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

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for implantation of a Medtronic biventricular cardioverter defibrillator. The American College of Cardiology Foundation (ACCF), American Heart Association (AHA), and Heart Rhythm Society (HRS) guidelines recommend biventricular cardioverter defibrillator implantation for the primary prevention of sudden cardiac death as well as cardiac resynchronization therapy addressing the left ventricular dysfunction and heart failure symptoms in patients with an underlying left bundle branch block (LBBB) with a wide QRS. In this case, given that the records document an underlying LBBB and a QRS duration of 180 ms, the service at issue was medically indicated. Therefore, implantation of a Medtronic biventricular cardioverter defibrillator was medically necessary for the treatment of this patientFinal Result: The reviewer determined that the service at issue was 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 cardiovascular 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: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for balloon ostial dilation maxillary sinuses (code 31295).Findings:  Two of the three physician reviewers found that at this time, the medical evidence has not demonstrated the superiority of balloon ostial dilation over functional endoscopic sinus surgery for recurrent acute sinusitis. In this patient with recurrent acute sinusitis, balloon ostial dilation is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy, such as functional endoscopic sinus surgery. Alternative treatment options include oral antibiotics of two to four weeks duration for patients with chronic sinusitis or multiple one-week to three-week courses for patients with recurrent acute sinusitis, systemic and/or topical steroids, saline irrigations, topical and/or systemic decongestants, and treatment of concomitant allergic rhinitis, including avoidance measures, pharmacotherapy, and/or immunotherapy. Therefore, balloon ostial dilation maxillary sinuses (code 31295) is not likely to be superior over other available treatment modalities. 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.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for digital breast tomosynthesis for evaluation of the enrollee, who was asymptomatic. Findings:  The physician reviewers found that Breast tomosynthesis is a technique that was developed several years agb as a problem solving adjunct to routine mammography.  Applying the same basic concept as computed tomography (CT) scanning, the logic is that by separating the various layers of breast tissue, one can better detect abnormalities.  This has been shown to be most useful in the evaluation of dense breasts.  In this patients case, her breasts were heterogeneously dense.  It is specifically those patients who have dense breasts that can benefit most from tomosynthesis.  The ability to separate out the overlapping structures enables the possibility of demonstrating an otherwise occult tumor.  Thus, digital breast tomosynthesis was likely to have been superior over other methods of evaluating this patient. Final Result: All three reviewers determined that the service at issue was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications:  Physician reviewers number one, two, and three are board certified in diagnostic radiology and 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 a fitted shoe (orthotic boot) for treatment of his osteoarthritis of the left ankle.  The physician reviewer found that a review of the literature reveals that for well selected patients, normal footwear is all that is needed following ankle fusion. However, articles also discuss several different types of shoe modifications, in-shoe orthoses, and ankle foot orthoses that are very commonly used for many patients following this procedure. Sirveaux and colleagues reported that modifying shoegear to increase the instep of the shoe improves the biomechanical abnormalities that occur. After a complete review of the patients medical record, as well as the current medical literature, a shoe modification and possibly an in-shoe orthotic or an ankle-foot orthotic is medically necessary for treatment of this patients medical condition status post ankle fusion. The patient sustained an open talar fracture, which later went on to an ankle fusion. One known sequelae of traumatic injury going on to ankle fusion is limb length discrepancy. For this reason, an evaluation of this problem and a shoe modification to address it is medically necessary. In conclusion, a specially modified shoe, with or without an in-shoe orthotic, or an ankle-foot orthosis, is medically necessary. 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 podiatry 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.  Findings:  The physician reviewer found that
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for VenaSeal closure system procedure. Findings:  The physician reviewer found that patient presents with symptomatic chronic venous insufficiency. The patients venous duplex revealed significant reflux in the right anterior accessory vein, right and left GSV, and left SSV. The patients provider has recommended treatment with VenaSeal, which is an accepted venous ablation technique that has been demonstrated in the peer-reviewed medical literature to be equivalent in efficacy when compared to radiofrequency ablation (Gibson, et al.; Hirsch). However, this patients medical records fail to document the current location of reflux in the left and right GSV, including whether the distribution of reflux is above or below the knee. In this clinical setting, VenaSeal is not likely to confer substantial additional benefit to treatment with radiofrequency ablation in the treatment of this patients symptomatic chronic venous insufficiency. Accordingly, the requested VenaSeal closure system procedure is not 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 requested VenaSeal closure system procedure 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 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 general surgery with subspecialty 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: Urgent Care
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for psychiatric emergency medical services on an emergent basis or urgent basis. Findings: The physician reviewer found that at issue in this case is whether the enrollee received psychiatric emergency medical services on the dates of service in question. California law defines emergency services and care as an additional screening, examination, and evaluation by a physician, or other personnel to the extent permitted by applicable law and within the scope of their licensure and clinical privileges, to determine if a psychiatric emergency medical condition exists, and the care and treatment necessary to relieve or eliminate the psychiatric emergency medical condition, within the capability of the facility. A screening examination in an emergency department, and any medical services received from on-call specialists in the emergency department, are, by definition, an emergency medical service. In general, emergency medical services are indicated in an acute psychiatric syndrome and typically delivered in a specialized acute inpatient unit. In addition, a common exclusionary criterion for IOP programming is the presence of a psychiatric emergent condition. Although the level of care in this case was reasonably expected to improve the patients condition and prevent a more serious episode of illness, the patient did not receive emergency medical services during the dates of service at issue. The episode of care originated in the outpatient setting before progressing from the more restrictive environment afforded by the residential facility to the IOP level of care. The patient had no change in diagnoses. He had an unremarkable mental status examination.  His thought processing was logical, organized and goal directed. His appearance was appropriate and his behavior was cooperative. He denied any suicidal ideation or homicidal ideation, and there was no mention of psychosis, intoxication, withdrawal, agitation or paranoia. In sum, although anxious, the patient was not experiencing an acute psychiatric syndrome. Final Result: The reviewers determined that the patient did not receive psychiatric emergency medical services on the dates of service at issue. 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: Overturned

