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

The patient is a 60-year-old man with blood in his stool. The results of an EGD only showed some linear erosions. Apparently the patient has abdominal pain and has experienced a change in bowel movements. He has never undergone a colonoscopy. His last flexible sigmoidoscopy was performed in 1997. The patient has requested authorization for a colonoscopy. The Health Plan has denied the request on the basis that the requested procedure is not medically necessary for evaluation of the patients medical condition. The Health Plans denial should be overturned. The patient has never undergone a colonoscopy. The results of the EGD do not completely explain the patients symptoms. In light of the unknown etiology of the patients abdominal pain and change in bowel movements, as well as his age, a colonoscopy is medically appropriate and indicated. Therefore, I have determined that the requested procedure is medically necessary for evaluation of the patients medical condition. The Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Upheld

A 63-year-old male enrollee has requested for minimally invasive left total knee arthroplasty for treatment of his osteoarthritis. Findings:  The physician reviewer found that there are no long-term and well-controlled studies demonstrating a clear benefit with minimally invasive knee replacement. The gold standard is total knee replacement and there are numerous ways to perform the replacement once the skin is incised, all of which are considered the standard of care. While the smaller incision may appear to be advantageous, there is more risk of suboptimal positioning of the knee implant and no significant difference in recovery. The long term durability of this technique has yet to be established.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for sclerotherapy injections. Findings:  Three physician reviewers found that the documentation does not support an indication for sclerotherapy for treatment of this patients varicose veins. There is no formal duplex report provided and no confirmation of a patent deep venous system. In addition, there is no record of an effort to treat conservatively and there is no indication that any of the procedures were urgent or emergent. Furthermore, the majority of the procedures were performed in the absence of symptoms. Given the availability of standard treatment options that were not considered or attempted, the use of sclerotherapy injections provided. Final Result: Three reviewers determined that the services at issue were 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 surgery with sub-specialty certification 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: Overturned

Nature of Statutory Criteria/Case Summary:   An enrollee has requested clostridial collagenase histolyticum (Xiaflex) for treatment of his medical condition.  Findings:  The physician reviewer found that according to the American Urological Association (AUA), Peyronies disease can be treated with Xiaflex injections in patients for the reduction of penile curvature in patients with stable Peyronies disease. Per the AUA guidelines, patients with penile curvature of more than 30 degrees and less than 90 degrees and intact erectile function with or without medications, are good candidates for this treatment. Further, intralesional therapy with Xiaflex has been approved by the U.S. Food and Drug Administration (FDA) for the treatment of adult men with Peyronies disease with a palpable plaque and curvature deformity of at least 30 degrees at the start of therapy. All told, there is adequate scientific evidence supporting the medical necessity of the requested Xiaflex injections for treatment of this patients Peyronies disease.  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 urology 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 patients parent has requested authorization and coverage for a standing power wheelchair with attendant control (CPT E2331), power seat elevation (CPT E2300), and powered standing feature (CPT E2301). Use of custom powered mobility and standing devices in patients with permanent mobility impairment allows increased function, independence, and participation in activities in and outside of the home. Current evidence shows that standing wheelchairs allow for frequent position changes without physical transfer and facilitate autonomous and meaningful participation in age appropriate physical, social and educational activities. For this patient, use of the powered standing and wheelchair device will enable him to reach his rehabilitation goals. In addition, standing with use of a power wheelchair is an essential component in the medical and rehabilitative care of this patient. The powered standing feature will allow the patient ongoing weight bearing without the need for two-person maximum assistance. Moreover, the standing power wheelchair with requested features will enable to patient to independently access tools and materials in the classroom. The standing wheelchair will permit the patient to function to his maximum capacity. Given these findings, the requested standing power wheelchair with attendant control (CPT E2331), power seat elevation (CPT E2300), and powered standing feature (CPT E2301) are medically necessary for treatment of this patient. Final Result: The reviewer determined that the requested equipment 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 physical medicine and rehabilitation with subspecialty certification in pediatric rehabilitation 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: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for endoscopic balloon dilation procedure of the Eustachian tubes. This patient presented with a history of nasal and ear congestion, as well as complaints of ear clicking and popping. Treatment with the standard of care has included Flonase, Claritin, and Astelin. Given the lack of symptomatic improvement, the patient underwent balloon dilation of the Eustachian tubes. Treatment options for patients with obstructive Eustachian tube dysfunction such as placement of pressure equalization tubes create an alternative route for ventilation, but do not address the problem at the Eustachian tube and may cause complications. Multiple studies have assessed the short- and long-term efficacy of balloon dilation of the Eustachian tubes (Poe, et al.). Meyer and colleagues randomized 60 patients to undergo balloon dilatation of the Eustachian tubes or continued medical therapy. The authors noted that, Balloon dilation is a safe and effective treatment for persistent Eustachian tube dysfunction. Moreover, the authors concluded that their findings support balloon dilation as superior to continued medical management for patients with persistent Eustachian tube dysfunction. All told, the endoscopic balloon dilation procedure of the Eustachian tubes was likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Findings: Two of the three physician reviewers found the endoscopic balloon dilation procedure of the Eustachian tubes was likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the services at issue were likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: Physician reviewers 1, 2, and 3 are board certified in otolaryngology and is 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 62-year-old male enrollee has requested the medication Nucynta (50 mg twice daily) for treatment of his diabetic neuropathy. Findings:  The physician reviewer found that in this patients case, there were no medical records submitted for review which indicate whether the requested Nucynta medication being requested is immediate or extended release. Moreover, there were no medical records submitted whatsoever. Lastly, the use of fluphenazine with Elavil has been shown to be an effective alternative for the treatment of painful diabetic neuropathy (Davis and colleagues). All told, in the absence of such medical documentation, the medical necessity of the requested medication is not supported.
Appeal type: Urgent Care
Decision: Overturned

