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

A 28-year-old male enrollee has requested authorization and coverage for Nuvigil for treatment of the enrollees bipolar disorder.  Findings:  The physician reviewer found that based on review of the available records, this patient presents with a history of bipolar disorder, NOS, and has been treated with a number of different medications with poor success. He was started on Nuvigil by his provider to treat his mood disorder and fatigue of bipolar disorder. However, according to the FDA indications for Nuvigil, mood disorder, fatigue, and bipolar disorder are not included. Specifically, Nuvigil is indicated by the FDA for shift work disorder, obstructive sleep apnea and narcolepsy. This patients records do not document any of the diagnoses approved for treatment with Nuvigil. The use of this product for bipolar disorder is defined as an off-label use with mixed results in the peer-reviewed medical literature. Some of the studies suggest that Nuvigil, or other similar medications, can produce hypomanic effects. Consistent with these findings, the requested Nuvigil has not been demonstrated to be medically necessary for treatment of this patients medical condition. Therefore, the Health Plans denial was appropriate.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary:  An enrollee has requested authorization and coverage for botulinum toxin injections for hands and feet.Botox (onabotulinumtoxinA) is approved by the U.S. Food and Drug Administration for the treatment of severe primary axillary hyperhidrosis in patients who are unable to obtain relief using antiperspirants. The efficacy of botulinum toxin for palmar and plantar hyperhidrosis is also supported by multiple studies, including a few small randomized trials, and it is generally regarded as a second-line therapy. Additionally, Lecouflet and colleagues reported, an increase in the duration of efficacy of botulinum toxin A injections with the repetition of injections in patients with primary axillary hyperhidrosis. In this case, the patient has hyperhidrosis. Additionally, the patient has tried and failed first-line therapies, such as aluminum chloride solution. There is sufficient support for the requested services in this clinical setting. Therefore, botulinum toxin injections for hands and feet are medically necessary for treatment of the patients medical condition.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 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

The patient has requested reimbursement for Crinone 8% gel. This patients records document a history of early pregnancy loss. Her provider recommended treatment with Crinone 8% gel. The use of Crinone has not been demonstrated to provide benefit in this clinical situation. According to the current medical literature and guidelines from the American College of Obstetricians and Gynecologists (ACOG), vaginal progesterone in any form oral, vaginal or intramuscular has not been shown to be beneficial in the prevention of recurrent early pregnancy loss. All told, the Crinone 8% gel was not medically necessary for treatment of this patient. Final Result: The reviewer determined that the medication at issue was 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 obstetrics and gynecology 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 reimbursement for a doctor visit and echocardiogram services. The submitted documentation fails to demonstrate the medical necessity of the services at issue. In this patients case, the records documented a prior small ventricular septal defect that was only questionably present on the most recent echocardiogram in 2013 and was not associated with any documented recent cardiac symptoms, cardiac abnormalities on recent physical examination or recent electrocardiogram. In addition, no murmur was identified suggesting that the ventricular septal defect has spontaneously closed, which is a common occurrence.  Moreover, the scheduled breast augmentation surgery is a low-risk non-cardiac surgical procedure that does not warrant a preoperative echocardiogram in the absence of cardiac symptoms or objective cardiac abnormalities on physical examination or electrocardiogram. In aggregate, in a stable patient without documented cardiac symptoms or findings scheduled for a low risk non-cardiac procedure, a repeat echocardiogram is not medically necessary and not recommended by current guidelines. Thus, the doctor visit and echocardiogram services were not medically necessary for the evaluation of this patient. Final Result: The reviewer determined that the services at issue were not medically necessary for evaluation of the patients medical condition. Therefore, the Health Plans denial should be upheld.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: Overturned

