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

This patient is a 54-year-old female with a complex medical history of including extensive spinal deformity, myelopathy, multiple surgeries and osteoporosis. She uses a walker for mobility and her physical therapist recommended the additional of forearm platforms to transfer weight bearing from the hands and wrists to the forearms. There is no information in the record provided for review regarding the current condition of the patients upper extremities. The patient has purchased the forearm platforms, and has submitted a request for reimbursement to the Health Plan.  The Health Plan denied the requested reimbursement based upon a determination that the forearm platforms were not medially necessary for the patients mobility.The medical information provided through July 2006 contains no reference to upper extremity strength, sensation, or functional ability. There are no physician records documenting an upper extremity neuropathy or a recent work-up of upper extremity deficits. The patients physical therapist did provide a letter dated August 2006 indicating that the patient needs the forearm platforms.  However, there are no physical therapy progress notes or any indication in the physicians notes the patient was referred for physical therapy. As such, the available records do not contain sufficient information to substantiate the medical basis for the requested forearm platforms.Based upon the information set forth above, I have determined the equipment at issue was not medically necessary for the patients mobility. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patients parent has requested authorization and coverage for NuvaRing 0.12 mg/0.015 mg every 24 hours, two (2) per month. Findings:  The physician reviewer found that the NuvaRing is the only intravaginal hormonal contraceptive currently approved by the U.S. Food and Drug Administration (FDA). The NuvaRing is a flexible polymer ring with a 54-mm outer diameter and a 50-mm inner diameter. Its core releases a daily dose of 15 g ethinyl estradiol and 120 g of the progestin etonogestrel. These doses effectively inhibit ovulation. The NuvaRing is initially inserted within five days after the onset of menses. It is removed after three weeks for one week to allow withdrawal bleeding. After this, a new NuvaRing is inserted. However, the use of two rings per application is not FDA approved. There is a paucity of evidence in the medical literature that supports the use of two NuvaRing devices per cycle in this clinical setting. Therefore, the requested NuvaRing 0.12 mg/0.015 mg every 24 hours, two (2) per month is not medically necessary for treatment of this patients medical condition.Final Result: The reviewer determined that the requested medication dosage 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 obstetrics and gynecology with sub-specialty certification in reproductive endocrinology 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 55-year-old female enrollee has requested a follow-up colonoscopy for evaluation of her medical condition.   Findings:  The physician reviewer found that based on currently available recommendations from the American Gastroenterological Association and the American Cancer Society, this patient should be followed with a repeat colonoscopy every 10 years. The patient does not have any documentation of a first degree relative with colorectal cancer, and findings on previous colonoscopy has not increased the patients risk for colorectal cancer such that more frequent testing is indicated. All told, the requested services are not supported as medically necessary for treatment of this patients medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for LINX procedure for treatment of the enrollees gastroesophageal reflux disease (GERD). Findings: Three physician reviewers found that there is a lack of randomized controlled trials comparing LINX with Nissen fundoplication or other surgical anti-reflux procedures. One evidence review concluded that the long-term safety and efficacy of LINX - both alone and in comparison to current GERD therapies - remains to be determined. Another best-evidence review concluded that long-term comparative outcome data past one year are needed in order to further understand the efficacy of magnetic sphincter augmentation. Adverse events, such as erosion through the esophagus, have been reported in the period after U.S. Food and Drug Administration (FDA) approval. Additionally, LINX more than surgical fundoplication is associated with severe dysphagia requiring endoscopic intervention. The currently available peer-reviewed literature does not definitively support the conclusion that LINX is more likely to be beneficial in this case than standard treatment  surgical fundoplication. American College of Gastroenterology guidelines for the management of reflux disease also state that more evidence is needed before LINX can be recommended. Given these findings, the requested LINX procedure 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 procedure 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: All three physician reviewers are board certified in internal medicine with sub-specialty certification in gastroenterology 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: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for the magnetic esophageal sphincter augmentation (LINX) procedure for treatment of the enrollees gastroesophageal reflux disease (GERD), osteoporosis, and Ehlers-Danlos syndrome. Findings:  Three physician reviewers found that based on the data provided, there is little evidence that the patients symptoms are due to acid reflux. The first 24 hours of the Bravo pH test was borderline positive but Day 2 showed no evidence of acid reflux and this was done off proton pump inhibitor (PPI) and histamine receptor antagonist (H2RA) therapy. Additionally, there was a poor correlation between the patients symptoms and acidification of the esophagus. Final Result: Three reviewers determined that the requested procedure 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: All three reviewers are board certified in internal medicine with sub-specialty certification in gastroenterology 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: Experimental/Investigational
