplasty (30520), this procedure appears to have been requested for the condition of acquired or congenital septal deviation and, as such, would be considered medically necessary for treatment of the patients deviated septum.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for endoluminal ablation of varicose veins in the lower extremities for treatment of the enrollees varicose veins of the lower extremitiesFindings:  Two physician reviewers found that the patient has a family history of coronary artery disease and has a history of smoking, hypertension, hyperlipidemia, and leg pain with cramping and possible ulceration resistant to compression stockings. In this clinical setting, the records do not demonstrate that the patients symptoms are attributable to accessory vein reflux without an assessment of lower extremity arterial perfusion. In the absence of an assessment of the lower extremity arterial perfusion, endoluminal ablation of varicose veins in the lower extremities has not been established likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Final Result: Two 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: All three physician reviewers are board certified in vascular surgery 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 has requested surgical excision of a sebaceous (inclusion) cyst for the treatment of her skin condition.  Findings:  The physician reviewer found that based on the medical record, the patients inclusion cyst was not causing any health problems. The indication for removal was the patients desire to have it removed rather than to maintain or improve her health. According to the H&P, the cyst was not bothersome. The records do not document any recent change in size or a concern that the mass might be malignant. The cyst was removed for a cosmetic reason, rather than a medically necessary indication.
Appeal type: Urgent Care
Decision: Upheld

A 67-year-old female enrollee requested urgent care services for medical care of her medical condition.  Findings:  The physician reviewer found that review of the submitted clinical documentation demonstrates that a prudent layperson would not have sought immediate medical attention on the date in question. In this case, the patient presented to an urgent care facility with complaints of sore throat, swollen glands, fever and chills. However, the patient was not hemodynamically unstable, she was not suffering from severe respiratory abnormalities/ventilation abnormalities, she did not have a significant fever and she was not in severe pain.  Additionally, on physical examination it was noted the patient appeared in no acute distress. Moreover, the patient was not suffering from an acute illness that was likely to place the patients health in serious jeopardy, cause serious impairment to body functions or cause series dysfunction to a body organ or part. All told, based on the documentation provided for review the patients symptoms did not meet prudent layperson criteria for emergency care.