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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for laboratory testing (CPT codes 86001, 88184, and 88185). Hammond and colleagues note that the gold standard for diagnosis of immunoglobulin E (IgE)-mediated food allergy remains the oral food challenge, with serum IgE testing and skin prick testing serving as acceptable alternatives. The authors further note that alternative diagnostic procedures, including IgG testing, electrodermal testing, cytotoxic testing, provocation/neutralization, and applied kinesiology, for suspected food allergies have largely been unproven and may lead to unnecessary elimination diets. In this clinical setting, immunoassays have a high positive predictive accuracy in children for several of the major food allergens. Therefore, laboratory testing (CPT codes 86001, 88184, and 88185) is not likely to be more beneficial for evaluation of the patients condition than any available standard therapy.Findings:  Three of the three physician reviewers found the requested laboratory testing (CPT codes 86001, 88184, and 88185) 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 service is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: Physician reviewer 1 is board certified in allergy and immunology and is actively practicing. Physician reviewer 2 is board certified in internal medicine and allergy and  immunology and is actively practicing. Physician reviewer 3 is board certified in allergy and immunology and pediatrics and is 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

A male enrollee requested Botox injections for medical treatment of his cervical spasticity.  Findings:  Three physician reviewers found that Hallett and colleagues report that Botox is not supported for muscle spasm or chronic neck pain. The available medical records otherwise do not demonstrate findings of torticollis or cervical dystonia for which Botox is indicated. All told the Botox injections were not and are not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.
Appeal type: Medical Necessity
Decision: Upheld

A 44-year-old female enrollee requested BRCA genetic testing for medical evaluation of her risk for breast cancer.   Findings:  The physician reviewer found that well-established guidelines identify those patients in whom genetic screening is warranted. In this case, the patients risk has been extensively evaluated by more than one geneticist that agree the patients provided family history indicates that her risk of a germ-line BRCA mutation is low, and that testing is not warranted. All told, based on the available documentation, the requested BRCA genetic testing is not supported as medically necessary for evaluation of this patients medical condition
Appeal type: Medical Necessity
Decision: Overturned

A sixty-three year-old male with a carcinoma is requesting authorization and coverage for a laryngoscopy.Reviewers Findings:  The reviewing physician found that a laryngoscopy is medically necessary to evaluate the patient for possible recurrence.  The Health Plan denial was overturned.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: A patient has requested authorization and coverage for a power scooter. The Health Plan has denied this request indicating that the requested equipment is not medically necessary for treatment of the enrollees chronic pain syndrome. The submitted documentation fails to demonstrate the medical necessity of the requested equipment. Studies show that power mobility devices are not recommended if the functional mobility deficit can be sufficiently resolved by the prescription of a cane or walker, or the patient has sufficient upper extremity function to propel a manual wheelchair, or there is a caregiver who is available, willing, and able to provide assistance with a manual wheelchair. Early exercise, mobilization and independence should be encouraged at all steps of the injury recovery process, and if there is any mobility with canes or other assistive devices, a motorized scooter is not essential to care. In this  case, the submitted documentation does not indicate the patient meets criteria for a power scooter based on the cited guidelines. The records indicate he is able to walk 100 feet independently. There is no documentation to justify why he cannot use a manual wheelchair. There is no documentation of a diagnosis which would preclude walking with a cane or a walker. Therefore, the requested power scooter is not medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested services are not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is board certified in 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: Overturned

A 61-year-old female enrollee has requested NeuroStar transcranial magnetic stimulation for treatment of her major depressive disorder.  Findings:  Two physician reviewers found that this patient has treatment-resistant depression. Multiple antidepressants and augmentation strategies have not successfully brought on remission.  There is adequate support in the medical literature for the services at issue in this patients case. Schutter reported that transcranial magnetic stimulation has a moderate effect on treatment-resistant depression. George and colleagues showed that transcranial magnetic stimulation was significantly more likely than sham treatment to produce remission in patients with treatment-resistant depression. Avery and colleagues provided evidence demonstrating that transcranial magnetic stimulation is a safe and effective treatment for major depressive disorder. In this patients case, NeuroStar transcranial magnetic stimulation provided during the said timeframe was likely to have been more efficacious than other available treatment alternatives.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for magnetic resonance imaging (MRI) of the breast for evaluation of the enrollee, who has a history of dense breast tissue.Findings:  Two physician reviewers found that MRI studies of the breast are highly sensitive, but have a relatively low level of specificity.  The literature consistently does not recommend the use of breast MRI as a replacement for routine breast mammography and ultrasound. In some studies, the specificity of breast MRI has been reported to be as low as 37%. This patient has consistently stable mammograms, which is probably the best indication that she does not have tumor.  The most valuable tool in interpreting a mammogram is a comparison with an older mammogram, especially when there are no palpable masses.  There is a lack of evidence to support the use of MRI as a surveillance tool rather than conventional mammography.  Per the records, this patient does not meet the criteria for being at high risk for developing breast cancer, which is defined as having a 20 to 25% likelihood of developing the disease.  On the mammogram report, there was no mention of inadequate imaging, and no suspicious abnormalities were seen.  The implants were intact, and there is no reason to expect an implant rupture. Final Result: Two reviewers determined that the requested services 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: All three physician reviewers are board certified in diagnostic radiology 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