Decision: Overturned

A 35-year-old male has requested a gastrointestinal (GI) tract capsule endoscopy for evaluation of his abdominal pain and diarrhea.  Findings:  Two physician reviewers found that the patient is under evaluation for abdominal pain and weight loss. The patient underwent an upper endoscopy and colonoscopy both of which were normal. The patient reports having 15-20 bowel movements per day. The provider noted possible inflammatory bowel disease (IBD) and started the patient on Pentasa for small bowel Crohns disease. A computed tomography (CT) scan was abnormal and suggestive of possible small bowel Crohns. A small bowel wireless capsule endoscopy (WCE) has been requested to evaluate the patient for small bowel Crohns disease.  Based on the information provided, the requested WCE is likely to provide new information relevant to diagnosing this patients medical condition. The provider indicates the patient should be evaluated for Crohns disease of the small bowel given the patients presenting symptoms. Use of WCE has become the standard of care under these clinical circumstances and provides greater sensitivity than a barium radiograph and avoids ionizing radiation. A WCE in this particular patient is appropriate and likely to result in an improved health outcome when compared with standard interventions.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for the medication Pifeltro 100 mg.Doravirine is a non-nucleoside reverse transcriptase inhibitor. Other members of that class include Sustiva (efavirenz), Intelence (etravirene), and Viramune (nevirapine).Findings:  The physician reviewer found that doravirine has been shown to have a better safety profile than Sustiva and a low potential for drug to drug interactions. It has also been shown to have a higher barrier to the development of resistance than rilpivirine (RPV) and efavirenz (EFV) at the concentrations achieved in the clinic setting (Feng, et al.). In addition, it has been demonstrated that food had no clinically meaningful effect on doravirine (Behm, et al.). Doravirine is also non-inferior to Sustiva.In this case, the patient is reported to have had issues with tolerating antiretroviral therapy (ART) and a concern for clinically demonstrated side effects. In this setting, it is the standard of care to adjust the regimen to the safest regimen with the least potential for interactions. Under these circumstances, the requested medication Pifeltro 100 mg is medically necessary for treatment of the 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 subspecialty certification in infectious 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: Medical Necessity
Decision: Upheld

The patient has requested authorization and coverage for Euflexxa injections. An exhaustive review of current medical literature pertaining to the viscosupplementation reveals mixed results. Evidence from systematic reviews and randomized controlled trials indicate that although viscosupplementation may relieve knee pain in some patients with osteoarthritis, data has not established which patients will benefit. Current evidence is limited and guidelines from organizations such as the American Academy of Orthopedic Surgeons (AAOS) indicate that the data on safety and efficacy remain inconclusive. As such, the AAOS does not currently support viscosupplementation as standard treatment for osteoarthritis of the knees. Viscosupplementation is only be recommended in patients with a history of lasting benefit from prior injections and in carefully selected cases where the remaining options are limited. In this case, there is a lack of documentation of substantial relief of symptoms with prior Euflexxa injections. The course of three injections performed did not result in significant pain relief. Medical records document the need for weight reduction prior to total knee arthroplasty. Based on the lack of documentation of significant relief from three Euflexxa injections, the requested Euflexxa injections are not medically necessary. 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 orthopedic surgery and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for a LifeWatch extended heart monitoring system (external electrocardiographic recording). Steinberg and colleagues note that extended ambulatory monitoring may improve diagnostic yield, especially since atrial tachyarrhythmias are more likely to cause pre-syncopal symptoms in patients with underlying cardiomyopathy. In this case, the patient has a depressed ejection fraction and would be a candidate for an implantable cardioverter-defibrillator without improvement. The records note that the patients clinical symptoms include dizziness and pre-syncope along with documented non-sustained ventricular tachycardia and atrial tachycardias. In this clinical setting, given that information regarding the frequency and burden of the various arrhythmias, including the correlation of specific types of arrhythmia with clinical symptoms, is needed in order to evaluate the appropriateness of medical and ablative therapy, the requested equipment is medically indicated. Therefore, a LifeWatch extended heart monitoring system (external electrocardiographic recording) is medically necessary 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 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: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for acute inpatient psychiatric treatment for treatment of the enrollees behavioral health conditions. Findings:  The physician reviewer found that the submitted documentation fails to support the medical necessity of the services at issue.  