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

A 54-year-old male enrollee requested authorization and coverage of a stress echo cardiogram.  The enrollee has a family history of heart disease and on a routine chest x-ray it was noted that the proximal descending aorta is at the upper limits of normal size. 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 services are not medically necessary for treatment of the patients medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned

A 51-year-old female enrollee has requested angioplasty and/or stent replacement for the treatment of her increased intracranial pressure. Findings:  Three physician reviewers found that this patient has been treated conservatively with Diamox without improvement. There is no other treatment other than the requested procedures. She is having visual symptoms, and the requested procedures are medically appropriate and warranted for treatment of this patient.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the Zoll LifeVest. Findings:  Two of the three physician reviewers found that this patient experienced a ventricular fibrillation arrest that was secondary to an acute myocardial infarction due to complete occlusion of the mid left anterior descending coronary artery. In this circumstance, ventricular fibrillation within the first 24-hours of an acute myocardial infarction is not predictive of subsequent ventricular fibrillation, especially after the treatment rendered in this case and the normal ejection fraction recorded. There is potential for recovery of any regional left ventricular dysfunction after treatment, and there was no documented indication for immediate placement of a defibrillator, such as sustained or inducible post-myocardial infarction ventricular tachycardia. Placement of a prophylactic defibrillator is not recommended until a period of time, greater than 90 days, where continued left ventricular dysfunction is documented to persist despite appropriate treatment. A prophylactic defibrillator before this time has not been demonstrated to improve outcome. A prophylactic wearable external defibrillator would be indicated only if accepted criteria for an implantable defibrillator were met and an implantable defibrillator could not be placed, needed to be significantly delayed or required explantation. In sum, the Zoll LifeVest was not likely to have been superior over other available treatment options.Final Result: The reviewers determined that the device at issue was 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 internal medicine with sub-specialty certification in cardiovascular disease and are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

A 59-year-old female enrollee has requested authorization and coverage for surgical removal of excess skin for treatment of her excess abdominal, back and leg skin.  Findings:  The physician reviewer found that the patient is not sick from her excess skin, and has not had ulcerations, panniculitis or sepsis from her infections. She has not required hospitalization or treatment with IV or oral antifungal or antibiotic medications. Her excess skin has not jeopardized her health. She does have intermittent, bothersome infections that affect her quality of life, but it is not clear that they significantly compromise her health.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Forteo for two years continuous treatment. The records provided for review document that this patient has a history of severe osteoporosis on dual energy x-ray absorptiometry (DEXA) report with a T-score of -3.6 in the left femoral neck. The patients provider has recommended treatment with Forteo. Historically, bisphosphonates have been considered the first-line treatment option for the management of patients with osteoporosis. However, numerous new treatments have become available in recent years, including Forteo. Researchers conducted a meta-analysis to compare the efficacy of Forteo and bisphosphonates for reducing vertebral fracture risk and bone mineral density (BMD) in lumbar spine and femoral neck in postmenopausal women with osteoporosis. The authors found that Forteo has been shown that directly promote bone formation and thereby reduce the attendant risk of fractures. Moreover, the U.S. Food and Drug Administration (FDA) has approved Forteo for the treatment of osteoporosis in postmenopausal women at high risk for fracture. Given this patients extremely low BMD and history of fracture, she is a good candidate for therapy with Forteo. Given these findings, the requested Forteo for two years continuous treatment 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 diabetes, endocrinology, and metabolism and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld

A 64-year-old male enrollee has requested  percutaneous tibial nerve stimulation (PTNS) and future PTNS treatments for treatment of his overactive bladder. Findings:  Two physician reviewers found that in this patients case, the services at issue were not and are not likely to be more effective than other treatment modalities.  The submitted documentation does not support the services at issue in this clinical setting.  The records do not include details regarding prior medications.  Additionally, details regarding dietary restrictions or attempts at bladder retraining were not provided.  The current medical literature does not support the long-term utilization of this modality.  All told, the superior efficacy of PTNS treatment provided from the time frame specified and future PTNS treatments has not been established.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary:   An enrollee has requested a right brace for treatment of her anterior cruciate ligament (ACL) injury. Findings:  The physician reviewer found that the standard of care in the setting of therapy for anterior cruciate ligament (ACL) injuries is physiotherapy with a focus on recovery of strength, range of motion and agility. When relevant, this is often followed by gradual return to sports activities starting with basic agility and sports-specific drills, then part-time and full-time competition. If swelling develops or there is loss of range of motion, activities are reduced until the swelling subsides and range of motion restored. A neoprene sleeve can be used as an option for additional support. However, a functional ACL brace has not been proven in the medical literature to be an effective intervention for this condition. Authors performed a systematic review of the extant level one evidence (consisting of 12 randomized controlled trials) of bracing in the setting of postoperative recovery. The authors reported they found no evidence that pain, range of motion, graft stability, or protection from subsequent injury were affected by brace use, supporting their hypothesis that the use of postoperative ACL braces could not be rationalized by evidence of improved outcome including measurements of pain, range of motion, graft stability, or protection from injury. A large scale randomized, controlled clinical trial, concluded that, A functional knee brace does not result in superior outcomes compared with a neoprene sleeve after ACL reconstruction. Current evidence does not support the recommendation of using an ACL functional knee brace after ACL reconstruction. In addition, the literature concluded that the use of a postoperative knee brace does not affect the clinical outcome after ACL reconstruction. In sum, there is insufficient evidence in the medical literature that would support the medical necessity of the device at issue for this patient. Moreover, the documentation submitted for review fails to demonstrate the patient has knee instability. Based on the medical literature and clinical documentation provided, the right brace was not medically necessary for treatment of the 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 physical medicine and rehabilitation 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 parent of a female enrollee has requested authorization and coverage for Aptiom (eslicarbazepine acetate) 800 mg.  The patient has refractory localization-related epilepsy that has come under control with Aptiom 800mg and Keppra. Although other anticonvulsants are available on the Health Plan formulary, it is unknown whether any other monotherapy or combination antiepileptic drug regimen would control the patient's seizures. In 30-year review of 1795 patients with newly diagnosed epilepsy, colleagues stated that Most patients who attain control do so with the first or second antiepileptic drug. The probability of achieving seizure freedom diminishes substantially with each subsequent antiepileptic drug regimen tried. More than one-third of patients experience epilepsy that remains uncontrolled. Colleagues noted that epilepsy associated with tumors is generally poorly controlled by antiepileptic drugs. Colleagues explained that Aptiom (eslicarbazepine acetate) is effective in the treatment of refractory partial seizures in children, and that it is well tolerated from a neurocognitive and behavioral standpoint. Therefore, Aptiom 800 mg is medically necessary 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 pediatrics and neurology, with special qualification in pediatric neurology, 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: Urgent Care
Decision: Overturned

Nature of Statutory Criteria/Case Summary: A female enrollee has requested reimbursement for emergency services. After careful review of the enclosed information and the health plan definition for emergent care, this patient did receive emergency care. It is well documented that this patients provider was unable to perform a matrixectomy for this patients paronychia. The patient was placed on oral antibiotics and advised to see a podiatrist for care. The next available appointment was nine days later. Given the patients infection, pain, and history of diabetes, immediate treatment was appropriate to avoid potential complications. It is also noted that the patients blood glucose was elevated, likely due to infection. For these reasons, the partial matrixectomy performed on this patients right hallux was performed emergently and was a necessary procedure. Final Result: The reviewer determined that the services at issue were necessary for treatment of an emergency 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: Overturned

A 57-year-old female enrollee has requested adult acute psychiatric inpatient services for treatment of her major depression. Findings:  The physician reviewer found that on admission, the patient was noted to be severely depressed, with impaired concentration and memory, and derailed thoughts. She was described as fearful with feelings of hopelessness and worthlessness and commented that sometimes she felt that her family would be better off without her. Given the documented history of severe depression with significant decrease in level of functioning and lack of improvement with attempts at outpatient treatment, psychiatric hospitalization during the time period in question was medically necessary for this patient. In addition, the patients treatment was consistent with the guidelines provided by the American Psychiatric Association (APA) and the level of care utilization system (LOCUS) for psychiatric and addiction services. The patient was able to benefit and respond to the intense treatment provided, and progress was evident at the time of discharge.
Appeal type: Medical Necessity
Decision: Upheld

A 35-year-old female filed a formal complaint regarding the length of time she must wait for a consultation for gastric bypass surgery.  The enrollee has to wait between six and 12 months before her consultation and wants one sooner.  The health plan denied the enrollees request indicating a consultation for the bypass surgery has been approved; however, the enrollee has been advised that it will be six to 12 months before she can see the physician.The physician reviewer has decided that it is not medically necessary for the enrollee to have her consultation for gastric bypass surgery earlier than the expected six- to 12-month wait.
Appeal type: Experimental/Investigational
Decision: Overturned