A 45-year-old female enrollee requested medical services on an emergent or urgently needed basis. Findings: The physician reviewer found that the patient presented with complaints of severe abdominal pain. Based on the documentation submitted for review, a prudent layperson would have sought medical care due to the severe abdominal pain such that the absence of immediate medical attention could reasonably be expected to result in placing the patients health in serious jeopardy. In sum, based on the patients clinical presentation she did meet prudent layperson criteria for urgently needed services. However, subsequent clinical documentation demonstrates that a prudent layperson would not have sought subsequent immediate medical attention. Follow-up images such as magnetic resonance imaging (MRI) were not performed for diagnosis. Typical management includes hydration, pain management, and antibiotics, which was not performed. The patient was treated with surgery for a non-acute presentation. Pathology after surgery was not consistent with acute/chronic degenerative changes. 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 serious 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 subsequent emergency care. In sum, based on the patients subsequent clinical presentation, she did not meet prudent layperson criteria for urgently needed services. I have determined that a portion of the services requested met prudent layperson criteria for emergency care or urgently needed services.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement and prospective authorization and coverage for bilateral Botox injections. Herd and colleagues found that, Botulinum toxin may reduce the number of migraine days per month in the chronic migraine population by 3.1 days. Frampton and Silberstein noted that the safety and efficacy of Botox was demonstrated in two phase III studies. The authors commented that the totality of evidence from clinical trials suggests that Botox is an effective and generally well tolerated option for the prevention of chronic migraine that may be particularly useful for patients who have previously failed to respond to or are intolerant of commonly prescribed oral prophylactics. This patients records document complaints of chronic non-specific headaches for several years that have been treated with medication management using several different classes of medications unsuccessfully. The patient previously underwent treatment with Botox therapy for headaches with reported benefit. The records substantiate that the patient experienced daily migraines headaches lasting for over four hours that have not responded to other treatments. Based on this information, the patient meets criteria for repeating Botox injections. Therefore, the bilateral Botox injections were and are medically necessary for treatment of this patient.Final Result: The reviewer determined that the services at issue were and are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in anesthesiology with subspecialty 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: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for bilateral radiofrequency ablation (RFA) of the perforator veins. The documentation provided for review does not support the medical necessity of RFA of the bilateral perforator veins for this patient. It is not possible to attribute persistent symptoms to his perforator veins in the absence of an assessment of arterial perfusion, especially since the patient has a history of pelvic injury and is having persistent disabling symptoms despite ablation of all four major superficial veins. In addition, the records do not report that the patient continues to have lifestyle limiting symptoms despite bilateral greater saphenous vein (GSV) and small saphenous vein (SSV) ablations. Insufficient time has passed for the inflammation associated with four ablation procedures to resolve for such reevaluation. The duplex examination of the right leg on 9/21/20 indicate that the patients persistent symptoms are mild, and no other reflux was noted. RFA of the perforator veins is supported for patients with active or healed ulcer, which is not documented in this patients case. For these reasons, the requested bilateral RFA of the perforator veins is not medically necessary for treatment of this patient.Final Result: The reviewer determined that the requested services 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 surgery with subspecialty certification in vascular 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: Experimental/Investigational
Decision: Upheld

