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

A 48-year-old male enrollee has requested an H-wave system/treatment (rental) for the treatment of his neck/cervical injury. Findings:  Two physician reviewers found that H-wave (electrical stimulation therapy) does not currently have high-grade medical literature support. The scientific literature demonstrates only weak preliminary evidence of support (e.g., anecdotal reports, case series, and survey studies) for the H-wave machine.  A 2006 study by Blum and colleagues (submitted with this appeal) was a cross-sectional survey of 6774 subjects with chronic soft tissue injury or neuropathic pain using a Customer Service Questionnaire that evaluated user responses (subjective) to the H-wave device. A majority of users reported favorable results using the H-wave device in pain and function on the survey. A 2008 industry-sponsored meta-analysis (Blum and colleagues 2008) identified five studies in the literature. Given the large size of the 2006 survey in comparison to the other studies, the results were basically a re-iteration of the 2006 survey results. Multiple, significant limitations of the research were identified by the authors, including the very heterogeneous nature of the included studies, the subjectivity of the majority of the data, a lack of data collection with regards to adverse effects, and a lack of formal examination findings, test results or laboratory results. Overall, there is insufficient data from disinterested, evidenced-based, peer-reviewed studies published in the medical literature to establish the efficacy of this modality for the patients conditions. There is no literature support of any efficacy over self-directed exercise and basic palliative modalities such as self-applied thermal modalities (i.e., heat or ice).
Appeal type: Medical Necessity
Decision: Overturned

A 20-year-old female enrollee has requested for residential treatment level of care services for treatment of her eating disorder. Findings:  The physician reviewer found that the American Psychiatric Association (APA) treatment guidelines state that patients who are discharged to partial hospitalization programs before they are clinically ready have a high rate of early relapse. Additionally, such patients experience greater struggles with recovery and slower rates of progress. The APA guidelines indicate that residential treatment is appropriate for patients who struggle with intrusive repetitive thoughts 4-6 hours per day, for patients who are cooperative but who need supervision with meals, and for patients who can ask for and utilize support. This patient meets these criteria. Furthermore, an article by Swinburn suggests that social isolation, dysfunctional family interactions, and insufficient response to outpatient treatment are also indications for 24-hour level of care. Overall, the medical literature indicates that residential level of care is appropriate for patients with limited support systems.
Appeal type: Experimental/Investigational
Decision: Upheld

A 54-year-old female enrollee has requested Leukine therapy for the treatment of her melanoma. Findings:  Three physician reviewers found that the patient is a 54-year-old female who has now been diagnosed with Stage III melanoma. Her nodal disease has been resected, and adjuvant Leukine therapy (GM-CSF) has been recommended. There is very little data to support the use of GM-CSF in the adjuvant treatment of melanoma. A single arm study suggested improved outcomes compared to historical experience. No randomized comparative data is available to support this recommendation.
Appeal type: Medical Necessity
Decision: Upheld

The patient is a 40-year-old female who has abdominal wall laxity that is an expected outcome of pregnancy and is a natural occurrence. She has requested authorization from her Health Plan for an abdominoplasty. The Health Plan has denied her request on the basis that the requested procedure is not medically necessary for treatment of the patients condition.The proposed abdominoplasty is not medically necessary.  The patient states that she has back pain due to her diastasis and abdominal wall laxity. The records, however, do not contain any PCP documentation of a workup or conservative treatment (e.g., physical therapy) for her back pain. Her back pain may be due to a lack of core muscle strength that could be improved with physical therapy or medically supervised strengthening. The medical literature does not include any studies that show that excess abdominal skin causes or exacerbates back pain. In any event, the proposed procedure is not a conventional option for the treatment of back pain. Abdominal wall reconstruction using the techniques described by Toranto or Ramirez (cited above) should certainly be considered as a last resort type of procedure for patients that have undergone a thorough evaluation to rule out other causes for back pain and have failed a regimen of more standard conservative treatments for their symptoms. This does not appear to be the case for this particular patient.This patient has diastasis recti.  According to Sabistons Textbook of Surgery, the most common variant of normal anatomy seen in the abdominal wall is diastasis recti.  This consists of an upper midline protrusion of the abdominal wall between the right and the left rectus abdominis muscles. This abnormality represents a weakness of the linea alba and does not require treatment unless an epigastric hernia occurs in association with the diastasis.  The records do not document that the patient had a true ventral or epigastric hernia and therefore, diastasis recti repair is not medically necessary.The proposed procedure is a standard cosmetic abdominoplasty to improve abdominal contour and remove excess skin. The requested procedure is cosmetic in nature and is not medically warranted.For the reasons stated above, 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: Overturned

