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

Nature of Statutory Criteria/Case Summary: The patients parent has requested authorization and coverage for Xifaxan 550 mg (one tablet by mouth three times daily for 14 days, quantity 42 tablets). As noted in the medical literature, small intestinal bacterial overgrowth (SIBO) is a recognized cause of gastrointestinal distress and is likely a primary contributing factor to irritable bowel syndrome (IBS). Per the American Gastroenterological Association (AGA) practice guidelines on SIBO, no single antibiotic regimen is recommended (Quigley, et al.). The U.S. Food and Drug Administration (FDA) has approved rifaximin (Xifaxan) for the treatment of adult patients with irritable bowel syndrome, diarrhea predominant (IBS-D). In addition, Xifaxan has been demonstrated to be one of the most effective medications in the treatment of SIBO in adult patients (Gatta and Scarpignato). However, the treatment of this pediatric patients methanogenic SIBO is less well studied. Ghoshal and colleagues found that combination of both rifaximin and neomycin is more effective in decreasing methane production than either antibiotic alone. Scarpellini and colleagues reported on non-controlled prospective data demonstrating the effectiveness of Xifaxan in the treatment of pediatric patients with SIBO. Avelar Rodriguez and colleagues concluded that Xifaxan has demonstrated safety in a greater number of participants and studies. Considering this patients age and the presence of methane on her lactulose breath test, Xifaxan is likely the safest and most effective treatment choice, especially in combination with neomycin. All told, the requested Xifaxan 550 mg (one tablet by mouth three times daily for 14 days, quantity 42 tablets) is medically necessary for 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 pediatrics with subspecialty certification 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 a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Euflexxa injection series (one time per week for three weeks). Evidence from systematic reviews and randomized controlled trials indicate that although viscosupplementation may relieve knee pain in some patients with osteoarthritis, data has not established which patients will benefit. Guidelines from the American Academy of Orthopedic Surgeons (AAOS) indicate that the data on safety and efficacy of viscosupplementation remain inconclusive. As such, the AAOS does not currently recommend viscosupplementation as routine treatment for osteoarthritis of the knees. Viscosupplementation is reserved for patients with a history of lasting benefit from prior injections and in cases where the remaining options are limited. In this case, the patient has a history of benefitting from treatment with viscosupplementation with Euflexxa injections of both knees consistently for the last several years. The hyaluronan injections reportedly provided the patient was excellent pain relief and improved function, which lasted 5.5 months. Thus, the patient is a good candidate for additional viscosupplementation of both knees. Given these findings, the requested Euflexxa injection series (one time per week for three weeks) in both knees is medically necessary for treatment of this patient. 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

A 47-year-old female enrollee requested a scooter for medical treatment of her medical condition.  Findings:  The physician reviewer found that the patient was assessed by a physical therapist and it was noted that her home was not accessible to powered mobility.  There are no more recent therapy evaluations.  Later documentation noted that she could get up, dress and move around the house if pain was sufficiently controlled.  Although this patient has some mobility impairments, the records indicate that she is a household ambulator when pain is sufficiently controlled.  Additionally, the patient has chronic health conditions, such as arthropathy, that would benefit from increased physical activity and exercise.  All told, the requested scooter is not medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Overturned

