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

Nature of Statutory Criteria/Case Summary:   An enrollee has requested Euflexxa injections for treatment of his medical condition.  Findings:  The physician reviewer found that  evidence based peer-reviewed literature and clinical practice guidelines have indicated that intraarticular steroid injections are a first line pharmacological intervention consideration in the treatment of knee arthritis, while intraarticular hyaluronan injections like Euflexxa are a second line consideration (Cheng, et al; 2012; Henrotin, et al; and Hochberg, et al). Jevsevar and colleagues performed a systematic review of the published evidence and concluded that, Meta-analysis of only the double-blinded, sham-controlled trials with at least sixty patients did not show clinically important differences of HA treatment over placebo.  When all literature was added to the analysis, the overall effect was greater but was biased toward stronger treatment effects because of the influence of nonblinded or improperly blinded trials. In light of this recent evidence, viscosupplementation injections, like Euflexxa, may be used as a clinical consideration, but they should not be pursued unless other conservative clinical options are attempted and failed. In addition, the increasing risk of adverse effects in the setting of repeated injections should be considered (Webber, et al). In the present case, the patient underwent one steroid injection, but there is no documentation of any follow up since this injection was administered. In addition, a neoprene sleeve was recommended but there are no indications that this was initiated and had failed. Furthermore, there are no clear indications other conservative treatments have been tried and failed for treatment of this patients bilateral knee pain. Therefore, in consideration of the submitted clinical records and medical literature, the requested Euflexxa injections are not medically necessary.  Final Result: The reviewer determined that the requested injections 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 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: Experimental/Investigational
Decision: Upheld

An enrollee has requested authorization and coverage for a wireless capsule endoscopy (CPT 91110). The American Gastroenterological Association (AGA) and American Society for Gastrointestinal Endoscopy (ASGE) guidelines support wireless capsule endoscopy for investigation of iron-deficiency anemia or gastrointestinal bleeding when esophagogastroduodenoscopy and colonoscopy do not provide an explanation, polyposis syndromes, celiac disease, and Crohns disease (Wang, et al.). The current medical literature supports an indication for wireless capsule endoscope the physician reviewer found that y for the evaluation of patients with gastrointestinal bleeding, Crohns disease, or celiac disease, who have had negative or inconclusive endoscopic or imaging studies (Enns, et al.). Wireless capsule endoscopy is limited to detection of diseases that result in structural abnormalities that can be identified solely based on appearance. SIBO does not result in any visually apparent changes in the small intestine. In addition, the records do not support suspicion for Crohns disease or other diseases for which wireless capsule endoscopy is an appropriate test. Wireless capsule endoscopy is not a recommended test for the diagnosis of SIBO (Ponziani, et al.). For these reasons, a wireless capsule endoscopy (CPT 91110) is not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary:  An enrollee has requested Zometa infusions for treatment of her medical condition.   Findings:  Two physician reviewers found that Zometa infusions were and are likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Clinical trials have demonstrated that zoledronic acid added to endocrine therapy improved disease-free survival in premenopausal patients. Postmenopausal women receiving adjuvant letrozole were randomly assigned to immediate zoledronic acid (zoledronate) 4 mg every 6 months for 5 years, or delayed zoledronate (initiated for fracture or on-study bone mineral density (BMD) decrease). The primary end point was the change in lumbar spine BMD at 12 months. Lumbar spine and total hip BMD at subsequent follow-up, disease-free survival (DFS), and overall survival were assessed as secondary end points. Researchers concluded that Immediate zoledronate in postmenopausal women receiving letrozole preserved BMD and is associated with improved DFS compared with letrozole alone. Based on the clinical trial, zoledronic acid improves the disease free survival of breast cancer patients in the adjuvant setting. Furthermore, the Health Plan indicates that the patient has not had treatment failure with an oral bisphosphonate. However, Zometa is not equivalent to oral bisphosphonates. The idea that all the bisphosphonates are equivalent in their efficacy in the adjuvant setting has not been proven. Hence, the use of zoledronic acid in particular is discussed as a therapeutic option in the National Cancer Institutes Physicians Data Query. All told, there is sufficient support in the peer-reviewed literature for the medication at issue in this clinical setting.  Final Result: Two reviewers determined that the medication at issue was and is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned.  Credentials/Qualifications:  All three reviewers are board certified in internal medicine with sub-specialty certification in oncology 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: Overturned

Nature of Statutory Criteria/Case Summary: A patient has requested authorization and coverage for Mavyret The Health Plan has denied this request indicating that the requested medication regimen is not medically necessary for treatment of the patients chronic hepatitis C virus. The submitted documentation supports the medical necessity of the requested medication regimen. 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 nonliver-related conditions. The guidelines recommend that all patients should be treated, regardless of fibrosis stage. The guidelines recommend that non-cirrhotic, treatment naive, patients should be treated with Mavyret 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

