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

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement and prospective authorization and coverage for the hematopoietic stem cell transplant provided for treatment of the enrollees multiple sclerosis. Findings:  2/3 of the physician reviewers found that autologous stem cell therapy is still not considered to be within the standard of care for treatment of multiple sclerosis (MS). Overall, there have been no studies comparing stem cell transplant with highly active MS therapies such as Tysabri, Lemtrada, or Ocrevus to establish which therapy is most effective and has the best safety profile. This patient has a stable clinical examination and stable MRI findings after treatment with his first disease modifying therapy. Thus, the hematopoietic stem cell transplant services provided were not and are not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Final Result: 2/3 of the reviewers determined that the services at issue were not and are not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: Physician reviewer number one is board certified in neurology with sub-specialty certification in neuromuscular 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.Physician reviewer number two is board certified in neurology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.Physician reviewer number three is board certified in neurology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

A 35-year-old female enrollee requested authorization and coverage of Elidel 1% cream. The Health Plan denied the request indicating that the requested medication is not medically necessary for treatment of the enrollees vitiligo.One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer overturned the Health Plans denial on the basis that the requested medication is medically necessary.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary:enrollee has requested authorization and coverage for transoral incisionless fundoplication.Findings:  Three physician reviewers found that the efficacy of transoral incisionless fundoplication has been studied in randomized controlled trials, although the conclusions are contradictory. A randomized trial included 60 patients and found no improvement in esophageal acid exposure compared with baseline at 12 months. Normalization of pH was accomplished in only 29% in conjunction with deteriorated valve appearances at endoscopy and resumption of proton pump inhibitors in 61%. The study concluded that no long-term objective reflux control was achieved. At this time, the current medical evidence does not support transoral incisionless fundoplication as an alternative to medical therapy or traditional surgical therapy. Further safety and efficacy comparison is needed with conventional treatment, such as Nissen fundoplication. Guidelines from the American Society for Gastrointestinal Endoscopy (ASGE) report that the long-term follow-up data for transoral incisionless fundoplication is limited. In sum, transoral incisionless fundoplication is not likely to be more efficacious than other treatment options. Final Result: The reviewers determined that the requested services are not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: Physician reviewers 1, 2 and 3 are board certified in internal medicine with sub-specialty certification in gastroenterology and are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

A 43-year-old female enrollee has requested Botox injections for the treatment of her migraine. Findings:  The physician reviewer found that this patient has had episodic migraine at high frequency. She has required acute, abortive therapy as well as preventive therapy. She has been refractory to beta blockers, but has had reduction of headache severity and frequency with Botox therapy. A literature review shows that Botox can be beneficial for individuals with chronic headache as well as high frequency episodic migraine. The medical necessity of Botox therapy for this patient should be determined by whether she has a significant disease burden, as well as whether Botox therapy has a significant probability of success. In this patients particular clinical situation, Botox therapy does have a significant probability of success and the patient does have a significant disease burden.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested balloon sinuplasty for treatment of his medical condition. Findings: Three physician reviewers found that chronic rhinosinusitis is clinically defined as symptomatic involvement of the paranasal sinuses with complaints of facial pain, pressure, discolored anterior and posterior nasal drainage and discharge along with associated symptoms of low-grade fever usually lasting more than 12 weeks unrelieved with appropriate medical management with nasal irrigation techniques, antibiotics, adjunctive therapies including topical nasal steroids and objective documentation based on computed tomography (CT) imaging showing mucous membrane changes within the paranasal sinuses. In this case, the patient does not meet clinical criteria as the records submitted showed that the CT scan to be relatively normal with only very minimal membrane thickening within one paranasal sinus. In sum, clinical indications for sinus surgery have not been met. As such, balloon sinuplasty is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.  Final Result: All three 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 reviewers are board certified in otolaryngology 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

