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

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Xifaxan 550mg. Findings:  The physician reviewer found that the documentation provided for review demonstrates that this patient has SIBO. For treatment of SIBO, Xifaxan has been proven to be effective for eradication of bacteria and symptom relief. Further, Xifaxan has been shown to be more effective with fewer side effects than antibiotic alternatives such as metronidazole, neomycin, and fluoroquinolones. One prospective trial of patients with IBS and a positive breath test found that 86% of patients responded to Xifaxan with improvement in symptoms. For these reasons, the use of Xifaxan 550mg is supported as medically necessary for the 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 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: Urgent Care
Decision: Upheld

The parent of a five-year-old female enrollee has requested for emergency services on an emergent basis.  Findings:  The physician reviewer found that throat exam revealed tonsillar erythema. The patient was diagnosed with tonsillitis and discharged with a prescription for the antibiotic Zithromax.  The patient was discharged in stable condition.The issue in this case is whether a prudent layperson would have sought immediate medical attention for complaints of fever, cough and sore throat. An emergency is the sudden onset of symptoms of such severity that a prudent layperson would believe her health to be in jeopardy without immediate medical attention.
Appeal type: Medical Necessity
Decision: Upheld

A 62-year-old male enrollee has requested a silicone glove for the treatment of his status post right upper extremity above-elbow amputation.  Findings:  The physician reviewer found that the requested equipment is not medically necessary in this patients case. Upper limb prostheses have improved over the years, but still are generally considered poor replications of the biological hand.  Two of the primary issues are the lack of natural control of more than two degrees of freedom and the lack of sensory/haptic feedback.  Additions such as a custom silicone hand covering add a lifelike appearance, but these coverings are fragile and subject to damage, particularly due to the lack of sensory feedback.  These coverings, moreover, do not provide a functional need with respect to the patients activities of daily living that would not be provided by conventional plastic covers.  All told, the requested silicone glove is not medically indicated.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested Harvoni 90-400 mg 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 note that all patients should be treated, regardless of fibrosis stage. The guidelines recommend that treatment-naive genotype 1a 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.  Therefore, Harvoni 90-400 mg 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: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Nuvigil 200 mg three times per day for treatment of the enrollees idiopathic hypersomnia. Findings:  The physician reviewer found that Currently, there are no U.S. Food and Drug Administration (FDA) approved medications for the treatment of hypersomnia. In addition, a comprehensive review of the current medical literature does not reveal any peer-reviewed publications supporting the use of dosing at 600 mg of Nuvigil for the treatment of idiopathic hypersomnia. The FDA cautions against the use of doses of Nuvigil greater than 250 mg daily. While the patient and her treating provider state the patient has experienced superior results with their preferred treatment modality, the use of Nuvigil at 600 mg daily dosing for the treatment of idiopathic hypersomnia is not supported by the medical literature. Thus, the requested Nuvigil 200 mg three times per day is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Final Result: Two of three reviewers determined that the requested medication dosage 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 reviewer number one is board certified in oral and maxillofacial surgery with expertise in sleep medicin 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.Physician reviewer number two is board certified in neurology with sub-specialty certification in sleep 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.Physician reviewer number three is board certified in anesthesiology with sub-specialty certification in pain medicine and expertise in sleep 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

The patient is a 37-year-old man with a body mass index (BMI) of 50. The patients comorbidities include hypertension, gout, and asthma. The results of the patients psychological evaluation indicate the patient has a history of bulimic behavior. The patient wishes to undergo gastric bypass surgery. The Health Plan has denied authorization and coverage for the requested procedure based upon the results of the patients psychological evaluation.The patients eating disorder is a deterrent to successful weight loss surgery. The outcome of gastric bypass surgery is patient dependent. Over long periods of time 15% to 25% of patients will regain some or all of their lost weight. The success of gastric bypass is dependent upon the patients strict adherence to a limited food intake. Unless a patient is psychologically stable and ready for the lifelong dietary changes necessary for a successful outcome, it is highly likely the procedure will fail. The information provided does not demonstrate that this patient is an appropriate candidate for weight loss surgery.Based upon the information set forth above, I have determined that the requested procedure is not medically necessary for the treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.
Appeal type: Experimental/Investigational
Decision: Upheld

A 65-year-old male enrollee requested the LINX Reflux Management System for medical treatment of his gastroesophageal reflux disease.  Findings:  Three physician reviewers found that there is a lack of support for the requested LINX Reflux Management System in this clinical setting.  The documentation notes a history of gastroesophageal reflux disease.  However, the medical records do not demonstrate that this patients condition has been fully treated with available medications.  Furthermore, the records do not document if the patient has tried and failed different regimens.  All told, the requested LINX Reflux Management System is not likely to be more effective than other available modalities.
Appeal type: Medical Necessity
Decision: Upheld

