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

An 81-year-old male enrollee has requested authorization for cardiac EBCT for evaluation of his potential cardiac disease.  Findings:  Three physician reviewers found that Cardiac CT imaging is not a generally accepted screening or confirmatory test for the diagnosis of coronary artery disease in asymptomatic patients. It is not a medically accepted replacement for conventional screening such as treadmill stress testing or an appropriate substitute for coronary angiography. EBCT cannot accurately confirm or exclude important coronary obstruction. The use of cardiac EBCT for the diagnosis and prognosis of coronary artery disease remains an experimental/ investigational application of this technology.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary:  An enrollee has requested a 12 week course of Harvoni for treatment of his chronic hepatitis C virus genotype 1b.  Findings:  Two physician reviewers found that as per the American Association for the Study of Liver Diseases (AASLD) and Infectious Diseases Society of America (IDSA) guidelines, all patients with chronic active hepatitis C are eligible for treatment and should be treated with U.S. Food and Drug Administration (FDA) approved antiviral therapy regardless of fibrosis score. Successful hepatitis C treatment results in sustained virologic response (SVR), which is tantamount to virologic cure, and is expected to benefit nearly all chronically infected patients. The fixed dose combination ledipasvir-sofosbuvir (Harvoni) is FDA approved for the treatment of chronic hepatitis C genotype 1 in both treatment-naive and treatment-experienced patients. Therefore, the requested 12 week course of Harvoni is supported as medically necessary for treatment of this patients chronic hepatitis C virus. Final Result: Two reviewers 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 three reviewers are board certified in internal medicine with sub-specialty certification in gastroenterology 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

A 53-year-old male enrollee has requested for Xolair treatment injections for treatment of his allergic asthma.  Findings:  The physician reviewer found that there are a number of case reports that confirm that asthmatics with high IgEs have responded well to Xolair. The case reports indicate that with Xolair the incidence of adverse responses does not appear to be increased. Xolair has proven effective in hypereosinophilic gastroenteritis as reported in a preliminary study at the National Institutes of Health.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested breast tomosynthesis for evaluation of the enrollees medical condition. Findings:  Three physician reviewers found that breast tomosynthesis is a technique that was developed several years ago as a problem solving adjunct to routine mammography.  Applying the same basic concept as computed tomography (CT) scanning, the logic is that by separating the various layers of breast tissue, one can better detect abnormalities.  This has been shown to be most useful in the evaluation of dense breasts.  This is the specific clinical setting in which tomosynthesis has its greatest value.  The ability to separate overlapping structures enables visualization of an occult tumor which might otherwise have been missed.  Thus, breast tomosynthesis was likely to have been of greater benefit than other methods of evaluating this patient.  Final Result: Three 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: All three reviewers are board certified in diagnostic radiology and are actively practicing. All three reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

A 69-year-old male enrollee has requested Tenormin 100 mg for treatment of his hypertension.  Findings:  The physician reviewer found that based on the records provided the patient has essential hypertension that is being treated with a combination of Maxide and Tenormin. There are no documented blood pressure readings after the patient was started on the generic atenolol medication, no evidence of side effects, and no indication the patient was intolerant to the generic alternative. Further, there is no documented improved effectiveness of the name brand Tenormin relative to the generic alternative atenolol. All told, generic alternatives have been demonstrated to be of equal effectiveness in the treatment of medical conditions through rigorous studies prior to FDA approval. Generic alternatives contain the same active ingredients as their brand name counterparts and are identical or within an acceptable bioequivalent range to the brand name counterpart with respect to pharmacokinetic and pharmacodynamic properties. For these reasons, the continuation of the brand name Tenormin is not medically necessary in this case based on the records provided for review.
Appeal type: Medical Necessity
Decision: Upheld

The parent of a male enrollee requested occupational therapy for medical treatment of the enrollees developmental delay.  Findings:  The physician reviewer found that the submitted documentation fails to establish the medical necessity of the services at issue. Based upon the documentation provided, the patient has been receiving occupational therapy utilizing multiple techniques including sensory processing integration. The occupational therapy progress report demonstrates his motor coordination skill is still at the 7th percentile for age. Despite the intensity of his therapy his progressive improvement has been marginal; the patient has had intensive therapy with limited positive effects. Therefore, based on the medical literature cited above and the documentation submitted for review, occupational therapy is not medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld

A 43-year-old male enrollee requested authorization and coverage of endoscopic transforaminal lumbar discectomy. The Health Plan denied the request indicating that the requested procedure is not medically necessary for treatment of the enrollees herniated disc.One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer upheld the Health Plans denial on the basis that the requested procedure is not medically necessary.
Appeal type: Medical Necessity
Decision: Upheld

