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

The patient has requested authorization and coverage for an insulin pump.  Insulin pump therapy can be beneficial in patients with diabetes type 1 who are able to monitor and inject bolus insulin prior to meals. Insulin pump therapy can improve the rates of nocturnal hypoglycemia, whereas multiple doses of insulin or basal bolus therapy has been associated with less frequent diabetes ketoacidosis. Blood glucose targets should be individualized for patient age, insulin regimen, level of supervision, and other lifestyle issues, with the goal of achieving as many glucose values as close to target as possible without excessive hypoglycemia. This patient has been treated with the Medtronic 670G insulin pump that has the added technology of automated suspension of insulin delivery when a hypoglycemic threshold is crossed. However, the records indicate that the patient has been using the pump in manual mode. The patient would likely benefit from additional diabetes education to maximize the effectiveness of her current device. In addition, the records do not document that the patient has been checking her glucose levels before meals, which is essential to self-management of diabetes type 1. All told, the requested insulin pump is not medically necessary for treatment of this patient. Final Result: The reviewer determined that the requested equipment 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 with subspecialty certification in diabetes, endocrinology and metabolism 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 nine-year-old female who has a history of bipolar disorder and narcolepsy. The patient has failed a trial of Ritalin. The diagnosis of narcolepsy is based on a polysomnogram. The Health Plan indicates there was a discrepancy in the  sleep latency results and no confirmation of any REM time. In April 2005, the patients physician recommended she try Provigil. A six-week trial of Provigil was clinically effective. The Health Plan has denied authorization and coverage for the requested medication indicating the patient does not meet Health Plan criteria for Provigil.The diagnosis of narcolepsy is based on a polysomnogram and has not been confirmed. Further, the patient is a pediatric patient. FDA approval for Provigil in children has not been established. Though there is some data to support the efficacy of Provigil for treatment of narcolepsy in the pediatric age group, the diagnosis of narcolepsy has not been confirmed in this case. Thus, there is an insufficient foundation for continuing the use of Provigil in this patient. At this time, there is insufficient peer-reviewed literature investigating Provigil for the pediatric age group. There should be further investigation to establish the patients diagnosis and a subsequent treatment plan. Accordingly, I have determined the requested medication is not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested a 3.0 Tesla magnetic resonance imaging (MRI) of the thoracic spine, cervical spine and lumbar spine for evaluation of her thoracic spine pain.  Findings:  The physician reviewer found that the submitted documentation fails to establish the medical necessity of the services at issue. In this clinical setting, the medical literature does not support the use of Tesla 3.0 MRI. Moreover, a 1.5 Tesla MRI is the standard of care for the re-evaluation of this patients spine. There is a lack of medical literature supporting the medical necessity of a 3.0 Tesla study for chronic back pain. Based on the medical literature and clinical documentation provided, a 3.0 Tesla MRI of the thoracic spine, cervical spine and lumbar spine was not medically necessary for evaluation of the patients medical condition. 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 diagnostic radiology with sub-specialty certification in interventional 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: Experimental/Investigational
Decision: Overturned

A 53-year-old male enrollee has requested epidural steroid injections for treatment of his pain.  Findings:  Three physician reviewers found that this patient had a documented lumbar MRI consistent with his pain. The patient has tried and failed to receive relief with NSAIDs.  He has participated in physical therapy and a home exercise program.  The patient reported exacerbation of his pain following physical therapy.  The pain physician has provided educational, and psychosocial support, as well as a trial of narcotic therapy.  Vad and colleagues performed a prospective randomized study on transforaminal epidural steroid injections in lumbosacral radiculopathy. The authors concluded that fluoroscopically guided transforaminal epidural injections serve as an important tool in the nonsurgical management of lumbosacral radiculopathy secondary to a herniated nucleus pulposus. Botwin and colleagues found that fluoroscopically guided transforaminal epidural steroid injections may help reduce unilateral radicular pain and improve standing and walking tolerance in patients with lumbar degenerative spinal stenosis. Rosenberg and colleagues performed a prospective study to determine the effectiveness of transforaminal epidural steroid injections. They found that epidural steroid injections can offer significant pain reduction for up to one year after initiation of treatment in patients with discogenic pain and possibly in patients with spinal stenosis.  In this patients case, the requested epidural steroid injections are likely to be more efficacious than other treatment modalities.
Appeal type: Experimental/Investigational
Decision: Upheld