A 47-year-old female enrollee has requested for intensive outpatient program services for treatment of her anorexia nervosa. Findings:  The physician reviewer found that based upon the nature of the patients symptoms over the years and the symptoms exhibited at the time of admission, it was likely that her gains were not internalized. If she were discharged from the intensive outpatient program prematurely, there was a strong possibility of serious clinical regression.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for ocrelizumab (Ocrevus) injection, inject 300 mg into the vein on day 1 and day 15, then inject 600 mg into the vein every six months. Findings:  The physician reviewer found that The records indicate that this patient presents with a history of relapsing remitting multiple sclerosis. The patients diagnosis is supported by imaging results suggestive of active lesions and clinical episodes requiring intravenous steroid infusion. Ocrevus is FDA approved for the indication of treating patients with relapsing remitting multiple sclerosis. In one clinical study, Ocrevus demonstrated superior efficacy on the three major markers of disease activity by reducing relapses per year, slowing the progression of disability, and significantly reducing MRI lesions when compared to Rebif over a two-year treatment period .Similarly, Lamb performed a review of the available medications for the treatment of patients with multiple sclerosis. The author found that Ocrevus is an effective and well tolerated medication for patients with relapsing multiple sclerosis. Moreover, this patients provider noted that although there are other medications available for the treatment of multiple sclerosis, the use of an infrequently dosed intravenous medication such as Ocrevus is likely to be more effective than alternatives and reduce the potential for medication error in a patient given the concerns for poor medication adherence. For these reasons, the requested ocrelizumab (Ocrevus) injection, inject 300 mg into the vein on day 1 and day 15, then inject 600 mg into the vein every six months is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Findings: Three of the three physician reviewers found the requested medication is 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 medication is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: Physician reviewer 1 is board certified in neurology and is actively practicing. Physician reviewer 2 is board certified in neurology with subspecialty certification in vascular neurology and is actively practicing. Physician reviewer 3 is board certified in neurology with subspecialty certification in vascular neurology 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 60-year-old female enrollee has requested anti-reflux surgery (LINX) for treatment of her gastroesophageal reflux disease (GERD), hiatal hernia, and Barretts intestinal metaplasis.  Findings:  Two physician reviewers found the patient has a history of GERD manifested by the presence of Barretts esophagus. Per the medical history provided for review, the patient has not had an adequate response to medical therapy. There is no mention whether the patient experiences significant regurgitation. The request for the LINX procedure in lieu of hiatal hernia repair with fundoplication is not supported in the peer-reviewed medical literature. The long-term efficacy and durability of fundoplication have been well established. Ganz and colleagues published a cohort series that suggests the data on the LINX procedure remains premature. The authors also reported a substantial rate of dysphagia as a recognized complication. All told, there is a paucity of medical research and well designed randomized controlled trials demonstrating the superiority of the LINX procedure over standard alternatives.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: At issue is whether the Game Ready Pro 2.1 System and accessories was and the Med4 Elite Unit and their and their accessories are medically necessary for the treatment of the patients medical condition. The patient has been diagnosed with cerebral palsy (CP) congenital right spastic hemiparesis.  An examination revealed muscle strength in distal muscles of the right upper and lower extremities. The patient reports that one foot drags on certain occassions.There is a lack of scientific evidence to support the use of requested cold/heat compression devices requested in the care of this patient. The American College of Sports Medicine (ACSM) exercise recommendations for patients with chronic diseases and disabilities such as cerebral palsy and the American Academy of Pediatrics Committee on Children with Disabilities (AAPCCD) published recommendations serve as guidelines for families. There is no one specific cooling system modality included in the current recommendations. 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 physical medicine and rehabilitation with sub-specialty certification in pediatric rehabilitation 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. Findings:  The physician reviewer found that
Appeal type: Medical Necessity
Decision: Overturned

A 64-year-old male enrollee has requested for physical pulmonary exercise stress test for evaluation of his dyspnea on exertion. Findings:  The physician reviewer found that this patient has undergone an extensive cardiac workup that has demonstrated that his symptoms are of non-cardiac origin.  The physical pulmonary exercise stress test testing can potentially provide some helpful information as to this patients exercise intolerance and unexplained dyspnea on exertion.  For patients with unexplained dyspnea and for whom initial test results are non-diagnostic, the weight of evidence suggests that the requested testing is a useful tool in identifying cardiac and pulmonary causes, mitochondrial myopathy, psychological factors, or deconditioning.  Results from the physical pulmonary exercise stress test may efficiently direct further diagnostic testing to target the suspected organ system involved.  All told, the requested physical pulmonary exercise stress test is medically indicated for the evaluation of this patient.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for two (2) additional hours of Direct Applied Behavioral Analysis (ABA) therapy services (15 hours total) per week.At issue is whether the requested additional two (2) hours of Direct Applied Behavioral Analysis (ABA) therapy services (15 hours total) per week are medically necessary for the patients condition.In this case, the goals being addressed by the provider fit well within the description of focused treatment found in CASP guidelines, and the intensity requested reflects the patient's response to treatment and his individual needs (as is well documented in the provider's treatment authorization request). With 15 goals being addressed, covering both skill acquisition and interfering behavior reduction, 15 hours of direct ABA per week is an appropriate level of intensity to meet the patient's medical needs. Providing fewer hours will likely result in the overall duration of treatment being extended. Accordingly, the requested additional two (2) hours of Direct Applied Behavioral Analysis (ABA) therapy services (15 hours total) per week are medically necessary for the patients condition.Final Result: The reviewer determined that the requested services are medically necessary for the patients condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is a licensed psychologist who is a board certified behavior analyst 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 authorization and coverage for Orthovisc injection series in the left knee. Findings:  The physician reviewer found that although viscosupplementation may relieve knee pain in some individuals with osteoarthritis, it is not known as to which individuals will benefit. The current evidence is limited, and guidelines from organizations such as the American Academy of Orthopedic Surgeons indicate that the evidence is not conclusive. In light of the foregoing, viscosupplementation can only be recommended in individuals with a history of lasting benefit from prior injections and in carefully selected cases where everything else has been tried, and the options are limited. In this case, the patient has a history of osteoarthritis of the left knee, refractory to conservative treatment, with the alternative being a total knee arthroplasty. The records showed excellent lasting relief from viscosupplementation injections in the past. Given the patients limited options and based on the current medical literature, the requested services are medically indicated. Therefore, an Orthovisc injection series in the left knee is medically necessary for the treatment of this patient.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 deep sedation services. The American Dental Association guidelines for the use of sedation and general anesthesia by dentists states that moderate sedation, deep sedation, or general anesthesia is appropriate for individuals with significant medical considerations, for example with American Society of Anesthesiologists (ASA) classifications of ASA III and IV. In this case, the patient requires surgical tooth extraction. The patient reported anxiety regarding dental procedures. While the records reflect that the patient has requested intravenous general anesthesia, there is no documentation of medical necessity for deep sedation, such as previous  attempts to complete the proposed dental procedures with mild or moderate sedation. The records do not document that the patient has an ASA III or IV classification, or evidence of a difficult airway score. Therefore, deep sedation services 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 anesthesiology with sub-specialty certification in pain 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: Upheld