A 67-year-old female enrollee has requested authorization and coverage for a computed tomography angiography (CTA).  Findings:  The physician reviewer found that based on the records provided, the patient has some coronary risk, but with no documentation of symptoms that are suspicious for coronary ischemia and no documented suspicion of anomalous coronary artery disease. In this circumstance, screening CTA scanning to assess for coronary artery disease is not medically necessary and not considered standard accepted practice in the medical community. Current guidelines that are endorsed by several national organizations do not consider the use of CTA scanning for the assessment of coronary anatomy appropriate as a screening tool in asymptomatic patients. There are no documented accepted indications for CTA scanning in the records provided, such as suspicion of coronary anomaly, symptoms suspicious of coronary artery disease with equivocal stress test results, or concern for other forms of congenital heart disease. Therefore, the requested CTA is not medically necessary for evaluation of the patients condition.
Appeal type: Medical Necessity
Decision: Overturned

A 29-year-old male enrollee requested residential treatment and resumption of residential treatment for medical treatment of his alcohol dependence.  Findings:  The physician reviewer found that the submitted documentation supports the medical necessity of a portion of the services.  The patient had attempted treatment in a less restrictive setting.  However, his alcohol consumption quickly re-established domination of his daily routine, and continued to negatively impact his relationships and cause significant impairment across multiple domains of functionality.  At the time of presentation, the patient had completed a complicated detoxification and his social setting and living environment as arranged were unable to support his sobriety.  As such, residential treatment services were safe, appropriate and consistent with good practice.  Considering the clinical presentation and peer-reviewed literature, residential treatment was medically indicated for the treatment of this patient.   However, the record does not justify that a resumption of residential treatment is required at this time.  The patient had done well earlier with fairly brief residential admissions.  His most recent relapse occurred following the completion of an IOP program.  He had successfully maintained sobriety in settings less restrictive than residential.  Thus, there was no evidence to suggest that an intermediate setting, such as partial hospitalization or IOP with supportive living, would be insufficient.  As such, based on the documentation provided, the resumption of residential programming is not medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for computed tomography (CT) of the heart (CPT 75571). Based on the current guidelines from the American College of Cardiology (ACC), a coronary artery calcium score is reasonable for the purpose of determining whether a patient should start statin therapy for a borderline elevated low density lipoprotein (LDL) cholesterol level (Blankstein). However, there is a lack of support for using serial coronary artery calcium scoring to assist in the adjustment of statin dosing. This patients records do not include documentation of low density lipoprotein (LDL) cholesterol results either before or following statin initiation. As noted in the medical literature and guidelines, the chief purpose of the coronary artery calcium score is to aid in decision making as applied to statin therapy initiation. This patient was noted to have been on a statin at the time of CT scan of the heart. Further coronary artery calcium score tests have not been subjected to outcomes data in patients already on statins. For these reasons, the CT scan of the heart (CPT 75571) was not medically necessary for this patient. Final Result: The reviewer determined that the services at issue were 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 subspecialty certification in cardiology 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 42-year-old female enrollee has requested for Botox injections for treatment of her migraine headaches. Findings:  Two physician reviewers found that The use of Botox injections for the management of headaches remains an off-label indication. However, recent publications suggest that Botox is an effective treatment for chronic migraine without medication overuse, and Botox injections are helpful in managing refractory headache syndromes. Pharmacological treatments have not provided good long-term pain relief for patients.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for vertical sleeve gastrectomy. Applying the guidelines from the American Association of Clinical Endocrinologists (AACE), the Obesity Society, and American Society for Metabolic and Bariatric Surgery, (ASMBS), this patient does not meet the criteria for bariatric surgery at this time. The records do not document clinically severe obesity with a BMI of 40 kg/m2, or 35 kg/m2 or greater with serious co-morbid condition such as diabetes, hypertension, coronary artery disease or obstructive sleep apnea. Moreover, the records do not include a multidisciplinary evaluation and clearance for the requested surgical intervention. All told, the requested vertical sleeve gastrectomy is not medically necessary for treatment of this patient. Final Result: The reviewer determined that the requested services are not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in surgery with expertise in bariatric surgery and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

A 51-year-old female enrollee has requested bariatric surgery, specifically, a Lap Band procedure for treatment of her obesity.  Findings:  The physician reviewer found that review of the submitted documentation demonstrates that this patient meets the generally accepted criteria for bariatric surgery, including those criteria listed by the National Institutes of Health (NIH) Consensus Guidelines. The patient has clinically severe obesity with a BMI of greater than 38 and hypertension being treated with medication. She has failed supervised dietary efforts and has completed a thorough multidisciplinary evaluation that did not reveal any obvious barriers to surgery. Medical clearance is documented for the requested procedure and there is no documented evidence of any treatable metabolic causes of obesity in this patient. All told, the requested Lap Band procedure is medically necessary for treatment of the patients obesity.
Appeal type: Experimental/Investigational
Decision: Overturned