A 45-year-old male has requested immunotherapy injections for treatment of allergic rhinitis.  Findings:  Three physician reviewers found that the patient presents with perennial rhinitis and food allergies.  Per the submitted documentation, the patient has previously experienced good control with immunotherapy injections.  His symptoms include sneezing, itchy eyes, and a runny nose.  The patient reported that he has tried a nasal spray and oral antihistamines without achieving symptom control.  Skin testing to aeroallergens was significantly positive to dust mite and Johnson grass.  There were moderate reactions to olive tree pollen, Alder pollen, and maple pollen.  In this patients case, the requested immunotherapy is likely to be more efficacious than other treatment modalities.  This patient has not achieved symptom control with standard therapy. He has tried and failed treatment with nasal antihistamines and oral antihistamines.  The documentation indicates that the patient has experienced good control with immunotherapy injections.  There is adequate medical evidence supporting the requested immunotherapy in this clinical setting.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/ Case Summary:  The enrollees parent requested authorization and coverage for whole exome sequencing genetic test. The enrollee has developmental delays and central nervous system anomalies.  Her medical history is significant for hemiparesis, sensorineural hearing loss (SNHL) of the right ear with unrestricted hearing of the left ear, abnormal eye movements, cerebral ventriculomegaly, Dandy-Walker syndrome variant and pineal tumor.  Due to the heterogeneous nature of rare genetic diseases, her physician recommended whole exome sequencing genetic testing indicating results from this genetic test will have a direct impact on treatment and management and will provide prognostic information that will assist in clinical management. Peer-reviewed literature describes the clinical utility of whole exome sequencing (WES) studies; providing meaningful data to use in care planning, diagnosis, and clarification of reproductive risks for the extended family in a timely manner. This diagnostic performed better in this regard than standard methodologies. The procedure can yield new and relevant diagnoses; changing the management of affected children. Traditional methods of evaluating children with neurodevelopmental disorders (NDDs) yield molecular diagnoses in less than fifty percent. In a study, children with NDD who received whole-genome sequencing (WGS) and whole-exome sequencing (WES) resulted in a change in clinical care or impression of the pathophysiology in 49% of newly diagnosed families. The use of exome sequencing can impact the medical care of critically ill infants with genetic disorders. The enrollee is a good candidate for this test because she has developmental delay and brain congenital malformations. This test is recommended for children with developmental delay and/or congenital malformations.  This diagnostic is helpful for patients who have tested negative for genetic disorders, but for whom a high suspicion of genetic disease remains.  This testing is an important patient management tool, as it allows for  identifying causative mutations associated with actionable co-morbidities or by identifying appropriate clinical trials. WES is an accepted standard of care for the member.Final Result: Three of the three reviewers determined that the requested services are likely to be more beneficial than any available standard therapy for treatment of the enrollees medical condition. Credentials/Qualifications: Two reviewers are board certified in clinical genetics and one review board certified in pediatric neurology 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

Nature of Statutory Criteria/Case Summary:  An enrollee has requested triamterene hydrochlorothiazide (HCTZ) 37.5 mg, three times a day, for treatment of her medical condition. The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested medication quantity.  Menieres disease is considered a chronic condition.  Treatment may successfully relieve symptoms, but does not address the underlying abnormal pathophysiology.  The goals of treatment are to reduce the frequency and severity of vertigo attacks, reduce or eliminate hearing loss and tinnitus associated with attacks, alleviate chronic symptoms, and prevent disease progression, particularly hearing loss and imbalance.  Treatment consists of lifestyle modifications, medications, rehabilitation and surgical intervention.  Medications include diuretic medications.  Triamterene is used for the treatment of hypertension or edema when hypokalemia has developed on hydrochlorothiazide alone or when the development of hypokalemia must be avoided.  The U.S. Food and Drug Administration (FDA) approved dose is triamterene 37.5 mg, one to two doses daily.  In this case, the documentation does not support that the patient requires doses of triamterene in excess to the FDA recommendation.  All told, triamterene HCTZ 37.5 mg, three times a day is not medically indicated for the treatment of this patient.  Final Result: The reviewer determined that the requested medication quantity is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.  Credentials/Qualifications: The reviewer is board certified in internal medicine 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 fifty-four year-old male with a medical history of migraine headaches, chronic low back pain, anxiety and insomnia is requesting authorization and coverage for Norvasc.Reviewers Findings:  The reviewing physician found that there is sufficient evidence to conclude that Norvasc 15 mg per day is necessary for treatment of this patient.  The reviewing physician found that the Health Plan denial should be overturned.
Appeal type: Urgent Care
Decision: Upheld

A 44-year-old female enrollee has requested emergency medical transportation for the treatment of her condition. Findings:  The physician reviewer found that this patients symptoms had been present for one week. There is no documentation to support that the patient was suffering any acute difficulty breathing. She was not oxygen dependent and did not require oxygen or any other medical intervention during transport. This patient could safely have been transported to the hospital by transportation other than ambulance. She did not require services that only a fully equipped ambulance could provide.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary:The patient has requested authorization and coverage for Vemlidy 25 mg po daily (30 tabs with 11 refills for treatment of the enrollees chronic hepatitis B virus. Findings:  The physician reviewer found that Guidelines for the treatment of hepatitis B from the American Association for the Study of Liver Disease (AASLD) recommend Baraclude and tenofovir compared with alternatives for the treatment of chronic hepatitis B. In comparison with Viread, which the patient is taking, the Vemlidy formulation of tenofovir is effective for hepatitis B, but is associated with lower incidence of side effects such as osteopenia and renal disease. For this reason, the request for Vemlidy 25 mg po daily (30 tabs with 11 refills) is medically necessary for the treatment of this patients chronic hepatitis B. 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.