The parent of a 17-year-old male enrollee has for keloid surgery for treatment of the enrollees keloids. Findings:  The physician reviewer found that the records do not demonstrate symptoms such as bleeding, infection, skin irritation, discharge, inflammation or change in color.  The presence of a keloid scar in the absence of a  functional problem does not make its removal medically necessary.  Earlobe keloids are not generally painful.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested Harvoni for 12 weeks for treatment of her 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.  This applies regardless of fibrosis stage or viral load.  Per guidelines, treatment-naive genotype 1 patients should be treated with Harvoni for 12 weeks.  These guideline 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.  For these reasons, the requested treatment with Harvoni for 12 weeks is supported as medically necessary for the treatment of this patients hepatitis C infection. 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: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: A female enrollee has requested reimbursement for chiropractic visits for treatment of the enrollees cervical root disorder.  Findings:  The physician reviewer found that There is a lack of medical evidence to support further clinical improvement from continuous ongoing chiropractic care in this clinical setting. The submitted records indicate that this patient has had extensive chiropractic treatments with no significant improvement or change to her medical condition. Each visit note appears to be very similar and no significant changes or improvements to the patients medical condition have been noted by her provider. Moreover, there is little information available from clinical trials to support manual adjustments as an effective therapy for mechanical neck pain. In general, conservative interventions have not been studied in enough detail to assess efficacy or effectiveness adequately. In this patients case, the submitted records do not support a lasting benefit or clinical improvement in her symptoms. For these reasons, the services at issue were not medically necessary for treatment of this 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 chiropractic care 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 authorization and coverage for diastasis recti and fascial defect repairs (CPT code 15847 and 15830) for treatment of the enrollees chronic abdominal pain or back pain.   Findings:  The physician reviewer found that the patient reports chronic abdominal pain with pulling and weakness in the abdominal wall and loss of core strength. Diastasis repair and fascial defect repair will not relieve the patients abdominal symptoms. The proposed services could result in cosmetic improvement in the patients abdominal appearance but would not improve the patients medical/functional complaints. There is a lack of evidence demonstrating diastasis repair and fascial defect repair relieves chronic abdominal pain and weakness. Further, diastasis repair and fascial defect repair are not standard treatments for back pain. In the medical literature, according to the American Society of Plastic Surgeons (ASPS), true hernia repair involves opening fascia and/or dissection of a hernia sac with return of intraperitoneal contents back to the peritoneal cavity. A true hernia repair should not be confused with diastasis recti repair, which is part of a standard abdominoplasty. Abdominoplasty with wide abdominal rectus plication has been shown to be beneficial for some patients with back pain. However, the research cautions that the procedure is contraindicated in the presence of a negative abdominal compression test. Although these reports suggest that abdominoplasty may improve back pain, there is a lack of prospective, controlled, randomized clinical trials that support diastasis recti repair as an acceptable treatment for back pain. This patients records do not include any evidence of improved back pain with a brace and do not document a positive abdominal compression test. Preoperative testing to determine if the procedure will be helpful has not been done. Moreover, the records do not report that a radiologic work-up for back pain or an evaluation by a spine surgeon have been performed. Thus, the requested surgery is not supported as medically necessary for treatment of this patients medical condition. Diastasis recti is a common finding in women post pregnancy. The rectus muscles separate to accommodate the enlarging fetus. As such, diastasis recti is not an abnormal structure. Rather, almost all women post pregnancy have some element of diastasis recti. Final Result: The reviewer determined that the surgery is not medically necessary for treatment of the patients medical condition or reconstructive in nature. Credentials/Qualifications: The reviewer is board certified in plastic 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