A 44-year-old female enrollee has requested reimbursement for genetic testing  for evaluation of the enrollees ductal carcinoma in situ presenting as calcifications.  Findings:  Three physician reviewers found that the patient has a family history of endometrial cancer and a personal history of ductal carcinoma in situ (DCIS). The patient is status post bilateral mastectomy, with testing negative for BRCA mutation. Hereditary non-polyposis colorectal carcinoma (HPNCC) testing revealed a deleterious mutation in MSH6. The patient also has a history of hyperplasia on biopsy. The patients family history of cancer includes a mother who had endometrial cancer and maternal aunt and maternal grandmother who had colon cancer. The patient has requested reimbursement for the genetic testing. The patients Health Plan has denied reimbursement as they consider the diagnostic testing at issue to be experimental and investigational. This patient presents with a personal history of DCIS and a significant family history of endometrial and colon cancer. Although this patient may not meet the established criteria for testing, the patients mother, who most likely had this mutation, cannot be tested as she is deceased. Given the patients personal history and collective family history, the diagnostic testing at issue was likely to provide novel and helpful information relevant to monitoring and possible treatment of this patient. For these reasons, the diagnostic testing at issue was likely to be more beneficial than standard testing, and should therefore be approved.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient is a 55-year-old female with past medical history of hypertension and insomnia. She has taken zolpidem and requested a refill of zolpidem. The medical record does not document any non-pharmacologic management of insomnia and documents use of caffeine in the form of coffee. The provider documented a review of controlled substance utilization, review and evaluation system (CURES), which showed that the patient had obtained a zolpidem prescription from another provider. The provider documented that ongoing use of zolpidem was not recommended and that a non-controlled medication such as trazodone should be considered. At issue is whether zolpidem is medically necessary for treatment of this patient.Appropriate management of chronic insomnia includes therapy for any conditions that affect sleep quality or duration and behavioral recommendations for sleep hygiene and stimulus control. Behavioral therapies, including cognitive behavioral therapy, is recommended as first-line therapy. Pharmacologic therapy may be indicated when insomnia persists despite sleep hygiene, including avoidance of caffeine, and adequate behavioral therapy. Long-term treatment with medication alone is not the optimal treatment strategy for patients with insomnia. In this case, the patient has a diagnosis of insomnia that has been treated with long-term use of zolpidem. The provider recommended changing zolpidem to a non-controlled medication such as trazodone. The records do not suggest adherence to a sleep hygiene plan given the continued use of caffeine, and there is no documentation of trial of behavioral therapy. Therefore, the requested zolpidem is not medically necessary for treatment of the patients medical condition.Final Result: The reviewer determined that the requested medication 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 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 male enrollee requested the LINX surgery with an esophageal sphincter augmentation device (CPT 43289 and 43280) for medical treatment of his gastroesophageal reflux disease (GERD).   Findings:  Two physician reviewers found that overall, the currently available peer-reviewed literature and the FDA requirement for additional data do not indicate that LINX is more likely to be beneficial in this case than standard treatment such as surgical fundoplication (Sheu, et al). Accordingly, the requested LINX surgery with an esophageal sphincter augmentation device (CPT 43289 and 43280) is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.
Appeal type: Medical Necessity
Decision: Overturned

The patient is a 38-year-old female with Crohns disease. She also has a history of multiple failed resections of the small bowel. She had a stricture on the distal small intestine and some adhesions to the small intestine. She underwent a small bowel series, which confirmed that she has 65% of her small intestine remaining. The patients physician has recommended the patient undergo a stricturoplasty to preserve her remaining small intestine. The patient has requested a colorectal specialist perform the stricturoplasty. The Health Plan has denied the patient request on the basis that the requested referral is not medically necessary. Surgery in this patient with Crohns disease should be performed by a board certified colon and rectal surgeon. Given the complexity of the patients case, it is medically reasonable and appropriate that a surgeon with a certain level of specialization perform the procedure. It is medically appropriate and reasonable for the patient to be evaluated by a colon and rectal surgeon. Therefore, I have determined that the requested referral is medically necessary for the treatment of the patients medical condition. The Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a 14-month-old male enrollee has physical therapy for treatment of the enrollees motor hypotonia. Findings:  The physician reviewer found that cerebral palsy is due to an insult to the brain that controls motor function and to the cerebellum that controls motor tone. The physical pathology is apparent and the anatomical dysfunction is the failure of normal muscle control and movement. Generally accepted standards of care support the use of PT for patients with cerebral palsy. Therefore, it is medically necessary for the patient to receive individual PT for a period of time.  If reassessment at the end of the approved period shows improvement, then PT should continue at the same frequency until the patients motor function is at an age equivalency.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Vosevi tablets 400/100/100 mg, for an additional 12 weeks. According to the most recent joint guidelines issued by the American Association for the Study of Liver Diseases (AASLD) and the Infectious Diseases Society of America (IDSA), all patients with chronic hepatitis C, regardless of fibrosis, should be treated except those with limited life expectancy due to non-liver-related comorbid conditions. This applies to all patients, regardless of fibrosis. The guidelines recommend that patients with Childs B cirrhosis who are ribavirin-ineligible, as this patient is due to anemia, and genotype 3 hepatitis C should be treated with sofosbuvir/velpatasvir tablets for 24 weeks. However, for genotype 3 patients who have failed NS5A therapy, as in this patients case, the guidelines recommend the addition of Vosevi to overcome resistance, based on the POLARIS trial. Guidelines from the European Association for the Study of the Liver state that in difficult-to-cure patients with NS5A resistance, Vosevi can be used for 24 weeks for retreatment. For these reasons, the requested treatment with Vosevi for an additional 12 weeks (to complete 24 weeks of treatment in total) is appropriate for treatment of this patients hepatitis C infection. Thus, the requested Vosevi tablets 400/100/100 mg, for an additional 12 weeks is medically necessary for treatment of this patients medical condition. 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: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary:  An enrollee has requested monitored anesthesia care (MAC) during a colonoscopy for treatment of the enrollees medical condition.  Findings:  The physician reviewer found that review of the submitted documentation fails to establish the medical necessity of the services at issue. Colonoscopy may be safely and effectively performed with conscious sedation of a benzodiazepine alone or with a narcotic in an office-based setting and without the need of monitored anesthesia care with propofol. The standard of care for monitored anesthesia care for a minimally invasive procedure is airway difficulty, large fluid shifts and co-morbid conditions that would put the patient at risk during the procedure. There is no documentation of co-morbid conditions that would place the patient at risk for complications requiring the need for monitored anesthesia care. Given the above, the services at issue were 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 anesthesiology with sub-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: Overturned

