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

A 59-year-old female enrollee has requested transcranial magnetic stimulation therapy for treatment of her major depression. Findings:  Two physician reviewers found that this patient has been treated with several different antidepressants and they were not satisfactory to her.  Additionally, she has already been treated with ECT, with a poor response as well as significant side effects.  In this clinical scenario, the requested transcranial magnetic stimulation therapy is likely to be more efficacious than other available treatment alternatives.  The medical literature supports the use of transcranial magnetic stimulation in this clinical situation.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: A transgender female enrollee has requested authorization and coverage for consultation regarding voice modification surgery and speech therapy. The Health Plan has denied this request indicating that the requested services are not medically necessary for treatment of the enrollees medical condition. Findings: There is support in the medical literature for the medical necessity of the requested services in this clinical setting. This patient is requesting consultation regarding voice modification surgery and speech therapy. Voice and communication treatment by nonsurgical and surgical methods results in gains important to listeners perception of gender. People transitioning from male to female gender seek speech language pathology services when they feel their voice is betraying their genuine self or perhaps is the last obstacle to representing their authentic gender. Speaking fundamental frequency (pitch) and resonance are most often targets in treatment because the combination of these two voice characteristics can account for the majority of how listeners perceive a speakers gender. However, current studies indicate that pitch is not the sole contributor to perceptions of gender. Intonation, voice quality, pragmatics and nonverbal communication contribute to a lesser extent but are usually recommended in treatment guidelines. Modification of vocal resonance has been shown to increase perceptions of a speaker as female. There is evidence that encouraging precise articulation results in increased perceptions of the speaker as female. Voice and communication treatment results in gains in areas important to listeners perception of gender. A review of the literature suggests that speech and language therapy are successful at creating an acceptable fundamental frequency in transgender patients, as well as influencing other communication behaviors. Additionally, outcome measures have indicated that speech therapy is effective in increasing vocal pitch and perceptual femininity without compromising vocal quality. As such, in this patients case, consultation with a speech therapist can be an effective method for treating her symptoms related to gender dysphoria. In sum, the requested consultation regarding voice modification surgery and speech therapy have been established as medically necessary for treatment of this 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 otolaryngology 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 43-year-old female enrollee has requested revisional lap band surgery for the treatment of her morbid obesity. Findings:  Three physician reviewers found that the submitted medical documentation does not provide a detailed assessment of the issues related to failure of the patients RYGB procedure. It is not documented whether the failure was due to noncompliance or mechanical issues such as gastrogastric fistula.  It appears the next appropriate step for this patient would be to obtain an upper gastrointestinal (UGI) series to assess anatomy. In the absence of evidence of an anatomical problem or surgical complication, the failure of the initial bariatric procedure is presumed to be due to dietary incompliance, and as such, revisional lap band surgery is not likely to be any more effective than the patients initial procedure.
Appeal type: Medical Necessity
Decision: Overturned

The patient has requested reimbursement for the fertility preservation services. The records provided for review document a diagnosis of stage 3 left breast cancer. The patient is planned to undergo treatment with chemotherapy. Treatment with chemotherapy has been found to significantly impair future fertility. With current technology, embryo and oocyte cryopreservation is the standard of care in this clinical setting. The American Society of Clinical Oncology (ASCO) and the American Society for Reproductive Medicine (ASRM) support fertility-sparing treatment. All told, the fertility preservation services were medically necessary for treatment of this patient. Final Result: The reviewer determined that the services at issue were 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 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: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for durable medical equipment (DME) Elite Seat knee extension device. Findings:  The physician reviewer found that This patients records document a history of chronic flexion contracture due to longstanding osteoarthritis. The patients provider has recommended use of an Elite Seat knee extension device. Knee stretching devices, particularly the static progressive types, can be useful as an adjunct to physical therapy following an injury or surgery. Given that this patients condition is chronic in nature, with no reported recent injury or surgery, use of a knee extension device is not likely to provide significant improvement. In addition, the Elite Seat is a serial stretching device which has shown to be inferior to static progressive devices in randomized controlled clinical trials and case studies. For these reasons, the requested DME Elite Seat knee extension device 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 DME Elite Seat knee extension device 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, 2, and 3 are board certified in orthopedic 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: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for acupuncture services for treatment of the enrollees temporomandibular joint (TMJ) dysfunction. Findings: The physician reviewer found that a review of the submitted documentation and relevant literature demonstrates the medical necessity of the requested services. There is peer-reviewed literature supporting the utility of acupuncture for the treatment of the patients medical condition. A study evaluated short-term pain reduction from acupuncture in chronic myofascial pain. The researchers concluded that Pain tolerance in the masticatory muscles increased significantly more with acupuncture than sham acupuncture. In addition, another study evaluated the effectiveness of acupuncture in treating symptoms associated with myofascial pain of the jaw muscles. The researchers found that a single acupuncture session significantly reduced most myofascial pain endpoints when compared to sham acupuncture. In this case, the patient has difficulty opening her mouth with jaw locking and limited jaw opening. She underwent treatment with muscle relaxers, steroids and physical therapy with limited improvement. Based on the support in the peer-reviewed literature and limited improvement with prior conservative treatment, acupuncture services are supported as 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 physician reviewer is board certified in oriental 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

