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

A 24-year-old male enrollee has requested Intrepid Dynamic Exoskeletal Orthosis energy-storing ankle foot orthosis for treatment of his medical condition. Findings:  Three physician reviewers found that in this patients case, the requested equipment is not likely to be more effective than other treatment options.  The current medical evidence does not support the requested equipment in this clinical setting.  There is a lack of independent peer-reviewed articles that support this device and indicate its overall safety and efficacy.  Due to the paucity of information regarding this equipment, the superior efficacy of the requested Intrepid Dynamic Exoskeletal Orthosis energy-storing ankle foot orthosis has not been established.
Appeal type: Medical Necessity
Decision: Upheld

A 57-year-old female enrollee requested Xifaxan 550 mg three times per day for 14 days for medical treatment of her medical condition.   Findings:  The physician reviewer found that the efficacy of Xifaxan in treating non-constipated IBS is well documented in the peer-reviewed literature. Accordingly, Xifaxan is considered to represent a viable treatment option for this subset population and is under U.S. Food and Drug Administration (FDA) review for the indication of SIBO management. Menees and colleagues noted that Xifaxan proved more effective than placebo for global symptoms and bloating in IBS patients. Similarly, Pimentel and colleagues reported that treatment with rifaximin for two weeks provided significant relief of IBS symptoms, bloating, abdominal pain, and loose or watery stools. However, in this patients case, SIBO has not been demonstrated. In addition, her symptoms have shown diminishing response to repeated courses of Xifaxan. All told, the medical necessity for another 14-day trial of Xifaxan in this patient is not supported by the available medical records.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for computed tomography (CT) scan of the brain. The records provided for review document that this patient presented to his provider with complaints of dizziness and ear discomfort. The patient has requested evaluation with a CT scan of the brain. However, there is no documentation of any focal neurological signs to support an indication for a CT scan of the brain. For patients with focal neurological signs, there are data supporting a limited role for evaluation with magnetic resonance imaging (MRI) due to increased sensitivity for assessing the posterior circulation of the brain. Since this patients records do not document any focal neurological signs or symptoms, additional imaging is not indicated. Therefore, the requested CT scan of the brain is not medically necessary for this patient. Final Result: The reviewer determined that the requested services are 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 neurology with subspecialty 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.
Appeal type: Experimental/Investigational
Decision: Overturned