A 79-year-old male enrollee has requested a Zio Patch Monitor for evaluation of his syncope.   Findings:  Two physician reviewers found that the requested Zio Patch Monitor is not likely to be more effective for this patient than other available options. The Zio Patch Monitor, a 14-day wireless adhesive patch cardiac monitor, has compared favorably with a 24-hour conventional Holter monitoring in identifying cardiac dysrhythmias. This was reported in the study by Barrett and colleagues. Moreover, there is a lack of data at this time to demonstrate the clinical superiority of the Zio Patch Monitoring over conventional long term monitoring devices such as loop or event monitors in the diagnosis of clinical syncope. For the reasons provided, the requested services are not likely to be more beneficial for evaluation of the patients medical condition than other standard therapies.
Appeal type: Medical Necessity
Decision: Upheld

The patient is a 52-year-old male with recurrent sigmoid diverticulitis. Surgical resection of the sigmoid colon has been recommended. The patient wishes to have the procedure performed laparoscopically by a colorectal surgeon. The Health Plan has referred the patient to a general surgeon for consultation regarding possible surgical intervention.Standard therapy for recurrent sigmoid diverticulitis is sigmoid colectomy. The most appropriate method of resection today is via a laparoscopic approach. This technically advanced, demanding operation requires the skills of surgeon specifically trained and experienced in laparoscopic colon resection. The inflammatory nature of this disease makes surgical resection technically more difficult and therefore requires someone well versed in the laparoscopic approach. Medical literature supports the laparoscopic approach in diverticulitis. There are fewer complications, shorter hospital stays, and a more rapid return to pre-hospital activities. Although it is not medically necessary for a board certified colon and rectal surgeon to perform the laparoscopic sigmoid colectomy, the patient should be referred to a surgeon with extensive experience in laparoscopic colon surgery. The literature documents a minimum number of cases between 15 and 40 to show proficiency in this procedure. This does not necessarily mean that a board certified colorectal surgeon must be chosen, as there are many with minimal to no laparoscopic colon surgery experience. The patient should be referred to a surgeon, whether general or colorectal, who has extensive experience in laparoscopic colon surgery. Therefore, I have determined the requested referral is not medically necessary for treatment of the patients medical condition at this time. The Health Plans denial should be upheld at this time.
Appeal type: Urgent Care
Decision: Upheld

An enrollee has requested reimbursement for mental health treatment services received for treatment of experiencing a psychiatric emergency. Findings:  The physician reviewer found that patients who are experiencing a psychiatric emergency medical condition are considered an imminent danger to themselves or others. This can be due to a variety of factors including, mania, psychosis, suicidal ideation, homicidal ideation, delusions and delirium. Per the submitted documentation, the patient had none of these symptoms. Upon admission, the patient did not have any suicidal or homicidal ideation. She was anxious and depressed. The patient on multiple occasions stated that she preferred to be treated in a less restrictive environment as an outpatient. The patient stated that she felt stable and wished to be discharged home. Although the patient required treatment for her anorexia nervosa, anxiety and depression, the services rendered are not considered emergent services as defined above.  All told, based upon the submitted documentation, the patient was not experiencing a psychiatric emergency medical condition. Final Result: The reviewer determined that the patient did not receive psychiatric emergency medical services on the dates of service at issue. 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: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for sacroiliac surgery. Findings:  The physician reviewer found that there is sufficient support for the requested services in this patients case.  She presents with persistent left-sided buttocks pain radiating into the left posterior thigh and calf, with numbness and tingling down the leg.  Functional difficulty was documented in sitting tolerance and sleep.  She is eight years status post L4-5 lumbar fusion. There was evidence of long-term conservative treatment with activity modification, medications, sacroiliac injections, and sacroiliac radiofrequency ablation.  Clinical examination findings have documented tenderness at the left sacroiliac joint with three positive sacroiliac provocative tests.  There is radiographic evidence of sacroiliac joint spurring. She has been diagnosed with sacroiliitis.  There is evidence of an L5-S1 disc protrusion with annular fissure, but no physical examination or imaging evidence of nerve root compression.  Multiple left sacroiliac joint injections have produced at least 75% pain relief.  The current medical evidence supports the requested services in this clinical setting.  All told, the requested sacroiliac surgery is medically necessary for the treatment of this patient. 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 physician 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: Experimental/Investigational
Decision: Upheld

