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

A 31-year-old female enrollee has requested Xifaxan for treatment of her small intestinal bacterial overgrowth.  Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested medication in this patients case.  The medical records document small intestinal bacterial overgrowth by hydrogen breath test.  The patients symptoms include abdominal bloating and gas.  Her provider has recommended Xifaxan 550mg, three tablets per day.  The current medical literature has not established that Xifaxan is more effective than other antibiotics in this setting.  Per the submitted documentation, the patient has not tried other approved antibiotics for the treatment of this condition.  All told, Xifaxan is not medically indicated for the treatment of this patient.
Appeal type: Experimental/Investigational
Decision: Upheld

A 75-year-old male enrollee has requested intravitreal injections of Avastin for treatment of his macular edema. Findings:  Two physician reviewers found that intravitreal injection of Avastin is a promising treatment for choroidal neovascularization in macular degeneration. However, there is a lack of long-term peer-reviewed randomized studies to support that it is superior to ranibizumab, which has been approved and is standard therapy for treatment of treatment of choroidal neovascularization in age related macular degeneration. Avastin has been used off-label to treat choroidal revascularization with leakage. The medical records do not document that choroidal neovascularization is causing macular edema or that other therapy has been tried.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a 15-year-old male enrollee has requested celiac testing for evaluation of the enrollees cramping, nausea and diarrhea. Findings:  The physician reviewer found that according to the guidelines published by the National Institutes of Health and the North American Society for Pediatric Gastroenterology Hepatology and Nutrition, screening for celiac disease was necessary for this patient due to his abdominal pain and diarrhea. The guidelines recommend that a total serum IgA and an anti-human tissue transglutaminase be obtained as an initial screen.  The guidelines note that further testing, including a small bowel biopsy or HLA typing be performed as indicated by a positive screen. Thus, this patient meets national criteria for screening for celiac disease. However, the testing performed was more extensive than either guideline recommends.  In this patients case, the serum IgA and anti-human tissue transglutaminase were medically indicated.  The antigliadin IgG, antigliadin IgA, anti-endomysial IgA, HLA-DQ2 and HLA-DQ8 were not medically indicated, per national guidelines.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: A parent of an enrollee has requested reimbursement for the GeneSight attention deficit hyperactivity disorder (ADHD) testing for evaluation of the enrollee's major depressive disorder and ADHD. Findings: Three physician reviewers found that there is a lack of evidence that supports use of generalized pharmacogenetic testing in this clinical setting. Only a small portion of genetic markers are estimated to have a direct impact on drug response, which is likely influenced by environmental, genetic, and gene-environment interactions. Overall, current pharmacogenetic testing is not specific enough to provide accurate responses about expected drug responses. Moreover, there is a paucity of data to support MTHFR polymorphism testing in this patients evaluation. The American College of Medical Genetics (ACMG) recommends against testing patients for MTHFR variants, including those with known family history of polymorphisms, given the lack of clinical utility with such testing. All told, the GeneSight ADHD testing (to see how the patients body breaks down a drug) provided was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Final Result: All three reviewers determined that the testing at issue was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications:  One physician reviewer number is board certified in psychiatry and is actively practicing. Two physician reviewers are board certified in clinical genetics 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

A 53-year-old male enrollee requested authorization and coverage of adjustable silicone gastric banding (Lap-Band) surgery for treatment of morbid obesity.  The health plan denied the enrollees request indicating that the requested surgery is considered experimental.Three physician reviewers performed an experimental/investigational Independent Medical Review.  Two of the three physician reviewers concluded that the requested procedure is not likely to be more beneficial for treatment of the enrollees morbid obesity than any available standard therapy.  Because two of the three physician reviewers concluded that the requested treatment is not likely to be more beneficial for treatment of the enrollees medical condition than any available standard therapy, the review organization upheld the health plans denial.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a 15-year-old male enrollee has requested for a magnetic resonance imaging (MRI) scan of the head for evaluation of the enrollees headaches and dizziness. Findings:  The physician reviewer found that the imaging guidelines regarding chronic headaches recommend brain imaging in patients with recent changes in headache patterns, abnormal neurological examinations or clinical instability. While the probability of a clinically relevant abnormality is low, this patient meets the criteria for imaging. MRI is better able to visualize the posterior fossa, where abnormalities such as a Chiari malformation would occur. Specifically, a Chiari malformation is clinically associated with headache, dizziness, or numbness.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for vaginoplasty and prospective authorization and coverage for follow-up surgery for treatment of the enrollees gender dysphoria.  Findings:  The physician reviewer found that based on the documentation provided, the patient has gender dysphoria and is in the transition. Based on the patients gender dysphoria and identification as a female, a normal appearance of the genitals is the goal. The patients genital anatomy should be consistent with her gender. The patients gender dysphoria is well documented. The medical literature support bilateral orchiectomies and vaginoplasty as part of the surgical transition process for male to female transition. The patient has abnormal genitalia for a female that would not resolve with continued hormonal therapy. The patients age of 16 should not be used as a sole determinant of medical necessity. The records provided include documentation from providers from various disciplines who report the patients history of gender dysphoria. Therefore, vaginoplasty and prospective authorization and coverage for follow-up surgery scheduled were and are medically necessary for the treatment of this patients gender dysphoria. With regard to whether the services at issue were and are reconstructive in nature, the submitted documentation reveals that the patients male genitalia constitutes an abnormal structure of a female body. Based on the patients gender dysphoria and identification as a female, a normal female appearance of the patients genitalia is the ultimate goal. The genitalia of this patient should be more consistent with a female. The male genitalia can be considered a developmental abnormality of a female. The services at issue would offer more than a minimal improvement in the appearance of this patients genitalia. Final Result: The reviewer determined that the services at issue were and are medically necessary and were and are reconstructive in nature for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in plastic surgery and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