A 66-year-old male has requested coverage for an X-Stop interspinous process decompression procedure for treatment of his spinal stenosis.  Findings:  Three physician reviewers found that the patient has spinal stenosis noted in his history and clearly demonstrated on his MRI scans. The patient has declined standard surgical treatment of laminectomy and fusion and has requested an X-Stop procedure. Although the Food and Drug Administration (FDA) has approved this device, a long-term safety and effectiveness trial and reporting were requested by the FDA at 5, 7 and 10 years. The study has not yet been concluded, nor have results been reported. There are no other large, scientific reports published in the United States demonstrating the long-term safety and effectiveness of the X-Stop procedure. Only small, short-term studies have been reported to date (Kondrashov, et al. and Anderson, et al.). All told, since there is no data available demonstrating the long-term safety and efficacy of the X-Stop procedure, it remains of unproven efficacy at this time.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patients parent has requested authorization and coverage for bladder augmentation surgery. Szymanski  and colleagues note that bladder augmentation is a long-lasting treatment for patients with spina bifida. The authors further note that while benefiting continence and renal outcomes, this operation frequently requires additional surgeries, necessitating close follow-up. In this case, the patient has spina bifida with continued incontinence that is managed with clean intermittent catheters five times daily. Ongoing urinary leakage and incontinence in young adults may lead to psychological issues, depression, and poor self-esteem, and result in adverse physical impacts including the breakdown and infection of skin. Standard of care for the treatment of incontinence in young adults with spina bifida includes intervention and consideration of surgical options. Given that current medical literature supports bladder augmentation as a treatment option for patients with spina bifida, the requested service is medically indicated. Therefore, bladder augmentation surgery is medically necessary for the 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 urology with sub-specialty certification in pediatric urology 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 32-year-old female enrollee has requested a double-sided hospital grade electric breast pump for treatment of breastfeeding. Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested equipment in this clinical setting.  This patient underwent a Cesarean section, and the surgery and recovery were uncomplicated.  Per the medical records, there were no neonatal complications, and there is no reported difficulty with nursing.  Based upon the clinical notes, there is no evidence supporting the medical necessity of a hospital grade breast pump.  All told, the requested double-sided hospital grade electric breast pump is not medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The parent of a patient has requested authorization and coverage for Saizenprep 8.8 mg cartridge. The submitted documentation does not support the medical necessity of the requested medication. There is a lack of evidence in the literature that one brand of growth hormone is more effective than another for the treatment of idiopathic short stature. Furthermore, there is a lack of evidence that one brand of growth hormone carries a higher risk of adverse effects than another. The documentation submitted does not indicate that the patient has tried the preferred brand of growth hormone and has had an adverse effect or was unable to adhere to therapy due to needle-phobia. Therefore, Saizenprep 8.8 mg cartridge 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 pediatrics with sub-specialty certification in pediatric endocrinology 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 female enrollee requested Botox injections for treatment of her migraine headaches.  Findings:  Three physician reviewers found that the medical records do not document baseline headache frequency or characteristics to indicate the patient has chronic migraine. Botox has been established to be beneficial for chronic migraine with a specific treatment protocol, which entails injection of 5 units in 31 specific locations including frontal, temporal, occipital, paraspinal, and trapezius, with concentration of 5/0.1, at 12 week intervals. This patient appears to have been injected at cosmetic dosing and locations, and may have been injected with Botox cosmetic, as notes indicate a vial size of 50 units, while Botox therapeutic comes in vials of 100 and 200 units. In sum, the clinical records submitted for review do not confirm a diagnosis of chronic migraine. Based on the peer-reviewed literature and clinical documentation provided, Botox injections were not and are not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.
Appeal type: Experimental/Investigational
Decision: Overturned

A 52-year-old male enrollee has requested a PET scan for an evaluation of his metastatic glucagonoma. Findings:  Three physician reviewers found that the metaiodobenzylguanidine (MIBG) study accurately identified the skeletal metastases as well as the right upper lobe lung lesion. However, due to the small number of cases in the literature, it is reasonable to use every modality available to search for other remote sites of neoplasm. There are some articles present in the literature showing use of PET scans in the restaging of these tumors, and the diagnostic procedure may also be useful in evaluating treatment response. There are no large series providing the efficacy of this technique due to the rarity of the tumor. However, use of the PET scan adds information and is compatible with recently published recommendations for the use of PET scans in all soft tissue tumors by the National PET Oncology Registry.
Appeal type: Medical Necessity
Decision: Upheld

A 40-year-old male enrollee has requested for referral to a specific colorectal surgeon for treatment of his ulcerative colitis.  Findings:  The physician reviewer found that there is no clinical indication for the patient to be evaluated by an Out-of-Plan colorectal surgeon. After completing the recommended studies, the patients current GI provider may want to communicate with an In-Plan surgeon and review the findings. However, an Out-of-Plan referral is not medically necessary for evaluation and treatment of this patients medical condition.