A 60-year-old female enrollee requested bariatric revision surgery Apollo OverStitch for medical treatment of the enrollees morbid obesity.  Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested services in this patients case.  Some bariatric surgical patients do not achieve meaningful weight loss, or regain lost weight over time.  A recent systematic review by Dakin and colleagues determined that endoluminal procedures for weight regain tend to be well-tolerated with limited efficacy.  Endoscopic approaches for weight regain have yet to be proven effective in the long-term, and are currently not the standard of care in patients who regain weight after a remote bariatric procedure.  Gastro-gastric fistulas can lead to gastric ulcers in the pouch and abdominal pain.  Gastro-gastric fistulas have been associated with weight gain, but also have been discovered incidentally in patients who have maintained weight loss.  Whether these fistulas need to be corrected when found in a patient with weight regain following gastric bypass surgery, and whether fixing these fistulas can lead to durable weight loss has yet to be determined.  All told, the requested Apollo OverStitch is not medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld

A female enrollee requested Synvisc One injections for medical treatment of her osteoarthritis.  Findings:  The physician reviewer found that there was a lack of imaging studies provided for review to confirm the patient has osteoarthritis in either knee to support the requested Synvisc One injection.  Additionally, the records failed to indicate which of the knee joints is being treated at this time.  Although the patient had undergone a prior series of Synvisc injections to her right knee, the records do not document that she had pathology in the left knee of end stage osteoarthritis to warrant the injection.  There is a lack of support for the requested services in this clinical setting.  All told, the requested Synvisc One injections are not medically indicated for the treatment of this patient.
Appeal type: Urgent Care
Decision: Upheld

A 19-year-old male enrollee has requested urgent care services for treatment of his intermittent swelling of the left toes and left great toe. Findings:  The physician reviewer found that review of the submitted clinical documentation demonstrates that a prudent layperson would not have sought immediate medical attention.  The patient presented to an urgent care facility with swelling and redness of his toes for three weeks. His symptoms had commenced gradually and his pain was rated as mild. In a letter from the patient he states that he had excruciating pain and there was pus coming from his nail. However, this was not confirmed by the medical documentation provided. The medical records indicate the patient was afebrile, had mild pain and not in acute distress. On a subsequent date the patient returned to the urgent care facility and reported no improvement. He described his pain as 5/10, which was not severe. His nail was partially removed. During both dates of service in dispute, the patients symptoms were not of sufficient severity that a prudent layperson would reasonably believe the absence of immediate medical attention would place his health in serious jeopardy or result in serious impairment to bodily functions or serious dysfunction of a bodily organ or part. All told, based on the documentation provided for review the patients symptoms did not meet prudent layperson criteria for emergency care.
Appeal type: Medical Necessity
Decision: Overturned

The patient is a five-year-old male with congenital central hypoventilation syndrome (CCHS). He underwent surgery in October 2005 for placement of diaphragmatic pacemakers. Previously, he had a tracheostomy and required mechanical ventilation. The patient was successfully decannulated in July 2006, and has since been monitored at night with continuous pulse oximetry and home health nursing. Nursing notes have documented normal oxygen saturations at night with no need for supplemental oxygen. However, multiple nurses have described very restless sleep and the need for frequent repositioning to maintain the integrity of the pacers and to ensure adequate oxygenation and ventilation. The parents request for continued authorization of home health nursing services (84 hours per week) was denied by the Health Plan based upon a determination that these services are no longer medically necessaryCCHS is an extremely rare disorder characterized by generally adequate ventilation while the patient is awake but alveolar hypoventilation with typically normal respiratory rates and shallow breathing (diminished tidal volume) during sleep. Those who are more severely affected demonstrate hypoventilation during wakefulness as well as sleep. All CCHS patients lack the appropriate arousal response to hypoxemia and hypercarbia, putting them at long-term risk for cardiac abnormalities (e.g. right heart failure), pulmonary hypertension, and death. Generally, the management of CCHS involves ventilatory support: tracheostomy with mechanical ventilation or diaphragmatic pacing. Diaphragmatic pacing may allow more freedom for those who require ventilatory support only during sleep. Children with CCHS must be managed with extreme vigilance. There is no inherent physiological response to hypoxemia or hypercarbia. Even during waking hours, these children will not experience shortness of breath in response to pneumonia or increase their respiratory rate in response to physical exertion. Frequently, patients with CCHS will not develop fever in response to infection. Severe respiratory distress can occur with minimal external manifestations. In addition, children with CCHS do not pace themselves appropriately during strenuous exercise because they cannot sense hypoxemia or hypercarbia. The literature also reports that autonomic dysfunction and cardiac abnormalities are common in CCHS.The patient is at significant risk for complications from his disorder. He is being successfully managed now with vigilant nursing care while he sleeps. Not only does the home health nursing staff ensure adequate functioning of the pacers, but their constant vigilance allows for early identification and intervention with any event that could compromise the patients already tenuous cardiopulmonary status. Therefore, I have determined the requested services are medically necessary for treatment of the patients medical condition. The Health Plans denial should be overturned.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for advanced lipoprotein testing. Findings:  The physician reviewer found that despite some researchers advocating for use of the advanced lipoprotein analysis, the American College of Cardiology (ACC) guidelines do not support use of the advanced lipid testing. Rather, these guidelines recommend use of standard risk factors and standard lipid profile to make decisions about lipid management. In addition, the guidelines have moved away from specific target values. Instead, they emphasize use of the pooled risk score analysis for decisions regarding statin therapy. These guidelines are formulated based on thorough review of current literature. Accordingly, the advanced lipoprotein testing was not likely to have been of greater benefit over the standard lipid panels for the evaluation of this patient. Final Result: All three reviewers determined that the services at issue were not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: Physician reviewers 1, 2 & 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