A female enrollee requested revision surgery, replacing the Lap-band with the gastric sleeve for medical treatment of her morbid obesity.  Findings:  The physician reviewer found that this patient has a known complication of the Lap-band procedure, which includes slip with partial outlet obstruction.  In this clinical setting, removal of the Lap-band and port is medically necessary to relieve this obstruction and prevent secondary complications such as erosion and gastric necrosis.  However, the medical records do not support the medical necessity of the requested gastric sleeve procedure.  There is a lack of any updated behavioral evaluation documenting clear understanding of the risks, benefits of revisional surgery, discussion regarding her general compliance after the Lap-band procedure and any barriers to candidacy for revision.  All told, the submitted records support the medical necessity of removal of the Lap-band and port.  However, the medical necessity of the requested gastric sleeve procedure has not been established.
Appeal type: Medical Necessity
Decision: Upheld

The patient is a 53-year-old female with a bone mass density of the spine that is in normal range and a bone mass density of the greater trochanter of the hip that is barely in the osteopenic range and still within the usual accepted normal range of two standard deviations from the mean. The patients provider has recommended Miacalcin nasal spray (Miacalcin). The Health Plan has determined Miacalcin is not medically necessary for treatment of the patients medical condition.The Health Plans denial should be upheld. Miacalcin has not been found to be beneficial in prevention of hip or osteopenic spine fractures. Miacalcin is indicated only for treatment of osteoporosis not for prevention of fractures. Based upon the patients bone mass density, there is no indication for preventative measures or treatment at this time. 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: Experimental/Investigational
Decision: Overturned

A male enrollee requested clinical chemistry testing (Prometheus Anser IFX) for medical evaluation of his Crohns disease.  Findings:  Two physician reviewers found that the testing at issue was likely to be more effective for this patient than other available treatment options. Therapeutic drug monitoring is the clinical practice of measuring drug concentrations or metabolites to attain a targeted concentration in a patient's bloodstream, thereby optimizing individual dosage regimens. In this patients case, Prometheus Anser IFX testing was useful and likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.
Appeal type: Experimental/Investigational
Decision: Upheld