Nature of Statutory Criteria/Case Summary:  An enrollee has requested breast tomosynthesis for evaluation of her medical condition.  Findings:  Two physician reviewers found that breast tomosynthesis was approved for clinical use by the U.S. Food and Drug Administration (FDA). Despite the lack of long-term studies proving an increased survival rate when tomosynthesis has been added to standard mammographic protocol, the American College of Radiology (ACR) urged the technique be removed from the investigational category due to the advantages this tomographic technique brings to radiologists interpreting mammograms. The technique often allows the reader to separate dense glandular elements from underlying mass or architectural distortion resulting in a decrease in callbacks and increase in detection of small cancers. Thus, breast tomosynthesis was likely to have been more beneficial for evaluation of this patients medical condition than any available alternative. Final Result: Two reviewers determined that the diagnostic procedure 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:  All three reviewers are board certified in diagnostic radiology 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: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for LINQ heart monitor implantation for symptom review and mapping of hearth rhythm (for cardiac ablation). The Health Plan has denied this request indicating that the requested services are considered investigational for treatment of the enrollees condition. Findings:  The physician reviewer found that established indications for implantable cardiac monitors in current practice include unexplained syncope, palpitations, and management of atrial fibrillation. According recent literature, an expert consensus statement recommended a range from 24 to 48 hours to two weeks of ambulatory electrocardiographic monitoring for unexplained palpitations, depending on symptom frequency. Therefore, implantable monitors are not routinely indicated. This patient has documented frequent premature ventricular contractions with symptoms of persistent palpitations unresponsive to verapamil. If there remains a question as to the etiology of his symptoms beyond premature ventricular contractions, then more prolonged monitoring with standard devices could be considered. Moreover, an implantable loop recorder is generally considered appropriate for patients with recurrent syncope of uncertain cause or cryptogenic stroke with suspicion of paroxysmal atrial fibrillation, neither of which have been documented in this patient. This patient has not had the requisite indications for the justification of an implantable cardiac monitor.  Final Result: Two of the 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/QualificationsAll three reviewers are board certified in internal medicine with sub-specialty certification in cardiovascular disease 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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for vein ablation for treatment of her varicose veins.  Findings:  Three physician reviewers found that the hemodynamic significance of the calf perforating veins continues to be controversial. There is a bidirectional flow within calf perforators in healthy patients enabling a quick equilibration of pressure changes produced during calf muscle contractions and relaxations. In cases with saphenous reflux, the bidirectional flow within calf perforators has a distinct inward vector directed to the deep veins. In primary varicose veins, calf perforators cannot become the source of reflux because they are situated at the lower pole of the ambulatory pressure gradient, which occurs between thigh and lower leg veins during ambulation. The size of the calf perforators is determined by the amount of saphenous reflux. When the saphenous reflux is abolished by ablation or high ligation, the enlarged calf perforators generally diminish. Currently, there are insufficient level 1 or level 2 studies in the literature to demonstrate that ablation of perforators is appropriate and no evidence to support perforator surgery in the absence of stage 5 and 6 chronic venous disease. Given these findings, the requested vein ablation of the GSV and perforator are not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Final Results:  The reviewers determined that the requested service 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: All three reviewers are board certified in surgery with sub-specialty certification in vascular surgery and is actively practicing. The reviewer 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 37-year-old female enrollee has requested a spinal cord stimulator for the treatment of her chronic lower-back pain. Findings:  The physician reviewer found that this patient continues with back pain and bilateral leg symptoms. Follow-up MRI revealed spinal stenosis at L3-4 due to graft migration with canal compromise. The spinal cord stimulator is not the most appropriate procedure for treatment of this patient. Correction of her stenosis is medically appropriate and indicated. Additionally, she has not met the other necessary criteria for the spinal cord stimulator. Further surgery is not indicated. The requested procedure is not medically indicated for this patients condition.
Appeal type: Medical Necessity
Decision: Overturned

A 30-year-old female enrollee has requested orthognathic surgery for the treatment of her mandibular hypoplasia. Findings:  The physician reviewer found that the patient has a significant deformity. Furthermore, she has related difficulty with mastication and orthodontic treatment has been unsuccessful. Correction of this patients deformity is necessary to prevent progression of her condition. The requested procedure is considered standard of care to correct the deformity.
Appeal type: Medical Necessity
Decision: Overturned

A 58-year-old female enrollee has requested Xifaxan for the treatment of her condition. Findings:  The physician reviewer found that the use of Xifaxan is appropriate in this case to treat this patients symptoms of gas and bloating. The use of the medication for these symptoms is the community standard at this point even though the FDA approval is for the diagnosis of travelers diarrhea. The medical records support this course of treatment for this patients unexplained symptoms of gas and bloating.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for hepatology consultation In this patients case, physical examination and lab testing revealed hepatomegaly, elevated bilirubin, and potential liver changes due to cardiac function. These findings may be benign, but could be a sign of primary or secondary hepatic disease with long-term consequences. Further testing, including blood tests and liver biopsy, could help determine the underlying etiology for these findings, or rule out serious disease. Since these tests are associated with potential adverse effects, they should be performed only when required after an appropriate serologic work-up. For these reasons, this patients medical condition is best evaluated by a hepatologist, who is trained to evaluate for common and uncommon diseases of the liver in patients with findings suggestive of possible hepatic or biliary disease. For these reasons, the request for hepatology consultation is supported as medically necessary for the evaluation of this patients medical condition.Final Result: The reviewer determined that the requested services are medically necessary for evaluation 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 gastroenterology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