A 48-year-old male enrollee has requested for artificial disc replacement at level C5-C6 for treatment of his degenerative disc disease. Findings:  Three physician reviewers found that there is a lack of long-term studies supporting cervical artificial disc replacement over available standard treatment. Short-term studies are encouraging, but long-term results are needed before the efficacy of disc replacement can be established. Based upon the data currently available, the superiority of artificial disc replacement over standard interventions remains unproven at this time.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for the medication Posaconazole. Findings:  The physician reviewer found that Posaconazole, a fluorinated triazole antifungal drug, is approved by the U.S. Food and Drug Administration (FDA) for prophylaxis against Aspergillus and Candida infections in immunocompromised patients at high risk for these infections. Clark and colleagues have noted that posaconazole has potent in vitro activity against a broad range of fungi and molds, including Aspergillus, and has an excellent safety profile. In this case, the patient has had bilateral lung transplantation and is at high risk for the development of fungal infections including Aspergillus. Other medications such as voriconazole have a high incidence of side effects that limit their use in this patient population. Posaconazole has an advantageous side effect panel, it is effective for Aspergillus, and it is a standard prophylactic antifungal in this setting. Under these circumstances, the requested medication Posaconazole is medically necessary to treat the patient.Final Result: The reviewer determined that the requested medication is medically necessary to treat the patient. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in internal medicine, with subspecialty certification in infectious disease, 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: Urgent Care
Decision: Overturned

An enrollee has requested emergency services for the treatment of her condition. Findings:  The physician reviewer found that the patient presented to the medical center complaining of abdominal pain which she described to be of sufficient severity that a prudent layperson would reasonably seek immediate medical attention due to fear for jeopardy to her health and/or function.  Although she ended up not having a life-threatening disorder causing her abdominal pain, the evaluation was necessary to ensure that her health was not in jeopardy.
Appeal type: Medical Necessity
Decision: Upheld

The parent of a 12-year-old male enrollee has requested Increlex for the treatment of the enrollees short stature. Findings:  The physician reviewer found that the projected adult height according to the Greulich and Pyle Hand Atlas approximates the height at 5 foot, 6.8 inches.  It thus appears likely that the patient has a constitutional delay in his adolescence and is destined to achieve a normal adult height without treatment.  The diagnosis of IGF-1 deficiency seems unlikely since the IGF-1 level would be normal when matched to the pubertal stage, and GH levels were not elevated.  The increased growth from IGF-1 therapy in such an instance is interesting, but does not in and of itself make the case for IGF-1 therapy as a medical necessity.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The parent of a 17-year-old male enrollee has requested authorization and coverage for non-surgical scoliosis services activities of daily living (activities of daily living (ADL), posture, gait, and neuromuscular retraining - 97110, 97112, 97530, 97116; administration and prescribed home use of custom mechanical traction equipment - 97012, E1399; custom scoliosis brace - L1300, L1210, L1220, L1240, L1250, L1260, L1270, L1290, L0999). The use of non-surgical scoliosis services including ADL, posture, gait, and neuromuscular retraining, administration and prescribed home use of custom mechanical traction equipment is not supported as medically necessary for this patient with idiopathic scoliosis. There is currently a lack of peer-reviewed medical literature supporting the use of these items in this patient population. Moreover, these services are not supported by the Scoliosis Research Society. All told, the requested non-surgical scoliosis services (ADL, posture, gait, and neuromuscular retraining - 97110, 97112, 97530, 97116; administration and prescribed home use of custom mechanical traction equipment - 97012, E1399; custom scoliosis brace - L1300, L1210, L1220, L1240, L1250, L1260, L1270, L1290, L0999) are not medically necessary for treatment of this patients medical condition. 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 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.
Appeal type: Medical Necessity
Decision: Upheld

A 39-year-old male enrollee has requested physical therapy services for the treatment of his post-surgical back pain. Findings:  The physician reviewer found that the patient had sufficient physical therapy sessions to establish a home therapeutic exercise program. The physical therapy notes are consistent with a maintenance program rather than a restorative program. Additional physical therapy was not medically indicated, and the patient had plateaued by this time.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a three-year-old male enrollee has requested speech therapy for treatment of speech and language deficits.  Findings:  The physician reviewer found that if the patients speech deficits are a part of an autism spectrum disorder, speech therapy would be an integral part of a comprehensive treatment plan.
Appeal type: Experimental/Investigational
Decision: Upheld