A 49-year-old male enrollee has requested the BioniCare Electrical Stimulator for the treatment of his knee and low back pain.  Findings:  Three physician reviewers found that although the BioniCare device has been approved by the Food and Drug Administration, and there are some anecdotal reports that the use of pulsed electricity has been helpful on some occasions for knee pain, there is a lack of peer-reviewed literature which proves that this device is effective at providing long-term pain relief or improving the functionality of patients with osteoarthritis.
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 conditions.  Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the services at issue.  It appears that previous care was successful in breaking the cycle of substance use and capitalizing on the patients strengths.   Since the patient had no prior history of chemical dependency treatment in the outpatient setting, and considering the clinical presentation coupled with relevant peer-reviewed medical literature and current practice guidelines, there is no evidence to suggest that a less restrictive treatment setting would have been insufficient.  Thus, intensive outpatient program services were not and are not medically indicated for the treatment of this patient. 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 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 hydrocodone polistirex/chlorpheniramine polistirex extended-release (ER) oral suspension, for a quantity of 690 mL for 30 days. According to the American College of Chest Physicians (CHEST) guideline, the differential diagnosis for cough is extensive and may include intrinsic lung disease such as asthma, chronic obstructive pulmonary disease (COPD), pleural irritation, or interstitial lung disease. Recommendations for treatment include use of non-narcotic medications such as dextromethorphan, benzonatate, gabapentin or pregabalin. Non-narcotic formulations are preferable to narcotics due to risk of dependency. Further, long-term use of narcotics may lead to tolerance requiring higher doses of the medication. In this case, the patient has chronic cough associated with gastroesophageal reflux disease (GERD) and low grade Barretts esophagus or possibly anxiety-provoking situations. This disorder can cause symptoms of retrosternal discomfort, esophagitis, and occasionally cough. Most patients respond to treatment with PPIs with conservative therapy including anti-reflux measures. This patient underwent surgical fundoplication. However, the patients records do not document that the patient has exhausted optimal medical therapy, either with the use of another PPI, escalating, or splitting the dose. The use of the narcotic cough medication may relieve some of the symptoms of cough. However, with the use of narcotic medication comes the risk of dependency and tolerance. Moreover, the records suggest that this patient has become tolerant to hydrocodone polistirex/chlorpheniramine polistirex ER oral suspension as she reported persistent symptoms despite escalating her dose from 5 mL twice daily, to 8 mL every six hours, up to 690 mL per month. The most appropriate treatment for this patient is to optimize her GERD therapy with a non-narcotic option to treat her cough. Therefore, the requested hydrocodone polistirex/chlorpheniramine polistirex ER oral suspension, for a quantity of 690 mL for 30 days 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 internal medicine with expertise in pulmonary 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: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement and prospective authorization and coverage for residential facility center (RTC) services. Per American Society of Addiction Medicine (ASAM) criteria, this patient met Level 3.5 criteria for RTC services. ASAM criteria focuses on six dimensions to determine the appropriate level of care, which includes: (1) intoxication and withdrawal potential; (2) biomedical conditions; (3) emotional, behavioral and cognitive conditions; (4) readiness to change; (5) relapse, continued use, or continued problem potential; and (6) recovery environment. For dimension 1, the patient was noted to have withdrawal symptoms of vomiting, diaphoresis, and tremors. He declined withdrawal medications. The patients withdrawal needs were safely managed in level 3.1 setting. For dimension 2, the patient does not have active medical problems. His biomedical problems were stable and do not require medical or nurse monitoring.For dimension 3, the patient was diagnosed with depression and PTSD from employment as a paramedic and firefighter. He used alcohol to cope with emotional pain. The patients mental status was stable enough to permit participation, and was assessed as not posing a risk of harm to self or others.For dimension 4, the patient voluntarily admitted himself to RTC treatment after recognizing his inability to stop drinking on his own. The patient recognized specific negative consequences of his alcohol use. He was sufficiently ready to change and cooperative enough to respond to treatment at Level 3.1.For dimension 5, the patient reported drinking to the point of blackout at least five to seven days per week. He attempted participation in Alcoholics Anonymous (AA) but found the format unhelpful. He was unable to cope with his PTSD symptoms without the use of alcohol. The patient demonstrated limited coping skills to address relapse triggers and urges. He was in imminent danger of relapse with dangerous consequences and needed 24-hour structure to assist in applying recovery and coping skills.For dimension 6, the patient had unstable housing due to going through a divorce, staying in his car in order to drink, and staying with his sister. While he is able to cope for limited periods of time outside the 24-hour structure of a Level 3.1 program, continued exposure to the his living environment makes recovery unlikely, and the patient has insufficient resources and skills to maintain an adequate level of functioning outside of a 24-hour supportive environment.Given these findings, the patient met the six ASAM criteria for RTC services. Accordingly, RTC services 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.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Orthovisc injections for the right knee. The submitted documentation supports the medical necessity of the requested services. The current literature continues to support the use of viscosupplementation for osteoarthritis of the knees. There is good evidence that intraarticular hyaluronic acid injections reduce pain and increase function in knee osteoarthritis, and the benefits are long-lasting as compared with intraarticular corticosteroids. Evidence from real-life studies of repeat courses of intraarticular hyaluronic acid demonstrates an improvement in pain or function lasting up to 40 months, a reduction in use of concomitant analgesia by up to 50%, and suggests that there may be a delay in the need for total knee replacement of around 2 years. A systematic review of overlapping meta-analyses comparing viscosupplementation with other nonoperative treatment modalities for knee osteoarthritis. Their review found that the current highest level of evidence suggests that intraarticular hyaluronic acid is a viable option for knee osteoarthritis and that its use results in improvements in knee pain and function that can persist for up to 26 weeks. Intra-articular hyaluronic acid has a good safety profile, and its use should be considered in patients with knee osteoarthritis. There is sufficient support for the requested services in this clinical setting. Therefore, Orthovisc injections for the right knee are medically necessary to treat the patients medical condition at this time.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 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

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for an upper endoscopy and a thoracotomy. Surgical procedures that are considered standard of care for GERD include the LINX procedure and laparoscopic Nissen fundoplication. Thoracotomy or anti-reflux procedures performed via thoracotomy are not considered standard of care due to increased morbidity and risk. Surgical anti-reflux treatments are associated with higher risk for patients with a BMI over 35. In this case, the patients GERD is controlled on medication and her BMI is over 35. In this clinical setting, surgical anti-reflux procedures and thoracotomy are not medically indicated. Therefore, the requested upper endoscopy and  thoracotomy are 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.