A 58-year-old male enrollee has requested Pristiq 50mg for treatment of his social anxiety disorder. Findings:  The physician reviewer found that the submitted documentation has failed to establish the medical necessity of Pristiq 50mg. The history is sparse and is incongruent with standards according to the American Psychiatric Association guidelines for psychiatric assessment. Hence, a firm diagnosis is not established. Furthermore, American Psychiatric Association guidelines do not indicate this medication as an adjunct in treating alcohol withdrawal, and there is insufficient evidence to support the use of Pristiq in patients with social anxiety disorders. Additionally, current medical evidence does not demonstrate that other medications are contraindicated given the patients medical condition, or that Pristiq is likely to be safer than alternatives, such as SSRIs. All told, Pristiq 50mg is not medically indicated for the treatment of this patient.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for genetic testing.Findings:  Two of the three physician reviewers found that the American College of Obstetricians and Gynecologists recommends genetic screening for common recessive diseases in all populations. The genetic testing performed in this patients case has been validated. The genetic testing ordered included the diseases recommended by American College of Obstetricians and Gynecologists for screening. This screening is considered the standard of care for all pregnant patients. The testing allows for patients to make important medical decisions. In sum, genetic testing was likely to have been superior over other methods of evaluating this patient. Final Result: The reviewers determined that the services at issue were 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 reviewer 1 is board certified in clinical biochemical genetics and is actively practicing. Physician reviewer 2 is board certified in obstetrics and gynecology and is actively practicing. Physician reviewer 3 is board certified in clinical genetics and genomics 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: Upheld

A 41-year-old female enrollee requested genetic testing (APC gene fam variants, CPT 81202; BRAF gene, CPT 81210; JAK2 gene, CPT-81270; KRAS gene, CPT 81275; and molecular pathology CPT 81479) for evaluation of her medical condition. Findings:  Three physician reviewers found that the testing was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The standard of care for early breast cancer dictates that testing estrogen receptor status and expression of Her2-neu is critical in determining treatment.  A t this time, the requested testing is not considered the standard of care and was not likely to be more beneficial than other modalities.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for bariatric revision surgery (CPT 43848). The weight loss outcomes from revision to gastric bypass after sleeve gastrectomy is heterogenous and variable without consistent weight loss. As noted in the medical literature, conversion to gastric bypass after sleeve gastrectomy is indicated for correction of complications, as general outcomes for weight loss are similar between the two procedures at five-year follow-up. This patient has no complications of her prior sleeve gastrectomy. The patient regained the majority of weight over the past 15 months. The patient endorses daily alcohol consumption, which is concerning for gastric bypass consideration given the unique alcohol pharmacokinetics. Moreover, the records provided for review report normal anatomy without evidence of complications of the sleeve gastrectomy. For these reasons, the requested bariatric revision surgery (CPT 43848) 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 expertise in bariatric and minimally invasive 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

Nature of Statutory Criteria/Case Summary:  An enrollee has requested authorization and coverage for an osteogenesis stimulator.A review of the literature pertaining to electrical stimulation for osteogenesis of a pars interarticularis defect reveals this to be a viable option. electrical stimulation has long been used for healing of fracture non-unions. a computational model showed that electrical stimulation facilitated bone restoration by stimulating osteoblasts. Further, a study that found that electrical stimulation showed some effectiveness in intercollegiate athletes who had acute lumbar spondylolysis. In this case, the patient was found to have a pars interarticularis fracture on the left side after a hemilaminectomy at L4-5. Therefore, an osteogenesis stimulator is medically necessary for the treatment of the patients medical condition.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 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 Accucheck Aviva Test Strips for treatment of the enrollees type 2 diabetes mellitus with other diabetic neurological complication. Findings:  The physician reviewer found that according to the American Diabetes Association a patient-centered approach should be used to guide the choice of pharmacologic agents. Considerations include efficacy, hypoglycemia risk, history of atherosclerotic cardiovascular disease, impact on weight, potential side effects, renal effects, delivery method (oral versus subcutaneous), cost, and patient preferences. This patient reportedly has had difficulty using and maintaining the covered Fora meter. Thus, the patient should be provided with a meter with which she is comfortable using properly. Improper use will only cause more clinical and economic problems due to inaccurate readings. There are brands that are considered equally reliable and accurate, and the peer-reviewed literature does not demonstrate that the Accucheck Aviva brand is medically necessary. All told, the medical literature does not support the requested Accucheck Aviva Test Strips as medically necessary for treatment of this patients medical condition. Final Result: The reviewer determined that the requested equipment 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 sub-specialty certification in endocrinology, diabetes and metabolism and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.