The patient had a somewhat difficult course after his initial admission.  Despite his changing polypharmacy regimen, he remained actively psychotic, with intrusive and sometimes aggressive behavior.  He lacked either the ability or the desire to attend to hygiene and grooming.  He then developed transaminitis, his medications were held, and he cleared up.  His medications were changed, and he started Invega Sustenna.  He began to show improvement in hygiene, behavior, and psychotic symptoms.  He was not a danger to himself or others, he was no longer acutely psychotic, he was cooperative, and no medication changes had been made for at least two days.  He was awaiting placement at a facility.  He had returned to his baseline level of functioning, and at this point additional inpatient services were not medically necessary.  All told, acute inpatient psychiatric treatment were not medically indicated for the treatment of this patient. 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 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: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the magnetic resonance angiography (MRA) performed. This patients records do not document any history of focal neurological deficit, trauma or abnormal carotid ultrasound to indicate a possible vertebral or carotid dissection. Studies have shown a low positive yield for MRA of the head at 0.4% absent any focal neurological deficit. Carotid ultrasound would have been adequate to evaluate the patient for a dissection and most likely would have shown abnormal findings including elevated peak systolic velocities in the carotid arteries or perhaps reversal of flow in the vertebral arteries. In the absence of a focal neurological deficit, trauma or abnormal carotid ultrasound to indicate a possible vertebral or carotid dissection, the MRA performed was not medically necessary for evaluation of this patients medical condition. Final Result: The reviewer determined that the diagnostic procedure 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 diagnostic radiology 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 services during a colonoscopy for treatment of her medical condition.  Findings:  The physician reviewer found that anesthesia services provided during a colonoscopy were not medically necessary. The patient did not present with a significant history that would require monitored anesthesia care. There is no submitted documentation of co-morbid conditions that would place this patient at risk for complications requiring the need for monitored anesthesia care. 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. McQuaid and colleagues performed a systematic review of randomized controlled trials to compare efficacy, safety, and efficiency of agents used for moderate sedation in esophagogastroduodenoscopy (EGD) or colonoscopy. At the end of the review the authors concluded that moderate sedation [versus deep sedation] provides a high level of physician and patient satisfaction and low risk of serious adverse events with all currently available agents. For the reasons mentioned above, the requested anesthesia services were not medically necessary.  Final Result: The reviewer determined that the service at issue was 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 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 parent of an enrollee has requested authorization and coverage for an Emfit MM Movement Monitor.The submitted documentation does not support that the requested device is medically necessary. The patient has a history of generalized seizures. As the patient is currently seizure free and there is no documentation that the patient is not taking medications on a regular basis, there is no documentation that the patient requires continuous monitoring for seizure activity. While the requested device may be necessary for an individual who is currently having intractable seizures, this is not apparent from the documentation provided for the patient. Under these circumstances, the requested Emfit MM Movement Monitor is not medically necessary to treat the patients medical condition.Final Result: The reviewer determined that the requested device 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 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: Experimental/Investigational
Decision: Upheld

The parents of a four-year-old male enrollee requested authorization and coverage of an umbilical cord blood transplant for the treatment of sanfilippo syndrome type A. The health plan denied the enrollee's request indicating that the requested treatment is experimental. Three physician reviewers performed an experimental/investigational Independent Medical Review. All three physician reviewers determined that the requested treatment is not likely to be more beneficial for treatment of the enrollee's medical condition than any available standard therapy; therefore, the review organization upheld the health plan's denial.