A 36-year-old female enrollee has requested the use of a CPM machine for the treatment of her condition. Findings:  The physician reviewer found that there is no medical necessity for the use of CPM after total knee surgery. There is no class one study that demonstrates improved long-term outcomes with the use of CPM after routine total knee surgery. More quality outcomes data is needed to support the indications for CPM use after total knee surgery. It is not the standard of care at this time.
Appeal type: Medical Necessity
Decision: Overturned

The enrollee is requesting reimbursement for residential treatment center (RTC) services. She entered a residential treatment center after a five-day inpatient stay for an overdose. At the time of discharge, she denied thoughts of suicide, homicide, or self-harm. The Level of Care Utilization System (LOCUS), developed by the American Association of Community Psychiatrists, is a level of care assessment tool widely used by clinicians throughout the country to support accurate level of care recommendations. The six dimensions of LOCUS include risk of harm, functional status, comorbidity, recovery environment, level of support, and treatment and recovery history. The enrollee demonstrated a high risk of harm and a low ability to function. The enrollee had been unsuccessful with previous treatment attempts. The enrollee experienced difficulties with family or relationships, but did have a support system in place. The enrollees composite LOCUS score correlates with Level IV, a partial hospitalization program; however, the enrollees score of four on dimensions I, II and III requires a higher level of care.Final Result: The reviewer determined that the requested services were medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The physician 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 similar medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned

A 55-year-old female enrollee requested a water circulating cold pad with pump for medical treatment of shoulder.  Findings:  Two physician reviewers found that the device at issue was likely to be more effective for this patient than other available treatment options. The report by Ruiz-Suarez and Barber on postoperative pain control after shoulder surgery noted that postoperative management should include sleep medication, continuous cold-flow therapy and oral analgesics. In the postoperative setting, continuous-flow cryotherapy units have been demonstrated to decrease pain, inflammation, swelling, and medication usage. In this case, the device at issue was indicated for treatment of the patients postoperative arthroscopic right rotator cuff surgery. For the reasons provided, the device at issue was likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for radiofrequency ablation of the L3-4, L4-5 and L5-S1 bilateral lumbar facet. Findings:  The physician reviewer found that current guidelines for interventional techniques from the American Society of Interventional Pain Physicians states that, The evidence for therapeutic facet joint interventions is good for conventional radiofrequency. A systemic review by Manchikanti and colleagues reported Level II evidence supporting the long-term safety and efficacy of radiofrequency ablation for treatment of chronic pain in the lumbar spine. Similarly, Lee and colleagues found a reduction in pain at 12 months post procedure for patients with facet joint disease of the lumbar spine. In this case, the patient has chronic low back pain and underwent a diagnostic lumbar facet joint injection, which provided 80% relief of the pain along with functional improvements for one week. The patient has also undergone radiofrequency procedures in the past, most recently in 2019, with reported approximately eight months of relief. This outcome with lumbar radiofrequency ablation and the patients positive response to the diagnostic injection support an indication for repeat radiofrequency ablation of three lumbar facet joint levels. Moreover, this treatment plan is consistent with the current recommendations from the pain management national guidelines and evidence-based medical literature. For these reasons, the requested radiofrequency ablation of the L3-4, L4-5 and L5-S1 bilateral lumbar facet is medically necessary for 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 reviewer is board certified in anesthesiology with subspecialty certification in pain management 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 55-year-old female enrollee has requested a repeat colonoscopy for an evaluation of her risk for colon cancer. Findings:  The physician reviewer found that this patient is recommended to have a repeat colonoscopy every five years since she falls in the high-risk category based on her family history and personal history of cancer. Winawer and colleagues guidelines suggest that patients with first degree relatives who have colon cancer should be screened starting at 40 years of age and with follow-up testing every 5 years thereafter. In addition, patients with a personal history of cancer may also be at an increased risk for colon cancer and should be followed accordingly. This patient has a family history of colon cancer and a personal history of breast cancer. In congruence with the American Gastroenterological Association (AGA) guidelines discussed by Winawer and colleagues, this patient should have a repeat screening for evaluation of her risk for colon cancer, and as such, the procedure is medically necessary.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary:   An enrollee has requested eating disorder partial hospitalization program services for treatment of her behavioral health conditions. The physician reviewer found that the submitted documentation supports the medical necessity of the services at issue.  The patient was unable to adhere to her meal plan and refrain from purging.  She evidenced characterological pathology, but her eating disordered behavior continued to dominate her daily routine and contribute to signs and symptoms such as dizziness, orthostatic changes and hypertension.  The patient continued to restrict caloric intake and purge despite services being provided in the program, and there was no indication that this behavior would lessen.  Of further import, the patient had significant medical and psychiatric comorbidities which complicated the clinical picture.  She had limited social support and strained family dynamics.  Given these factors, the patient was at high-risk for relapse in the event of a premature discharge.  The partial hospital setting remained reasonably expected to improve her condition while preventing a more serious episode of illness.  In sum, the partial hospitalization program services represented a safe and appropriate disposition consistent with good medical practice.  All told, partial hospitalization services were medically indicated for the treatment of this patient.  Final Result: The reviewer determined that the services at issue were 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 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:  The enrollee requested authorization and coverage for the medication Xifaxan, 550mg tablets. The patient was having abdominal pain and bloating. A breath test was performed and was positive for bacterial overgrowth. The patients physician has advised treatment with Xifaxan. Alimentary Pharmacology and Therapeutic reported in an article entitled Systematic Review with meta-analysiss that rifaximin is effective and safe for the treatment of small intestine bacterial overgrowth that the results of the  meta-analysis provide evidence that rifaximin is clinically effective in eradicating small bowel intestinal overgrowth. The World Journal of Gastroenterology reports in an article entitled Use of rifaximin in gastrointestinal and liver disease that rifaximin has been shown to normalize the hydrogen breath test and improve symptoms in small intestinal bacterial overgrowth. The peer-reviewed scientific literature supports the use of rifaximin for small intestinal bacterial overgrowth. Clinical response rates to small intestinal overgrowth have been shown to be superior with rifaximin as compared to other antibiotics. Therefore, the medication Xifaxan is medically necessary to treat the patients medical condition. Final Result: The reviewer determined that the medication Xifaxan, 550mg tablets are medically necessary for the treatment of the enrollees medical condition.Credentials/Qualifications: The physician reviewer is board certified 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 similar medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned

A 46-year-old female enrollee has requested a continuous passive motion (CPM) machine for the treatment of her tibial plateau fracture. Findings:  Two physician reviewers found that this type of fracture is generally treated with a brace and restricted weight-bearing activity for six to eight weeks. It is important to move the knee joint during this time. The use of a CPM machine to achieve range of motion is not unreasonable or inappropriate and it certainly is not experimental. Patient compliance is high with this device, and it was likely to be more effective than the standard modalities.
Appeal type: Urgent Care
Decision: Overturned

A 43-year-old female enrollee has requested for urgent care services request indicating the services at issue were required on an urgent basis. Findings:  The physician reviewer found that the patient presented to the urgent care facility for evaluation of a growth on her right leg, which had been present for approximately two months but then bled acutely secondary to minor blunt trauma.  The patient was not in a significant degree of pain, and the bleeding had already stopped by the time that she was seen in the urgent care center. The patients symptoms did not meet prudent layperson criteria for emergency care, as a prudent layperson in the patients circumstances would not reasonably expect the absence of urgent care to jeopardize her health.
Appeal type: Experimental/Investigational
Decision: Overturned

A 63-year-old female enrollee has requested for a PET/CT scan for evaluation of her endometrial cancer.   Findings:  Two physician reviewers found that in peer-reviewed literature, PET/CT scans have been shown to be clinically pertinent in evaluation of patients with uterine cancer. The outcome of PET scans in patients with uterine cancer affected patient management in one-third of the cases according to Pandit-Tasker. Furthermore, the National Comprehensive Cancer Network (NCCN) recommends radiologic imaging for patients with incomplete surgical staging, as is the case with this patient.  PET/CT scans provide functional information in regards to metastatic disease involvement within lymph nodes. CT and MRI cannot provide functional information; they provide anatomical information only. The outcome of the PET/CT scan in this case will determine the proper radiation therapy for this patient. The proper radiation therapy treatment plan will affect the outcome of the patients known malignancy.
Appeal type: Experimental/Investigational
Decision: Overturned

A male enrollee requested Oncotype DX gene expression testing for medical evaluation of his prostate cancer.  Findings:  Two physician reviewers found that molecular profiling as obtained with Oncotype DX carries the promise of further, more accurate, risk profiling, and is useful in determining which patients would benefit from active management, and which could be safely observed. In this clinical setting the testing at issue was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.
Appeal type: Medical Necessity
Decision: Upheld

A 43-year-old female enrollee requested authorization and coverage of liposuction. The Health Plan denied the request indicating that the requested procedure is not medically necessary for treatment of the enrollees lipoma.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

Nature of Statutory Criteria/Case Summary: an enrollee has requested authorization and coverage for tobramycin. Findings:  The physician reviewer found that the patient had a positive sputum culture for Pseudomonas stutzeri, but the bronchoalveolar lavage results were not positive for this organism. The notes by the pulmonologist comment on the appearance of bronchiectasis on computed tomography, but the official radiology reports spanning a five month period did not state there was the presence of bronchiectasis.  The information provided documents only a single sputum Pseudomonas isolate (not found on bronchoalveolar lavage), and the patient does not have a documented history of recurrent infections to warrant treatment with inhaled tobramycin. 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 with sub-specialty certification in pulmonary 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.