A 63-year-old female enrollee has requested for radiofrequency lesioning of the sacroiliac joint nerves and thoracic facets for treatment of her degenerative disc disease in her lumbar spine.   Findings:  Three physician reviewers found that Van Wijk and colleagues designed a multicenter, randomized, double-blind, sham treatment controlled trial to determine the efficacy of radiofrequency rhizotomy, as it is routinely performed. The combined outcome measure showed no differences between radiofrequency rhizotomy and sham. Facet blocks are a useful diagnostic procedure but facet denervation has never been shown to be efficacious as a therapeutic maneuver.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary:   An enrollee has requested insertion of an artificial intervertebral disc for treatment of his medical condition.  Findings:  Two physician reviewers found that the peer-reviewed literature supports the use of artificial disc replacement in the setting of single level cervical degenerative disc disease when clinical indications are met as documented in this case. The patient presents with intractable single level cervical degenerative disc disease confirmed by imaging. Clinical exam findings document motor deficit and positive neurocompressive signs consistent with imaging. Detailed evidence of recent, reasonable and/or comprehensive non-operative treatment protocol trial and failure has been submitted. Moreover, the use of cervical disc arthroplasty will likely allow for motion preservation in this young patient. Therefore, the insertion of an artificial intervertebral disc was likely to be more beneficial for treatment of the enrollees medical condition than any available standard treatment.   Final Result: Two 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:  All three reviewers are board certified in orthopedic surgery 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

A 66-year-old female enrollee requested authorization and coverage of an open MRI. The Health Plan denied the request indicating that the requested MRI is not medically necessary for the evaluation of the enrollees neck pain.One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer upheld the Health Plans denial on the basis that the requested MRI is not medically necessary.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: A 53-year-old female enrollee has requested reimbursement for gastric sleeve surgery.  Findings:  The physician reviewer found that This patient documents morbid obesity with a body mass index (BMI) of at least 35 kg/m2 and sleep apnea, which is a serious obesity related co-morbid condition. The patient has failed dietary efforts and completed a comprehensive multidisciplinary evaluation that did not reveal any obvious dietary or behavioral barriers to surgery. The patient meets standard nationally accepted criteria for bariatric surgery including the American Society for Metabolic and Bariatric Surgery. Thus, the gastric sleeve surgery (CPT 43775) was medically necessary for 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 surgery with sub-specialty certification in bariatric 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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for gastric sleeve surgery. The submitted documentation fails to demonstrate the medical necessity of the requested services. The requested services are not medically necessary since psychological clearance has not been obtained. Although the patient was evaluated, certain recommendations were not completed. There is a lack of clear national standards or guidelines on the use of cannabis before or after bariatric surgery. However, it is appropriate for the provider to establish best practices that are safe or reasonable given the potential concern of maladaptive eating behaviors that may be higher in patients who are using marijuana. Therefore, the requested gastric sleeve surgery is not medically necessary for the 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 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 radiofrequency ablation for treatment of the enrollees low back pain. Findings: Two reviewers found that there is sufficient support for the requested services in this clinical setting.  The records noted low back pain from spondylolisthesis and facet arthropathy at L4-5.  The patient reported a good response to medial branch blocks, with greater than 70% reduction of axial back pain on the left side. Additionally, prior radiofrequency ablation provided 85% relief of her axial low back pain for five months. Therefore, given the prior response to radiofrequency ablation as well as the 70% diagnostic benefit from the medial branch blocks, the requested radiofrequency ablation is likely to be more efficacious than other treatment options.Final Result: Two reviewers determined that the requested services are 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: All three physician reviewers are board certified in anesthesiology with sub-specialty certification in pain medicine 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: Experimental/Investigational
Decision: Upheld

The parent of a 20-month-old male enrollee requested special wound product, ACell for medical treatment of the enrollees burns.  Findings:  Three physician reviewers found that there is a lack of case reports in the medical literature on the use of Matristem ACell in acute burns. In the absence of support from peer-reviewed medical literature on the use of Matristem ACell on acute burns, the services at issue were not likely to be more beneficial for treatment than any available standard therapy.