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Xifaxan 550 mg tablet (three tablets a day for 14 days). The records provided for review document that this patient has a history of inflammatory bowel syndrome, diarrhea predominant (IBS-D). The patients provider has recommended treatment with Xifaxan. The U.S. Food and Drug Administration (FDA) has approved Xifaxan for the treatment of patients with IBS-D. In addition, Xifaxan has been demonstrated to be safe and effective in randomized placebo controlled clinical trials on the treatment of patients with IBS-D (Schoenfeld, et al.). In addition, the American College of Gastroenterology (ACG) guidelines for the treatment of IBS state that Xifaxan has been shown to be safe and effective for use in this patients clinical setting (Ford, et al.; Cangemi, et al.). The clinical trials and the FDA approval for Xifaxan in the treatment of IBS-D support the use of Xifaxan 550 mg three times daily for 14 days. For these reasons, the requested Xifaxan 550 mg tablet (three tablets a day for 14 days) 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 internal medicine with subspecialty 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

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for hyperbaric treatment. Indications for hyperbaric oxygen as an adjunct treatment include necrotizing infections, chronic refractory osteomyelitis, failed flaps, and acute peripheral ischemia. There is insufficient evidence for the use of hyperbaric oxygen to treat a non-healing wound, without additional supporting indications. In this patients case, the records and results of cultures do not support indications for the use of hyperbaric oxygen as a treatment. There is no documentation of a failed flap, necrotizing infection, or osteomyelitis. Rather, the use of negative pressure therapy and local wound care, or a plastic surgeon consultation may be appropriate. Therefore, hyperbaric treatment is not medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested treatment 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 family medicine with sub-specialty certification in undersea and hyperbaric 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 male enrollee has requested Cialis, 2.5 mg once per day for treatment of his Peyronies disease.  Findings:  The physician reviewer found that cialis is a class of drug known as 5-phosphodiesterase inhibitor, which improves blood flow to the penis through vasodilation. This patient presents with Peyronies disease, which is plaquing in tunica fascia that surround the corporeal bodies of the penis. There is a paucity of literature supporting the necessity of a vasodilator in improving the scarring in the tunica surrounding the corporeal bodies. In addition, Cialis is not recognized as a treatment for Peyronies disease. The Health Plan has recommended Levitra as an alternative for Cialis, which is appropriate if the patient needs to help establish better erections. However, since Peyronies disease alone may not result in poor erections, the use of Cialis in this instance has not been established as medically necessary for treatment of this patients condition.
Appeal type: Medical Necessity
Decision: Upheld

A 47-year-old female enrollee has requested physical therapy for the treatment of her back pain. Findings:  The physician reviewer found that the medical records show that this patient has received extensive PT.  For the dates under consideration, the PT seems to be maintenance in nature.  The records do not provide clear-cut documentation of progress.  Also, at this time the patient is likely able to be independent with a home exercise program and could continue without professional supervision.
Appeal type: Medical Necessity
Decision: Upheld