A 36-year-old male enrollee requested authorization and coverage for intradiscal electrothermal therapy (IDET) for treatment of chronic intractable pain.  The health plan has denied this request indicating that IDET is considered experimental for treatment of the enrollees medical condition.Three physician reviewers performed an experimental/investigational Independent Medical Review.  All three-physician reviewers concluded that the requested procedure is not likely to be more beneficial for treatment of your medical condition than any available standard therapy.  Because all three-physician reviewers concluded that the requested procedure is not likely to be more beneficial for treatment of your medical condition than any available standard therapy, the Health Plans denial has been upheld.
Appeal type: Medical Necessity
Decision: Upheld

The patient is a 36-year-old female who underwent Lap-band surgery in June 2004, and reports that after months of attempts to control her subsequent nausea and vomiting she elected to have the band removed. She then underwent a gastric bypass operation in July 2005. She reports only a 10-pound weight loss following that procedure. The patient at this time is reported to be 56 weighing 241 pounds with a body mass index (BMI) of 39. Her comorbid conditions include gastroesophageal reflux disease (GERD), asthma, exertional dyspnea, depression and anxiety. The patients provider has proposed gastric bypass revision to reduce the size of the patients stomach pouch and outlet. Review of the clinical evidence indicates the patients two previous weight loss surgical procedures were unsuccessful. The patients first procedure, the Lap-band, has a significant published rate of solid intolerance, nausea and vomiting associated with the procedure. After the gastric band was removed the patient underwent gastric bypass, also without success. The scientific data shows duodenal switch has the best long-term success of all weight loss surgical procedures. There is one peer-reviewed, published article that reports the outcome of patients with multiple weight loss surgical procedures. This article not only demonstrates the superior long-term outcome of the duodenal switch as a revisional operation, but also shows that patients with multiple previous restrictive operations (Lap-band, gastric bypass, etc.) will fail any other revision unless they have an operation that limits absorption as well.  The patient reports GERD as a comorbid condition. If her gastrojejunostomy anastomosis is reduced from 2.5 cm to 1.5 cm as proposed by her surgeon, it is likely the patients reflux disease will significantly worsen. Thus, although the patient meets criteria for a revisional weight loss procedure, the proposed procedure is not likely to result in adequate weight loss and will probably worsen her reflux disease. Therefore, I have determined the requested procedure is not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for implantation of a hypoglossal nerve stimulator. Findings:  The physician reviewer found that review of the submitted documentation indicates the patient has an AHI of 51.8. Although the U.S. Food and Drug Administration (FDA) indicates hypoglossal nerve stimulator implantation may be appropriate for patients with moderate to severe OSA with an AHI of 20 or more, but less than or equal to 60, there remains insufficient scientific data from independent researchers demonstrating the requested service is superior to standard therapy. While some studies suggest that hypoglossal nerve stimulation in treatment of OSA can provide a beneficial outcome with minimal adverse events, most of these studies are funded by the manufacturer. At this time, there is inadequate data from independent, well-designed, blinded studies comparing this therapy to standard available treatment options. As such, there is a lack of data demonstrating that hypoglossal nerve stimulation is superior to standard available therapy for patients with OSA. Given these findings, the requested hypoglossal nerve stimulator is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Final Result: The  2 of 3 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: Physician reviewers 1, 2 & 3 are board certified in otolaryngology and are 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 is a 57-year-old male with a history of depression. His condition has been managed on Celexa 20mg and outpatient psychotherapy. In addition, the patient is being followed by a psychiatrist. The patient has requested authorization and coverage for additional outpatient psychotherapy. The Health Plan has denied the request on the basis that the clinical evidence does not demonstrate additional psychotherapy is medically necessary.The Health Plans denial should be upheld. Based upon the information provided, it appears the patient has been responding to pharmacotherapy as managed by his psychiatrist. There is no indication of the focus of psychotherapy (i.e., cognitive behavior therapy, psychodynamic, etc.). All indications from the patients provider indicate the patient has improved without exacerbation of his depression. No evidence of new target symptoms has been provided. Furthermore, there is no plan to manage any specific symptoms or attain any specific goals. Therefore, I have determined the requested therapy is not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.