A 26-year-old female enrollee requested authorization and coverage of an implantation of a gastric electrical stimulator (enterra therapy)  for the treatment of diabetic gastroparesis.  The health plan denied the enrollees request indicating that the requested treatment is experimental.Three physician reviewers performed an experimental/investigational Independent Medical Review.  Each of the three physician reviewers concluded that an implantation of a gastric electrical stimulator (enterra therapy)  is likely to be more beneficial for treatment of the enrollees diabetic gastroparesis than any available standard therapy.  Because all three physician reviewers concluded that the requested treatment is likely to be more beneficial for treatment of the enrollees medical condition than any available standard therapy, the review organization overturned the health plans denial.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/ Case Summary:  The enrollee requested reimbursement for genetic cancer susceptibility panels (Guardant360 testing). The enrollee has a diagnosis of stage IV non-small cell lung carcinoma. He reported developing a dry cough that did not improve with inhalers and systemic treatment.  A chest x-ray showed a large left sided mass. A computed tomography (CT) scan showed a 6.8 x 5.8 cm left lower lobe (LLL) mass extending to the hilum with mild spiculated margins and surrounding ground glass opacifications.  A positron emission tomography (PET) scan confirmed a fluorodeoxyglucose (FDG)-avid 5.9 x 7.5 x 6.5 LLL mass with standardized uptake value (SUV) 19.5, FDG-positive left mediastinal and hilar nodes, a right fifth rib lesion and an L4 lesion.  A CT-guided biopsy of the lung mass confirmed primary adenocarcinoma of lung with lepidic growth pattern. Documentation notes the provider ordered Guardant360 for the enrollee to determine if his current treatment regimen was optimized to manage his care.  The provider wanted to determine if there were targeted therapy options before beginning treatments. The Guardant360 test results revealed three somatic alterations with one associated, approved therapy. Literature notes genotyping of tumor tissue to find alterations that can inform practice and guide treatment has become a routine practice in clinical oncology. However, this practice has significant inherent limitations; such as selection bias and the difficulty of obtaining a representative sample. Professional societies have not established standards or guidelines for the use of (cfDNA)/circulating tumor DNA testing for genetic alterations, due to the high false-positive rate of 30% and  the presence of other alterations not related to the tumor. Literature notes the Guardant360 is not currently approved by regulatory bodies. Professional organizations do not support the liquid version of the test; only the tissue version. The value of Next Generation Sequencing (NGS) to predict candidates for specific mutation-driven treatment holds promise but is not yet ready for routine clinical use. There is no peer-reviewed literature to show the test would improve the patient's outcome.Final Result: Three of the three reviewers determined that the requested services are not likely to be more beneficial than any available standard therapy for treatment of the enrollees medical condition. Credentials/Qualifications: Three reviewers are board certified in medical oncology 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 45-year-old male enrollee requested authorization and coverage of a referral to a gastroenterologist for the treatment of indigestion, abdominal pain and gas, rapid weight loss and nausea.  The Health Plan denied the enrollees request indicating that the requested treatment is not medically necessary.One physician reviewer performed a medical necessity Independent Medical Review.  The physician reviewer upheld the health plans denial on the basis that the requested referral is not medically necessary for treatment of the patients medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for DecisionDx-Melanoma test. For a thin melanoma, pathologic stage 1B, the current standard of care involves wide excision of the lesional site with appropriate margins and consideration of sentinel lymph node biopsy. This patient underwent a biopsy with pathology results describing the tumor to have a thickness of 1.5 mm with evidence of ulceration, regression, satellitosis, perineural invasion, or lymphovascular invasion. The patients provider recommended gene expression profiling (GEP) with the DecisionDx-Melanoma test. The standard of care per National Comprehensive Cancer Network (NCCN) guidelines includes re-excision with appropriate margins and discussion, consideration of sentinel lymph node biopsy (SLNB), and dermatologic surveillance. The current consensus statements published by the Melanoma Prevention Working Group (MPWG) state that more evidence is needed to support use of GEP testing to inform recommendations about sentinel lymph node biopsy, follow-up, or other adjuvant treatment (Grossman, et al.). The MPWG also advises against routine use of GEP testing to direct patient management. Thus, the DecisionDx-melanoma testing was unlikely to have added any significant benefit above the standard clinical care treatment as recommended by the NCCN guidelines namely re-excision with clinically appropriate margins and discussion of SLNB. Accordingly, the DecisionDx-Melanoma testing was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Findings: Three of the three physician reviewers found the services at issue were not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the services at issue were 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: Physician reviewer 1 is board certified in dermatology and is actively practicing. Physician reviewer 2 is board certified in dermatology and is actively practicing. Physician reviewer 3 is board certified in dermatology and is actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the residential treatment center (RTC) services. The records indicate that this patient continued to show moderate post-acute withdrawal symptoms. However, the patient was not provided with any detoxification medications. The patient was not a danger to self or others, nor was the patient aggressive or violent. There were no emotional, behavioral, cognitive, or impulsive symptoms that would warrant the RTC level of care. The patients cognitive impairment due to the previous encephalopathy did not require supervision, and it did not interfere with self-care. The patient was not manic or psychotic. The patient had no biomedical complications, and was psychiatrically stable to the extent that they did not need a 24-hour facility to render the remainder of their care. The patients medication management and medication assisted treatment could have been performed in an ambulatory setting. The patient was motivated and appeared to be working the program. The patient was cooperative and participating in the treatment plan. Moreover, the patients emotional stressors did not require them to be treated or monitored in RTC setting. From the date of denial forward, there were no further changes in that they continued to report high levels of cravings, and using dreams. Thus, the RTC services provided were not medically necessary for treatment of this patients medical condition. Final Result: The reviewer determined that the services at issue were 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 with sub-specialty certification in addiction medicine and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

A 53-year-old female enrollee has requested a bilateral or unilateral breast reconstruction for treatment of her stated condition of breast deformity secondary to lumpectomies.  Findings:  The physician reviewer found that review of the submitted documentation does not demonstrate that the requested procedure is medically necessary or reconstructive in nature. Overall, the patient appears to have mild changes as a result of previous breast biopsies and aspirations. The photographs and exam documentations are consistent with mild or minor deformities. As was stated in the evaluation by the plastic surgeon providing the second opinion, augmentation is not indicated due to the small amount of volume loss. A lumpectomy/partial mastectomy that requires breast reconstruction generally has created a moderate to significantly sized defect. A paper by Levine and colleagues discusses the treatment of partial mastectomy defects and possible options. Their discussion is based on cases with greater deformities than are present with this patient. In the case of this patient, the amount of deformity is less than that associated with typical breast reconstruction of partial mastectomy defects. The treatment of partial mastectomy defects depends upon an algorithm based on amount of resected tissue, size of the breast and anticipated type of treatment. In accordance with this algorithm, this patients deformities are not to the degree to warrant reconstruction of a partial mastectomy defect.  The severity of deformity that is present in this patient does not support augmentation.  Although this patient has had multiple biopsies as a result of tumors or disease that have resulted in mild deformities, the requested surgery would not improve the patients level of functioning or create a normal appearance, as a breast augmentation would be overtreatment of the patients mild deformities. All told, the requested procedure is not medically necessary or reconstructive in nature in this case.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Qsymia for treatment of the enrollees medical condition. Findings:  The physician reviewer found that there is support for the requested medication for treatment of this patients medical condition. The medication Qsymia is approved by the U.S. Food and Drug Administration for chronic weight management. Moreover, the medical literature recommends weight loss medication like Qsymia as an adjunct to a reduced-calorie diet and increased physical activity in patients with either an initial BMI greater than 30 kg/m2 or an initial BMI greater or equal to 27 kg/m2 and at least one weight-related comorbid condition. In this patients case, she has a BMI greater than 30 kg/m2. She is also currently participating in a dietary plan and is physically active three to four times per week. Previous treatments have included participation in weight loss programs, physical activity, dietary counseling and the use of Phentermine. However, she has not been able to maintain any weight loss with these programs.  Therefore, given the patients obesity and her failure to loose significant weight on a diet and exercise regimens, Qsymia is medically necessary for treatment of her obesity. 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: Physician reviewer number one is board certified in internal medicine and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