A 47-year-old female enrollee has requested Provigil 200mg for the treatment of her depression. Findings:  The physician reviewer found that Provigil may have some place as an adjunctive agent in the treatment of certain patients with depression. However, in this clinical situation, it was not clearly established that the patients depression was resistant, or that there was a specific need for added treatment with Provigil. The trial of Effexor involved a significantly large dose, but only for about two weeks - an inadequate amount of time. Pristiq was begun, but its effects are not documented in the records provided. Thus, the only antidepressant whose use is clearly documented is Cymbalta. It is on this basis that it would not be appropriate to conclude that the use of an off-label drug such as Provigil is appropriate and medically necessary. Accordingly, I concur with the Health Plan. The clinical need for treatment with Provigil has not been established.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Gelsyn-3 injection series for the left knee. Per the medical literature, 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 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. Given the patients limited options and based on the current medical literature, the requested services are medically indicated. Therefore, Gelsyn-3 injection series for 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: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for interspinous fixation (fusion) device, procedure codes 22869 and 22870. Findings:  Two of the three physician reviewers found that this patient presents with a history of low back pain with neurogenic claudication. Clinical examination findings have been consistent with imaging evidence of disc bulge, facet arthropathy, and ligamentum flavum thickening resulting in severe spinal stenosis with complete effacement of the cerebrospinal fluid and severe bilateral neural foraminal stenosis with mass effect on the exiting right L4 nerve root. There is evidence of 5-6 mm anterolisthesis of L4 on L5 with no instability reported on flexion/extension films. She has failed to improve despite at least six months of nonoperative treatment, including activity modification, medications, physical therapy, acupuncture, chiropractic care, and epidural steroid injection. The U.S. Food and Drug Administration (FDA) indications for the VertiFlex Superion Interspinous Spacer include moderate degenerative lumbar spinal stenosis. In this case, the patient has severe spinal and foraminal stenosis at the L4-5 level. Additionally, current evidence-based guidelines and peer-reviewed literature do not support the spinal decompression device procedure over the gold standard of lumbar laminectomy. There is no compelling rationale to support the spinal decompression device procedure over standard decompression with or without fusion in the setting of severe lumbar spinal stenosis. There is a lack of large volume, long-term peer-reviewed outcome studies to support the use of this device in this setting. In sum, interspinous fixation (fusion) device, procedure codes 22869 and 22870, is not likely to be superior over other available treatment options. 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, 2 and 3 are board certified in orthopedic 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: Medical Necessity
Decision: Overturned

A 58-year-old female enrollee requested authorization and coverage of intensity modulated radiation therapy (IMRT) for treatment post salivary gland adenocarcinoma.  The health plan denied the enrollees request indicating that the requested treatment is not medically necessary.Three physician reviewers performed a medical necessity Independent Medical Review.  Two of the three physician reviewers overturned the health plans denial on the basis that the requested IMRT is medically necessary.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: A 62-year-old female enrollee has requested authorization and coverage for Euflexxa shots series of three for the left knee every six months. In the current peer-reviewed medical literature, the authors conducted a systematic review on the efficacy and safety of repeat courses of hyaluronan therapy in patients with osteoarthritis of the knee. The authors concluded that repeat courses of the hyaluronans were safe and effective in the treatment of pain associated with osteoarthritis of the knee. Further, the researchers found that repeated cycles of intra-articular sodium hyaluronate in patients with knee osteoarthritis was found efficacious during a 54-month follow-up period. In addition, the American Medical Society for Sports Medicine (AMSSM) recommends hyaluronan acid for appropriate knee osteoarthritis patients, based on a large network meta-analysis. This patient presents recurrent left knee pain and stiffness. She had reportedly failed to improve with NSAIDs and analgesics. Prior viscosupplementation has been performed with good benefit and 50% pain reduction for at least six months. Evidence based medical peer-reviewed literature supports the use of viscosupplementation injections for the treatment of pain in patients with osteoarthritis of the knee. Given this patients previous response, repeat viscosupplementation injections are indicated. However, there is a paucity of data supporting a clinical indication for a series of Euflexxa injections to be repeated every six months. Therefore, current Euflexxa injections, one series of three injections, to the left knee is likely to be more beneficial for treatment of the patients medical condition than any available standard treatment. One reviewer found that Euflexxa shots series of three for the left knee every six months are not likely to be more beneficial for treatment of the patients medical condition than any available standard treatment. Final Result: Two of the three reviewers determined that a portion of the requested services 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 partially overturned.Credentials/Qualifications:  One reviewer is board certified in orthopedic surgery and is actively practicing. One Reviewer is board certified in orthopedic surgery and is actively practicing.  One Reviewer is board certified in orthopedic surgery and is 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.