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

Nature of Statutory Criteria/Case Summary: An enrollee has requested Harvoni for 12 weeks for treatment of her hepatitis C. Findings:  The physician reviewer found that according to the most recent joint guidelines issued by the American Association for the Study of Liver Diseases and the Infectious Diseases Society of America, all patients with chronic hepatitis C should be treated except those with limited life expectancy due to non-liver-related conditions.  This applies regardless of fibrosis stage or viral load.  Per the guidelines, treatment-naive genotype 1 patients should be treated with Harvoni for 12 weeks.  These guideline recommendations are based on multiple randomized clinical trials, and the medication is U.S. Food and Drug Administration (FDA) approved for all patients with chronic hepatitis C, genotype 1 regardless of fibrosis stage.  All told, Harvoni for 12 weeks is medically indicated for the treatment of this patient. Final Result: The reviewer determined that the requested medication is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in 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: Overturned

Nature of Statutory Criteria/Case Summary:   An enrollee has requested an orthotic shoe insert for treatment of the enrollees medical condition.  The physician review found that this patient has documented diagnoses of plantar fasciitis left side, pain in limb left side, and posterior tibial tendonitis left side.  Root type orthotics, which have been prescribed by this patients provider, have been used for many years for the treatment of lower extremity and foot pain.  The orthotics have been recommended to reduce abnormal biomechanics of this patients foot, alleviating pressure to the origin of the plantar fascia as well as the insertion of the posterior tibial tendon left side.  In this case, the orthotics are being used to correct abnormal biomechanics.  All told, the requested orthotic shoe insert is medically indicated for the treatment of this patient. Final Result: The reviewer determined that the requested equipment is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.  Credentials/Qualifications: The reviewer is board certified in podiatry and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

A 48-year-old male enrollee requested authorization and coverage of laparoscopic prostatectomy. The Health Plan denied the request indicating that the requested procedure is not medically necessary for the treatment of the enrollees prostate cancer.One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer upheld the Health Plans denial on the basis that the requested procedure is not medically necessary.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Cialis 5 mg. Findings:  The physician reviewer found that there is support in the medical literature for the requested medication in this clinical setting. The documentation provided indicates that this patient has tried multiple therapies for treatment of his BPH symptoms but his nocturia is still bothersome. The patient reported to his provider that he has worsening lower urinary tract symptoms for over five years. Cialis is considered an acceptable alternative for treatment of BPH symptoms.  As such, Cialis 5 mg is medically necessary for treatment of this patients medical condition. 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 urology 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 the carotid duplex scan. Findings:  The physician reviewer found that based on the records provided the patient presented with some coronary risk but no documented symptoms suggestive of any neurologic condition, no documented neurologic abnormalities on physical examination and no documented carotid bruits. In this circumstance of no symptoms or findings suggestive of carotid disease a screening carotid ultrasound is not medically necessary and not the standard of care. Current guidelines endorsed by U.S. Preventive Services Task Force also do not consider screening carotid ultrasounds appropriate in asymptomatic patients. For the reasons provided, the carotid duplex scan performed was not medically necessary for evaluation of the patients medical condition. Final Result: The reviewer determined that the service at issue was 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: Upheld

Nature of Statutory Criteria/ Case Summary:  The enrollee is requesting authorization and coverage for sclerotherapy/Varithena injection. The enrollee has a ten-year history of varicose veins and spider veins in both lower legs. A progress note reports the enrollees symptoms include aching, burning, restless legs, and swelling. The symptoms adversely affect the enrollees participation in activities of daily living. Over the last year, the enrollee has implemented conservative measures of compression stockings, leg elevation, exercise, and avoidance of long periods of standing, sitting or walking; however, these measures have not resulted in significant symptom improvement. The enrollee has not had any past vein treatment. The provider is recommending treatment with ultrasound-guided foam sclerotherapy. The enrollee is not considered a good candidate for sclerotherapy/Varithena injection. Evidence-based peer reviewed published literature is replete with studies consistently documenting that the majority of enrollees will achieve relief of their symptoms following ablation of the dominant refluxing vein in the leg. The procedures requested do not qualify as medically necessary as previous vein treatment has not bene attempted. Routine follow-up exams or ultrasound tests showing the presence of veins, with or without minor symptoms, do not constitute a standard of care indication for the requested service.Final Result: The reviewer determined that the requested service is not medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The physician reviewer is board certified in vascular 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 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: Three physician reviewers found that breast tomosynthesis is a technique that was developed several years ago as a problem solving adjunct to routine mammography.  Applying the same basic concept as computed tomography (CT) scanning, the logic is that by separating the various layers of breast tissue, one can better detect abnormalities.  It is specifically those patients who have dense breasts that can benefit most from tomosynthesis.   The ability to separate out the overlapping structures enables the possibility of demonstrating an otherwise occult tumor.  Thus, breast tomosynthesis was likely to have been of greater benefit than other methods of evaluating this patient.   Final Result: Three 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:  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: Medical Necessity
Decision: Upheld