The patient has requested authorization and coverage for Dupixent 300 mg/2 ml syringe. The patient has been diagnosed with atopic dermatitis (AD). Researchers states that the authors agreed that the general approach should be an intensive clearance period with a topical corticosteroids (TCSs) followed by a safe and individualized regimen of intermittent TCSs, topical calcineurin inhibitors (TCIs), or emollients to prevent flares. The patient has not had a successful clearance period. In this case, the patients atopic dermatitis is widespread, and he has failed topical treatment and two systemic steroid treatments. The difficulty controlling this patients disease and his involved body surface area merit systemic treatment. The medical evidence supports the requested medication in this clinical setting. Therefore, Dupixent 300 mg/2 ml syringe is medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested medication is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in dermatology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

A 63-year-old female enrollee has requested a semi-electric hospital bed, gel mattress overlay and rails for treatment of her medical condition. Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested equipment.  Semi-electric or fully electric hospital beds may be necessary if an individual requires head elevation or has other frequent positioning needs and is unable to perform these maneuvers independently.  Pressure relieving mattresses may be needed if an individual is unable to perform sufficient pressure relief independently.  However, the submitted records do not establish that the patient has any impairment that would require a semi-electric hospital bed, gel mattress overlay or bed rails.  The patient has various respiratory conditions, but no documented objective need to have the head of the bed frequently elevated.  She has no documented neurological or musculoskeletal conditions that would preclude self-repositioning in bed for her pain conditions.  There are no impairments, major risk factors for pressure ulcers, or other medical conditions that establish the need for a gel mattress overlay.  There are no impairments that need to be addressed with rails on a semi-electric bed.  All told, the requested semi-electric hospital bed, gel mattress overlay and rails are not medically necessary for the treatment of this patient.
Appeal type: Experimental/Investigational
Decision: Upheld

A 52-year-old female enrollee requested authorization and coverage of adjustable gastric banding for treatment of morbid obesity.  The health plan denied the enrollees request indicating that the requested procedure is considered experimental/investigational.Three physician reviewers performed an experimental/investigational Independent Medical Review.  Two of the three physician reviewers concluded that the adjustable gastric banding 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 procedure 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: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary:  An enrollee has requested reimbursement for FoundationOne CDx genetic testing (CPT code 0037U) provided by Foundation Medicine, Inc., on 10/22/20.Findings: Two out of three physician reviewers found that FoundationOne CDx genetic testing (CPT code 0037U) provided by Foundation Medicine, Inc., on 10/22/20 was likely to have been more beneficial for the enrollee than any available standard therapy.Understanding the molecular drivers of cancer progression and metastases is an area of ongoing and active research, predominantly driven by the goal of identifying specific genomic aberrations that may ultimately result in individualized cancer treatment. In addition to likely providing prognostic information, the value of next generation sequencing (NGS) to predict candidates for specific mutation-driven treatment holds promise. Patients with inflammatory and metastatic breast cancers benefit from NGS to identify markers that may indicate benefit from targeted treatment or clinical trials. For hormone receptor (HR)-positive/human epidermal growth factor receptor 2 (HER2)-negative breast cancer, testing for PIK3CA mutations with tumor or liquid biopsy to identify candidates for alpelisib plus fulvestrant should be performed. For patients that have exhausted standard treatments, novel markers may indicate eligibility for clinical trials or compassionate use medications. The use of NGS such as with FoundationOne is likely to be more effective than available standard therapy. Therefore, FoundationOne CDx genetic testing (CPT code 0037U) provided by Foundation Medicine, Inc., on 10/22/20 was likely to have been more beneficial for evaluation of the patients condition than any available standard therapy.Final Result: The reviewers determined that the requested service was likely to have been more beneficial than any available standard treatment for the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer 1, reviewer 2, and reviewer 3 are board certified in board certified in internal medicine with sub-specialty certification in medical oncology. All reviewers 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