A 55-year-old female enrollee has requested for a spinal cord stimulator trial for treatment of her back and hip pain status post laminotomies and foraminotomies with nerve root and spinal canal decompression.  Findings:  Two physician reviewers found that the proportion of patients with intractable pain successfully managed with spinal cord stimulation (SCS) remains disputed. They analyzed 27 consecutive patients with intractable pain treated with SCS using identical hardware (Itrel II System) by a single satisfactory diagnosis. A rigid selection protocol was used including: 1) satisfactory diagnosis of the pathologic process resulting in pain; 2) corrective surgical procedure was judged not feasible by surgeons experienced in the particular pathology, (i.e., vascular peripheral nerve, spine); 3) lack of satisfactory response to non-interventional pain management modalities by an interdisciplinary pain clinic; and 4) independent psychological evaluation, including a structured interview was performed by a psychologist specializing in chronic pain management. In the last eight cases, a battery of self-report tests designed to assess psychosocial and behavioral consequences of the chronic pain problem were administered as well. All cases were of nonmalignant pain, except for one patient. Thirteen cases were diagnosed with failed back surgery syndrome (FBSS), one older patient with lumbosacral radiculopathy who refused decompression, one patient with cervical radiculopathy and Klippel-Feil syndrome, six with reflex sympathetic dystrophy (RSD), two with peripheral vascular ischemic disease, one with post-thoracotomy pain syndrome, one with leg pain following resection of angiolipoma, one with traumatic superficial peroneal neuropathy, and one with Pancoast's tumor. All patients underwent a three day trial screening with Pisces-Quad/Resume epidural leads connected to a temporary external stimulator. An Itrel II System pulse-generator was internalized in each of the 24 patients who had successful trials (3 cervical and 21 thoracic-lumbar). There was no morbidity. Pain reduction was sustained in 22 out of the 24 patients who continued to use the stimulator. The same number would choose to receive an electrical stimulator again. Normalization or improvement in Quantitative Sudomotor Axon Reflex Test (Q-SART) and Thermography were documented in the patients with RSD. They concluded that rigid selection protocol can maximize the proportion of patients with intractable pain who are successfully treated with SCS. Strict neurosurgical technique eliminates infection risk. Hardware selection minimizes incidence of malfunction.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary:  The parent of an enrollee has requested cryopreservation of oocytes for treatment of the enrollee's medical condition.  Two physician reviewers found that upon review of the submitted documentation, it is not clear that the patient has expressed a desire to procreate in the future and/or to preserve his fertility via cryopreservation of oocytes. While the clinical documentation provided discusses the patients desire to transition to the male gender by pursuing hormonal therapy and breast removal surgery, there is no evidence the patient has discussed the issue of fertility preservation with his providers. Before such services can be determined to be medically necessary, there must be compelling evidence that the patient has the requisite understanding of the ramifications of the impact that hormonal treatment will have on later childbearing as well as comprehension of the consequences of the decision to attempt to preserve fertility via cryopreservation. In the absence of such findings, the medical necessity of the requested cryopreservation of oocytes has not been established. Final Result: Two reviewers determined that the requested service is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.  Credentials/Qualifications: One reviewer is board certified in endocrinology and is actively practicing. One reviewer is board certified in psychiatry and is actively practicing. Both reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld

A 25-year-old male enrollee has requested injections for spine disc x-ray (CPT code 62291), office consultation (CPT code 99243) and x-ray/CT spine disc (CPT code 72285) for an evaluation of his pain. Findings:  Two physician reviewers found that according to the articles by Manchikanti and colleagues, the major obstacle confronting proponents of cervical discography is the lack of consensus as to what constitutes a positive response. Widespread variations in criteria exist not only for pain provocation, but also for morphological classification. The authors note that while some investigators have interpreted certain patterns of contrast dispersion as being indicative of disc pathology, others have found a lack of correlation between morphology and pain reproduction. They also indicate that multiple questions have been raised regarding the utility of cervical discography, including the high reported false-positive rate, the lack of standardization, and the discrepancies regarding the need for control levels, pain concordance, pain intensity threshold and utilization. Another issue in this patients case is determining the validity of the results in a patient with an artificial disc in an adjacent level. There is a lack of published literature addressing this specific concern.
Appeal type: Medical Necessity
Decision: Overturned

A 43-year-old female enrollee requested authorization and coverage of bariatric surgery. The Health Plan denied the request indicating that the requested procedure is not medically necessary for treatment of the enrollees morbid obesity.One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer overturned the Health Plans denial on the basis that the requested procedure is medically necessary.
Appeal type: Medical Necessity
Decision: Upheld

A 51-year-old female enrollee has requested for bilateral liposuction of the axillary area for treatment of her breast asymmetry. Findings:  The physician reviewer found that medically supervised weight loss offers a non-surgical approach to treating this condition. At this juncture, axillary liposuction may be performed as a component part of the breast reduction surgery to shorten the axillary scars and provide a better cosmetic result. The records do not document that the patients axillary lipodystrophy is causing any functional problems.