A 59-year-old male enrollee has requested Xifaxan for treatment of idiopathic chronic constipation.  Findings:  The physician reviewer found that irritable bowel syndrome (IBS) is a frequent diagnosis in gastroenterology, but it is now clear that an altered dynamic equilibrium and bacterial overgrowth in the small intestine may mimic an IBS-like syndrome. Results of clinical trials demonstrate that the reduction or elimination of small intestinal bacterial overgrowth (SIBO) with antibiotics can alleviate IBS symptoms. In a recently published study, SIBO was observed in about 45% of the patients based on abnormal H-2 breath test. These patients were treated with rifaximin 1200 mg for 14 days with significant improvement in their symptoms of IBS, and H-2 breath test in majority of patients. The efficacy of rifaximin in the treatment of IBS was evaluated in a randomized, double-blind, placebo-controlled, parallel-group study of 87 patients who met Rome I criteria for IBS. These patients had not received oral antibiotics in the 3 months prior to the study and were not being treated with tegaserod or antidepressants. Patients received rifaximin (Xifaxan) at a dose of 400 mg three times daily (tid) or identical placebo tid for 10 days. Statistically significant improvement in IBS symptoms was observed with rifaximin over placebo during the 10-week follow-up period among 80 of the 87 patients who had at least one follow-up assessment (36% vs. 21%). In an editorial accompanying the study (Drossman, Annals of Internal Medicine), it was stated although rifaximin improved patients' self-reported global symptoms of IBS in this preliminary, single-centre study, these findings warrant additional multicentre trials with a larger patient population, longer study duration and less subjective outcome measures to confirm the long-term effects of rifaximin on individual symptoms of IBS. Although the above-mentioned results are promising, further data is needed before the safety and efficacy of Xifaxan for the treatment of chronic constipation is established.
Appeal type: Experimental/Investigational
Decision: Upheld

A 47-year-old male enrollee has requested for medication Fentora for treatment of his chronic pain syndrome. Findings:  Three physician reviewers found that Published studies on the use of rapid-onset opioids have focused on measuring analgesic effects in patients with cancer related pain. Additional research with regard to chronic, non-cancer pain is needed to measure both analgesic effect and  patient functioning. Other unanswered questions involve the potential for an increased risk for opioid misuse and abuse, the potential for rebound pain and the potential for poorer patient compliance when analgesics are dosed as needed versus around the clock. The record does not indicate that more standard alternatives such of MS IR and OxyFast have been tried.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Harvoni 90/400 for 12 weeks for treatment of the enrollees hepatitis C. Findings:  The physician reviewer found that according to the most recent joint guidelines issued by the American Association for the Study of Liver Diseases and the Infectious Diseases Society of America, all patients with chronic hepatitis C should be treated except those with limited life expectancy due to non-liver-related conditions.  The guidelines recommend that all patients should be treated, regardless of fibrosis stage.  The guidelines note that non-cirrhotic, treatment-naive, genotype 1 patients should be treated with Harvoni for 12 weeks.  These recommendations are based on multiple randomized clinical trials, and the medication is U.S. Food and Drug Administration (FDA) approved for all patients with chronic hepatitis C, genotype 1 regardless of fibrosis stage.  The current guidelines cite data showing reduced survival with delayed treatment.  For these reasons, Harvoni 90/400 for 12 weeks is medically indicated for the treatment of this patient.Final Result: The reviewer determined that the requested medication regimen 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 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: Experimental/Investigational
Decision: Upheld

A 39-year-old male enrollee has requested cauterization of the inner nose (CPT 30802) for the treatment of his sleep apnea. Findings:  Two physician reviewers found that this patient has obstructive sleep apnea (OSA) and complaints of chronic nasal obstruction. His provider describes him as having a septal deviation and inferior turbinate hyperplasia. The patient has had a trial of continuous positive airway pressure (CPAP) machine use but is intolerant of this treatment method. The patients provider recommended surgery with uvulopalatopharyngoplasty (CPT 42145), septoplasty (CPT 30520), tonsillectomy (CPT 42826) and inferior turbinate reduction (CPT 30802). The patients request for the inferior turbinate reduction, which is for cautery of the inferior turbinates, was denied by the Health Plan as experimental/investigational. The literature supports reduction in the size of hyperplastic turbinates as medically beneficial for patients with OSA in terms of improving sleep quality and in facilitating the use of CPAP. However, there is insufficient scientific literary support demonstrating that cautery of the inferior turbinates is superior to standard submucous resection. The patient is likely to derive the same benefit from standard resection as compared to the requested procedure.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Injectafer parenteral iron infusions (CPT code J1439). Some patients with reduced or absent iron stores who have not yet developed anemia may have symptoms such as fatigue or reduced exercise tolerance (Vaucher, et al.). Although this patients anemia has improved, her iron stores remain low. The recommended treatment regimen with IV Injectafer is likely to improve the patients symptoms, and failure to treat is likely eventually to result in recurrent health issues (Camaschella). Intravenous iron is medically necessary since the patient is unable to tolerate oral iron and needs to have her stores replenished. Therefore, Injectafer parenteral iron infusions (CPT code J1439) are 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 internal medicine with subspecialty certifications in medical oncology and hematology 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 65-year-old female enrollee requested authorization and coverage of a power-operated vehicle (POV). The Health Plan denied the request indicating that the requested equipment is not medically necessary for treatment of the enrollees foot ulcers.One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer upheld the Health Plans denial on the basis that the requested equipment is not medically necessary.
Appeal type: Medical Necessity
Decision: Upheld