The patient is a 62-year-old male with moderate to severe chronic pain related to microvascular decompression of the trigeminal nerve. He is being treated with Neurontin for this condition. Records submitted demonstrate he is experiencing significant sedation from the Neurontin. He is seeking authorization for Provigil to mitigate the sedating effects of the Neurontin. Records indicate Provigil has been beneficial with regards to the sedating effects of Neurontin. The Health Plan has denied authorization for Provigil.The patients condition is chronic and unrelenting. Provigil is a reasonable and commonly utilized therapy prescribed to improve the excessive daytime somnolence associated with the use of pain medication. For this patient Provigil is reasonable and medically indicated and has already benefited the patient. Therefore, I have determined the requested medication is medically necessary for treatment of the patients medical condition. The Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/ Case Summary:  The enrollees parent is requesting reimbursement for esophageal Bravo pH probe monitoring. The enrollee has a history consistent with rumination syndrome. He had frequent, non-forceful regurgitation of food but did not have signs of gastroesophageal reflux disease (GERD) as he had no nocturnal symptoms or pain. His pediatric gastroenterologist indicates based on family history, the enrollee seemed to have rumination syndrome. He underwent an esophagogastroduodenoscopy (EGD) with biopsy and Bravo pH probe, which showed findings consistent with rumination syndrome. The studies showed normal visual upper endoscopy, Hill Grade II lower esophageal sphincter (LES) region, and no hiatal hernia, with successful placement of a Bravo pH probe. Biopsies did not show any significant esophagitis. Bravo pH probe showed positive severe, excessive GERD recorded, but time course seemed very consistent with rumination as vast majority of GERD occurs in daytime and almost resolves completely when asleep. The doctor ordered omeprazole 10mg capsule, orally twice a day to protect esophagus and teeth and wait until the enrollee is older to try breathing techniques to decrease rumination events. The record indicates the enrollee presented with non-forceful regurgitation of food. He had previously been tried on Zantac which did not help.  His Bravo probe showed severe, excessive GERD (Gastroesophageal Reflux Disease), with the majority of GERD events in the daytime with resolution while the enrollee was sleeping (interpreted to be consistent with rumination). Biopsies showed normal esophageal mucosa. Clinical notes indicate the enrollee has up to 40 regurgitation events per day, as well as rumination noises. In this case, where the provider was concerned for rumination based on clinical assessment, the literature indicates neither ph-impedance testing nor simple acid reflux testing are the diagnostic methods of choice. In fact, objective testing is not required to render a diagnosis of rumination syndrome as this diagnosis is based on Rome IV criteria, which are primarily clinical. Failure to respond to antacid therapy is also consistent with the diagnosis. Based on the medical literature, the multiple reflux events as were clinically witnessed would confirm a diagnosis of rumination and would not require Bravo pH testing. Final Result: The reviewer determined that the requested services were not medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The physician reviewer is board certified in pediatric 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 similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

The parent of a six-year-old male enrollee requested occupational therapy (OT) at the frequency of one hour per week for treatment of the enrollees autism spectrum disorder.  Findings:  The physician reviewer found that the patient presents with mild delays in fine motor and gross motor skills. Moreover, his IEP reports that he is making progress. The patients parents have requested OT to address the patients sensory processing deficits. Given the lack of support for sensory based therapies in the medical literature and the patients delays in both fine and gross motor skills are only mild, the medical necessity for the requested therapy has not been established in this clinical setting.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary:  An enrollee has requested  gamma skin graft for treatment of his medical condition.  Findings:  Three physician reviewers found that there is a lack of support for the services at issue in this clinical setting.  The medical documentation does not support that non-biologic therapies were used as first-line wound care prior to surgical application of the allograft.  Per the medical evidence, skin allograft is not a first-line wound care technique.  Local wound care with hydrocolloids, closure by secondary intention and blood glucose control is tantamount to good wound closure.  In sum, gamma skin graft was not likely to have been of greater benefit than other treatment options.  Final Result: Three reviewers determined that the services at issue were not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld.  Credentials/Qualifications:   All three reviewers are board certified in 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: Experimental/Investigational
Decision: Upheld

A 38-year-old female enrollee has requested intradiscal thermal annuloplasty for the treatment of her low back pain. Findings:  Two physician reviewers found that there are no large, scientific studies available to show that intradiscal thermal annuloplasty is efficacious and results in long-term relief of symptoms. A systematic review of intradiscal thermal annuloplasty by Singh and colleagues concluded that although the procedure has been in utilization for a number of years and numerous procedures have been performed there continues to be a paucity of literature of randomized clinical trials. Gibson and Waddell consider this procedure to be a research technique. Its superiority in this setting remains unproven.