A 53-year-old female enrollee has requested for a positron emission tomography (PET) study for evaluation of her brain.   Findings:  Two physician reviewers found that there is data to support the use of PET scanning to assist in this patients diagnosis and the results of a PET scan will most likely significantly assist in directing the patients treatment plan.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for a bone growth stimulator. The records provided for review document that this patient has sustained an injury to her left fifth toe. X-rays demonstrated fracture through the conjoint phalanx of the fifth toe without significant displacement. Physical examination revealed no appreciable swelling around the forefoot or fifth toe. The patients provider has recommended a bone growth stimulator. Electrical stimulation has been used as an adjunct for treatment of nonunion in an effort to achieve bony healing of surgical fusions. There is paucity of peer-reviewed medical literature to support the routine use of a bone growth stimulator in the setting of toe fracture with delayed union. Typically, a fracture is considered to have gone on to nonunion six months following injury. The adjunctive use of a bone stimulator is only considered with no evidence of progressive healing on sequential imaging studies. In this case, the two imaging studies discussed included x-rays and computed tomography (CT) scan, which reportedly demonstrated healing with partial osseous bridging. Overall, there is a lack of scientific evidence to suggest a bone growth stimulator would be more beneficial than any available standard treatment for this patients left fifth toe phalanx fracture. All told, the requested bone growth stimulator (E0747) 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 bone growth stimulator (E0747) 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 services are 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 reviewer 1 is board certified in orthopedic surgery with expertise in hand surgery and sports medicine and is actively practicing. Physician reviewer 2 is board certified in orthopedic surgery and is actively practicing. Physician reviewer 3 is board certified in orthopedic surgery and is actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for air ambulance services provided for treatment of the enrollees status post stroke with resultant quadriplegia. Findings:  The physician reviewer found that the air ambulance transport from California to Florida to receive long-term care was not medically necessary. The patient has quadriplegia due to a stroke, who requires long-term care. She underwent acute rehabilitation after the stroke and then returned to live with her family as her caregivers. After an episode of respiratory failure she was stabilized and plans were made for long-term care in a facility rather than at home. She did not have an acute medical issue at the time of her transport by air ambulance. The medical literature shows that air travel has health risks. Medical monitoring can be provided with a ground ambulance. The medical records do not show that the route taken by a ground ambulance would lead to a delay in case of emergency relative to transport in an air ambulance where a medical emergency would necessitate arranging an unplanned landing then transfer to a ground ambulance. Air ambulance travel did not present a favorable risk-benefit profile compared to ground ambulance. As such, the air ambulance services provided was not medically necessary for transport to receive long-term care. 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 with sub-specialty certification in neuromuscular medicine and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Urgent Care
Decision: Upheld

A 62-year-old female enrollee has requested emergency ambulance transportation due to her medical condition. Findings:  The physician reviewer found that emergency transportation services are covered when a patient reasonably expects the absence of immediate medical attention to result in serious jeopardy to her health, and when a patient reasonably believes her condition requires ambulance transportation. Ambulance transportation is provided in order for patients to receive medical care during transport. The patient must reasonably expect that a delay in getting to the hospital would seriously jeopardize her health or that she requires acute medical intervention during transport. This patient reported pain in her right hip and low back that had commenced over several days. Even if she required a stretcher for transfer, this patient did not require any medical intervention during her transport. This patient could safely have been transported to the hospital by means other than ambulance. The patients symptoms did not meet prudent layperson criteria for emergency care. A prudent layperson with an average knowledge of medicine would not reasonably expect the absence of emergency care to jeopardize her health.