Findings:  The physician reviewer found that The patient has requested authorization and coverage for a Dexcom G6 transmitter, Dexcom G6 receiver, and Omnipod 5 supplies. Blood glucose monitoring is essential to diabetes management, with options including  self-monitoring with a fingerstick and use of a glucometer or use of a G6 continuous glucose monitor (CGM) such as the Dexcom G6. The American Diabetes Association (ADA) states, Real-time continuous glucose monitoring or intermittently scanned continuous glucose monitoring should be offered for diabetes management in adults with diabetes on multiple daily injections or continuous subcutaneous insulin infusion who are capable of using devices safely. The ADA further notes that insulin pumps should be offered for diabetes management to patients with type 1 diabetes who are capable of using the device safely, either by themselves or with a caregiver, and that the choice of device should be made based on patient circumstances, desires, and needs. Berget and colleagues report that the Omnipod 5 technology is a closed-loop system, with an insulin pump which can be synced only with the Dexcom G6 CGM and is able to adjust insulin delivery based on the blood sugar readings from the CGM. Brown and colleagues report that this system is safe and allows patients to significantly lower hemoglobin (Hb) A1c values and lessen glycemic variability, measured by time in the target range. In this case, the patient has demonstrated the knowledge and motivation to manage diabetes. While the patient's most recent HbA1c value of 6.3% indicated that diabetes is controlled, this value does not indicate whether the patient is still having wide glycemic variability or not. With use of the Dexcom G6 CGM and the Omnipod Dash insulin pump, the provider noted continued concern over the patients hypoglycemia. In this case, a closed-loop Omnipod 5 insulin pump and Dexcom G6 CGM may further benefit this patient in terms of reducing glycemic variability. Given the proven benefits of management of type 1 diabetes with the use of hybrid closed-loop insulin pumps and CGMs, the requested equipment and supplies are medically indicated. Therefore, a Dexcom G6 transmitter, Dexcom G6 receiver, and Omnipod 5 supplies are medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested equipment and supplies are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The enrollee has requested authorization and coverage for a rheumatologist referral. The Health Plan has denied this request indicating that the requested services are not medically necessary for evaluation of the enrollee who has a history of psoriatic arthritis.Finding: There is sufficient support in the medical literature for the requested services in this clinical setting. This is a patient with a history of psoriasis and PsA.  The record indicates that she is currently having active skin symptoms and joint pains. The patients medical condition is a lifelong chronic condition needing immunosuppressive agents. As such, a referral to rheumatology to evaluate and manage this patients symptoms is medically indicated. Therefore, a rheumatologist referral has been established as medically necessary for the evaluation of this patients medical condition.Final Result: The reviewer determined that the requested services are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified internal medicine with sub-specialty certification in rheumatology 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: The patient has requested authorization and coverage for Phenergan with codeine. Findings: In this case, the patient reports a lingering cough following a COVID-19 infection. The records noted multiple, frequent requests for Phenergan with codeine, a combination medication with an opioid and histamine H1 antagonist that carries the risk of opioid addiction, abuse, and misuse, and noted that the patient refused alternative medications. Given that the submitted records did not indicate symptoms of sufficient severity to support the use of a medication with the risk of a high abuse potential, and the documented frequency of the patients refill requests, the requested medication is not medically indicated. Therefore, Phenergan with codeine is not medically necessary for the treatment of this patient.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 internal medicine and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

A 48-year-old female enrollee has requested authorization for a continuous passive motion (CPM) machine and a cold/heat therapy unit for treatment, status post anterior cruciate ligament (ACL) reconstruction.  Findings:  The physician reviewer found that while some orthopedists do use the CPM machine following ACL reconstruction surgery, there is a lack of peer-reviewed literature indicating a clear benefit from this device over physical therapy alone. Cold therapy following ACL surgery or injury is an accepted standard of care. However, there is no proven benefit from a cold/heat therapy unit over standard ice application. The peer-reviewed literature lacks well controlled studies of efficacy. While this type of unit is convenient, it is not medically indicated.
Appeal type: Experimental/Investigational
Decision: Upheld

Physician 1: The patient is a 35-year-old male requesting reimbursement for V-beam laser therapy. The patient reports experiencing facial redness and pain. The patients provider reports the patient has tried and failed conservative therapy. The patient reports the therapy has been successful and therefore, he has also requested authorization for continued V-beam laser treatments. The Health Plan has denied coverage for V-beam laser therapy on the basis it is considered investigational.The Health Plans denial should be upheld. There is no documentation of prior trial and failure of conservative therapy. Review of the relevant medical literature does not provide any evidence that laser treatment of superficial telangiectasia prevents focal edema and papular and pustular breakouts. Furthermore, this therapy is considered cosmetic in nature. Therefore, I have determined that the therapy at issue is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Plans denial should be upheld.Physician 2: The patient is a 35-year-old male requesting coverage for V-beam laser therapy for treatment of rosacea. The patient reports he has failed conservative treatment, but V-beam laser therapy has been successful. The Health Plan has denied coverage for V-beam laser therapy on the basis it is considered investigational.Review of the relevant medical literature reveals no studies demonstrating that V-beam laser therapy is more effective than standard pharmacologic treatments at reducing the symptoms of rosacea. While use of laser therapy is an acceptable treatment for rosacea, the submitted evidence does not demonstrate such treatment was medically warranted. Therefore, I have determined that the therapy at issue is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Plans denial should be upheld.Physician 3: The patient is a 35-year-old male requesting coverage for V-beam laser therapy. The submitted clinical information indicates the patient has facial redness and pain. Conservative therapy has not been effective for this patient. The Health Plan has denied coverage for V-beam laser therapy on the basis it is considered investigational.V-beam laser therapy is both safe and efficacious in the treatment of telangiectasia associated with rosacea. This is documented in the Journal of American Academy of Dermatology articles cited above. Furthermore, V-beam laser therapy is standard of care for patients such as this patient. It is not likely the patient would have benefited from topical agents. Therefore, I have determined that the therapy at issue is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Plans denial should be overturned.