A 26-year-old male enrollee has requested a cardiac MRI for evaluation of his chest discomfort.  Findings:  The physician reviewer found that this patient has nonspecific symptoms that have been extensively evaluated and have yielded normal cardiovascular physical examinations, normal electrocardiograms, normal cardiac biomarkers, and several normal cardiac tests including echocardiography, stress echocardiography and coronary CT angiography.  In this circumstance, a cardiac MRI is not considered standard accepted practice in the medical community.  There is no clinical evidence of pericarditis or pericardial constriction (normal electrocardiogram, normal cardiac biomarkers, low jugular venous pressure, no pericardial rub, and no pericardial effusion on most noninvasive tests performed).  Since the pericardium has already been extensively imaged, additional imaging with cardiac MRI would not be of incremental value.  Current expert consensus guidelines do not consider cardiac MRI appropriate in this setting.  All told, the requested cardiac MRI is not medically indicated for the evaluation of this patient.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patients parent has requested reimbursement for an additional 12.5 hours of neuropsychological testing (5 units CPT 96133 and 15 units of CPT 96139 for 27 total hours/41 units).Findings:  The physician reviewer found that Health Plan approved 14.5 out of the 27 hours of neuropsychological testing requested. Given that the diagnosis of attention deficit hyperactivity disorder (ADHD) is most often a clinical diagnosis and does not require neuropsychological testing to confirm, Wechsler Individual Achievement Test, 5th Edition (WIAT-5) and Conners Continuous Performance Test, 3rd Edition (CPT-3) testing were not medically necessary. The total testing time for medically necessary tests was six hours, including the following tests: Behavioral Assessment System for Children, 3rd Edition (BASC-3); Behavior Rating Inventory of Executive Function 2 (BRIEF-2); Wechsler Intelligence Scale for Children, 5th Edition (WISC-5); California Verbal Learning Test Childrens Version (CVLT-C); Delis-Kaplan Executive Function System (D-KEFS); Rey Complex Figure Test and Recognition Trial (RCFT); Beery-Buktenica Developmental Test of Visual-Motor Integration, 6th Edition (BEERY VMI-6); ChAMP; Multidimensional Anxiety Scale for Children, 2nd Edition (MASC-2); and NEPSY-II. Allotting an additional three hours to score these tests, one hour of neurobehavioral status examination, one hour of professional integration of patient data, four hours for report writing, and one hour of feedback brings the total time of medically indicated neuropsychological testing to 16 hours. Therefore, an additional 1.5 hours in addition to the originally approved 14.5 hours was medically indicated. In this patients case, an additional 1.5 hours was in accordance with the generally accepted standards of mental health and substance use disorder care. Additionally, the service at issue was clinically appropriate in terms of type, frequency, extent, site, and duration. The service at issue was not primarily for the economic benefit of the health care service plan and subscribers or for the convenience of the patient, treating physician, or other health care provider. Therefore, an additional 1.5 hours was medically necessary for the evaluation of this patient.Final Result: The reviewer determined that a portion of the services at issue were medically necessary for evaluation of the patients medical condition. Therefore, the Health Plans denial should be partially overturned.Credentials/Qualifications: The reviewer is board certified in psychiatry with sub-specialty certification in child and adolescent psychiatry and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

A 59-year-old female enrollee has requested authorization and coverage for laparoscopic adjustable gastric banding (Lap Band) for treatment of her morbid obesity.  Findings:  The physician reviewer found that since FDA approval of the Lap Band in 2001, the medical literature has consistently documented its efficacy. While it is true that the initial weight loss is more modest with the Lap Band than with the Roux-en-Y gastric bypass or the duodenal switch procedure, the morbidity is significantly less. Furthermore, there is increasing evidence that weight loss continues for as long three years with the Lap Band, resulting in weight loss levels similar to the more invasive procedures.