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested authorization and coverage for laboratory testing (CPT codes 82784, 82787 and 83520).Oral food challenges and oral food desensitizations have been performed successfully by allergists and immunologists. While oral food desensitization has been achieved in the majority of individuals in randomized controlled studies, few go on to develop `tolerance` or sustained unresponsiveness to the allergic stimulant. It is the standard of care to measure immunoglobulin E (IgE) levels to specific foods in question for a patient. However, an extensive array of blood tests examining foods to which a patient has not had a reaction to and proceeding with oral desensitization to a multitude of foods to which there is no history of anaphylaxis is not supported by the medical literature. In this case, the requested laboratory testing (quantitative immunoglobulin (CPT 82784), immunoglobulin G (IgG) subclasses (CPT 82787), and immunoassay for analyte (CPT 83520)) is not supported by the medical literature. Furthermore, while oral food challenges are medically appropriate to rule out immunoglobulin E (IgE) mediated food allergy, there is a lack of evidence supporting oral dosing protocols for foods that are considered intolerances or IgE mediated allergies based on IgG and patch testing. Therefore, the requested laboratory testing (CPT codes 82784, 82787 and 83520) is not medically necessary for the evaluation of the patients medical condition. 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 allergy and immunology 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 24-year-old female enrollee has requested inpatient care for the treatment of her alcohol dependence, anorexia nervosa and major depressive disorder. Findings:  The physician reviewer found that this patient was particularly ill and in need of care in a sub-acute residential substance abuse treatment program, or a higher level of care, during the period in question. She was an overt danger to herself because of her eating disorder and alcohol abuse. She clearly required 24/7 professional supervision without which her purging, use of laxatives and other behaviors would have created a life-threatening event. The records indicate the presence of various treatment plans that were directed toward treatment of a severe mental illness. This included, but was not limited to, psychopharmacologic treatment. The progress notes provide sufficient detail to support the medical necessity of this level of care. There was weekly, and often more than weekly, documented psychiatric visits. The patients ambivalent motivation appears to have been a manifestation of her psychopathology. Based upon the submitted clinical documentation, any lesser level of care would not have been appropriate or safe. This patient required inpatient psychiatric care of the nature.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for any or all prescription medication of C-Cefazolin 50 mg/mL. In this case, the patient had a significant infection of her left lacrimal duct with associated stone formation consistent with actinomyces. Given that this patient required an ophthalmic formulation of an antibiotic to treat actinomyces, the medication at issue was medically indicated. Therefore, the prescription medication of C-Cefazolin 50 mg/mL was medically necessary for the treatment of this patient.Final Result: The reviewer determined that the medication at issue was 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 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: Experimental/Investigational
Decision: Upheld

A female enrollee requested balloon sinus ostial dilation for medical treatment of her chronic sinusitis.  Findings:  Two physician reviewers found that the computed tomography scan of the sinuses showed no disease in the right frontal sinus and mild disease in the left side. The physical examination of the sinuses by the provider using nasal endoscopy shows no evidence of disease. In this case, it is possible that the patient is suffering from a primary headache problem. Prior to proceeding with surgery, a neurology consultation should be obtained. Based on the documentation submitted for review, the requested services are not likely to be more beneficial than any standard treatments for this patients medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for Botox injections Findings:  Two of the three physician reviewers found that the use of Botox is indicated for the treatment of chronic headaches in individuals who have at least 14 headache days per month. Furthermore, Botox has been approved by the U.S. Food and Drug Administration (FDA) for the treatment of migraines. It is widely used by neurologists for this purpose. Therefore, Botox injections were likely to have been of greater benefit than other treatment options. Final Result: The reviewers determined that the services at issue were likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: Physician reviewers 1, 2 and 3 are board certified in neurology 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.