A 58-year-old female enrollee has requested robot assisted laparoscopic abdominal perineal resection with lymph node dissection and colostomy for the treatment of her rectal cancer. Findings:  Three physician reviewers found that robotic surgery is the most recent development in the field of minimally invasive surgery, having been approved by the Food and Drug Administration for clinical use in 2000. The benefits touted by its proponents include a magnified 3D view of the operative field, increased manual dexterity, elimination of surgical tremor and decreased surgeon fatigue. The reported disadvantages include a steep learning curve with initial increased operative times. There are numerous reports in the medical literature showing that robot assisted laparoscopic rectal surgery is safe and effective, yet there is a paucity of evidence demonstrating that the procedure is superior to traditional laparoscopy. Patriti and colleagues noted that, Robot-assisted surgery is considered an evolution of traditional laparoscopy, but little data support any real benefits of the technology. Ng and colleagues stated: Although the laparoscopic approach in colorectal surgery has been shown to be beneficial and oncologically safe, its use is still not widespread. Hellan and colleagues indicate that future studies are still needed to determine the long-term oncological outcomes of robotic-assisted total mesorectal excision. Therefore, while this patient would likely benefit most from laparoscopic resection, the robotic assistance is not medically indicated.
Appeal type: Medical Necessity
Decision: Overturned

The patient is a 58-year-old female who has treatment refractory depression with suicidal ideation that has failed to respond to several medications such as Zoloft, Celexa, Wellbutrin, Effexor and Effexor augmented with Ritalin. However, her physician states she has had a response to Effexor and Provigil with her mood becoming euthymic with a cease in suicidal ideation and an increase in her interest in work. She is requesting further treatment with Provigil. The Health Plan has denied this request and has recommended empiric trials of other medications. This patient is stable on her current medications including Provigil. There is a growing body of evidence indicating Provigil is effective in the treatment of depression. There is no medical indication to have the patient start new empiric trials, which may or may not be effective. There is potential if the patient is taken off her current medications and new trials are initiated the patient could deteriorate leading to hospitalization. The patient is benefiting from her current medication regimen and there is sufficient evidence in the medical literature to support Provigil as useful for treatment of her condition. Therefore, I have determined that the requested medication is medically necessary for treatment of the patients medical condition. The Health Plans denial should be overturned.
Appeal type: Experimental/Investigational
Decision: Upheld

A 52-year-old female enrollee has requested for subcutaneous hormone pellet implantation for treatment of her low estrogen level. Findings:  Three physician reviewers found that replantable estrogen pellets remain unproven at this time. There are alternative patches with different adhesives and chemical formations that do not appear to have been tried in this case. Additionally, there are multiple oral agents that can be used. Furthermore, the patients measured estradiol levels post patch and pellet implantation are 150 to 200% of the upper limits of normal. These are not physiological levels and may have serious potential negative consequences, i.e., VTE, CVD, dyslipidemia, etc. There is no substantive data on the efficacy or safety of the pellets compared to standard dermal and oral therapy.
Appeal type: Medical Necessity
Decision: Upheld

A 39-year-old male enrollee requested authorization and coverage of an MRI of the cervical spine for the treatment of neck pain.  The Health Plan denied the enrollees request indicating that the requested treatment is not medically necessary.One physician reviewer performed a medical necessity Independent Medical Review.  The physician reviewer upheld the health plans denial on the basis that the requested services are not medically necessary for treatment of the patients medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned

A 32-year-old female enrollee has requested Botox injections for treatment of her migraines.  Findings:  Two physician reviewers found that in the past, the patient has tried multiple medications for her headaches including Maxalt, naproxen, Imitrex, Tylenol, Tylenol #3, Vicodin, and Topamax without substantial relief or with intolerable side effects. Although Botox is not a first-line therapy for migraine or chronic headaches, there is adequate literature supporting its use for patients with refractory headaches. Examples of some clinical studies are provided above. In this particular case, the patient has tried many first-line therapies without success or with side effects. For these reasons, treatment with Botox is medically reasonable. A reassessment after 12-15 months should be considered to determine if the patient has sustained continued benefit. Accordingly, I have determined the requested therapy is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.
Appeal type: Medical Necessity
Decision: Upheld

A 29-year-old male enrollee has requested coverage for acupuncture services for treatment of his shoulder, arm, leg and entire back pain.  Findings:  The physician reviewer found that review of the submitted documentation and relevant literature fails to demonstrate the medical necessity of the services at issue. According to the documentation submitted for review, the patient has had an unknown number acupuncture sessions for the treatment of his condition. The medical records fail to document a pre-care baseline in order to assess the benefits of an acupuncture trial. In addition, there are no measurable, objective symptoms, functional deficits improvements documented in order to support the medical necessity of the acupuncture services. Furthermore, the peer review literature cited above indicates that the use of acupuncture for the treatment of the patients condition is modest at best, suggesting that further research for is needed. Johansson and colleagues studied the effects of acupuncture and transcutaneous electrical nerve stimulation on functional outcome and quality of life after stroke versus a control group that received subliminal electrostimulation. The authors concluded, When compared with a control group that received subliminal electrostimulation, treatment during the subacute phase of stroke with acupuncture or transcutaneous electrical nerve stimulation with muscle contractions had no beneficial effects on functional outcome or life satisfaction. Based on the medical literature cited above and the documentation submitted for review, the services at issue were not and are not medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld

A 20-year-old male enrollee has requested for aquatic physical therapy for treatment of his Duchennes muscular dystrophy. Findings:  The physician reviewer found that Duchennes muscular dystrophy has a progressive course. As the muscles get progressively weaker, passive range of motion therapy may be needed to preserve joint range of motion.  Exercise in an aquatic setting may be appropriate to provide significant body weight unloading due to the profound motor weakness.There is no marginally significant benefit with respect to health or functional outcomes would be expected for this patient with the aquatic physical therapy under review provided in a formal setting over caregiver-supervised exercises and passive range of motion therapy.  Loss of range of motion and development of contractures is common in the setting of pediatric neuromuscular disease despite formal therapy.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage of Xifaxan (rifaximin) 550 mg three times daily for 14 daysFindings:  The physician reviewer found that there is support in the medical literature for the medical necessity of the requested medication in this clinical setting. Xifaxan has been proven effective for the treatment of irritable bowel syndrome, diarrhea-predominant. Unlike alternatives, the U.S. Food and Drug Administration (FDA) has approved Xifaxan for the treatment of IBS-D. The medication has been proven safe and effective in randomized placebo controlled trials for IBS-D. In the TARGET-3 trial of over 1,000 patients, Xifaxan 550 mg three times daily (the requested dose) proved effective with significant symptom improvement in irritable bowel syndrome. The American College of Gastroenterology guidelines for the treatment of irritable bowel syndrome state that Xifaxan is effective. The patient has already attempted alternatives such as dicyclomine with adverse effects. Additionally, the patient has small intestinal bacterial overgrowth and failed Augmentin. Xifaxan has proven highly effective in small intestinal bacterial overgrowth for eradication of bacteria and symptom relief . For bacterial overgrowth, eradication was demonstrated in 80% versus 54% for placebo. The medication had greater effectiveness with fewer side effects than antibiotic alternatives such as metronidazole, neomycin, and fluoroquinolones such as ciprofloxacin .  Results are sustained for several weeks after treatment. For these reasons, Xifaxan 550 mg three times daily for 14 days 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.