An enrollee has requested authorization and coverage for a functional electric stimulator (FES) (CPT E1399). There is a lack of proven improved function or other outcomes with the use of a FES cycle ergometer in this clinical setting of a traumatic brain injury complicated by large vessel stroke, resulting in hemiparesis/hemiplegia. In a systematic review and meta-analysis, Ambrosini and colleagues conclude that cycling training with FES cannot be recommended in terms of being better than usual care in subacute stroke survivors. Current medical literature and guidelines do not mention the use of this type of device as an evidence-based component of in stroke or other brain injury management, rehabilitation, or prevention of complications, and do not support its use over standard therapy, including occupational therapy or independent exercise and splinting, even if a full neurological and functional recovery is not elicited by these standard therapies. Therefore, FES (CPT E1399) is not likely to be more beneficial for treatment of the patients condition than any available standard therapy.Findings:  Three of the three physician reviewers found the requested FES (CPT E1399) 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 device 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 reviewers 1 and 3 are board certified in physical medicine and rehabilitation and are actively practicing. Physician reviewer 2 is board certified in physical medicine and rehabilitation with sub-specialty certification in neuromuscular medicine 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: Experimental/Investigational
Decision: Overturned

A 38-year-old female enrollee has requested gastric electrical stimulation for the treatment of her severe gastroparesis. Findings:  Two physician reviewers found that the alternative treatments available in this setting including parenteral nutritional support and surgical intervention are inappropriately invasive at this juncture. The GES is a widely accepted treatment for refractory gastroparesis. Mearin and colleagues note that, For several years, treatment in the most severe cases has consisted of implantation of a gastric pacemaker. Although the results are far from perfect, new data were presented that allow better patient selection to achieve greater symptom control. This statement is consistent with the conclusion by Patrick and Epstein as well as Waseems comment that the GES will offer benefit to patients with refractory gastroparesis. All told, the GES has been proven to be safe and effective in the scientific literature and is appropriate for use in patients such as this patient with documented refractory gastroparesis.
Appeal type: Medical Necessity
Decision: Upheld

The parent of a 17-year-old female enrollee has requested  for residential treatment for treatment of the enrollees behavioral health issues.  Findings:  The physician reviewer found that records provided for review do not demonstrate that the patient has any co-morbid medical conditions that require the intensity of care provided in a 24-hour structured facility. The patients medications are being adjusted. However, medication management can take place in intensive outpatient program (IOP) or partial hospitalization program (PHP) settings. Applying the American Psychiatric Association (APA) and Milliman Care Guidelines, this patient is a candidate for a less restrictive level of care. Consistent with these findings, the services at issue were not and are not medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a female enrollee requested growth hormone (GH) therapy Nutropin 0.5 mg daily for medical treatment of the enrollees Turner syndrome.  Findings:  The physician reviewer found that Turner syndrome is a well-established indication for GH treatment, and GH has been shown to be safe and effective in improving adult height in girls with Turner syndrome treated with GH. Consistent with these findings, the requested GH therapy Nutropin 0.5 mg daily is supported as medically necessary for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld

The parent of a 16-year-old male enrollee has requested Botox injections for treatment of the enrollee, who has a history of facial pain. Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested services in this patients case.  He has a history of facial pain.  However, his distribution of pain is unusual for typical trigeminal neuralgia.  A trial of amitriptyline was not beneficial.  There are multiple additional medications that are used for management of neuropathic pain.  For patients with classic trigeminal neuralgia, carbamazepine or oxcarbazepine are noted to be first-line therapy.  The data regarding the use of Botox for trigeminal neuralgia has yielded mixed results.  Botox injections may be an option for patients with medically refractory trigeminal neuralgia.  However, in this patients case, the records do not demonstrate trials of other medications which may be beneficial in this setting.  All told, Botox injections are not medically necessary for the treatment of this patient.