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

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for a sleep study. The submitted documentation supports that the services at issue were medically necessary. There has been a shift in the provision of sleep study services from the in-laboratory attended setting over to the home-based environment. In this case, the patient had symptoms and complaints that were suggestive of the presence of OSA. Specifically, he complained of snoring, non-restorative sleep, and excessive daytime sleepiness. All of these symptoms are suggestive of OSA. Given that the patient had symptoms suggestive of sleep-disordered breathing and other complaints that were suggestive of OSA, it was clinically appropriate for the patient to undergo diagnostic sleep testing. The patient did not have any contraindications to the provision of services in the home setting. Accordingly, the sleep study performed for the patient was medically necessary for the treatment of the patients medical condition.Final Result: The reviewer determined that the service 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 neurology, with subspecialty certification in sleep 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: Overturned

A 54-year-old female enrollee has requested a dual energy x-ray absorptiometry (DEXA) bone density scan for an evaluation of her osteoporosis. Findings:  The physician reviewer found that osteoporosis can be prevented, and the risk for fracture decreased with proper evaluation and pharmacological treatment. The National Osteoporosis Foundation suggests that providers evaluate and treat, younger postmenopausal women and men age 50 to 69 when there is concern based on their clinical risk factor profile and women in the menopausal transition if there is a specific risk factor associated with increased fracture risk such as low body weight, prior low-trauma fracture or high risk medication. This patient is in menopause and has a family history of osteoporosis, which is a risk factor for osteoporosis. It is standard of care and consistent with the recommendations of the National Osteoporosis Foundation and the American Academy of Clinical Endocrinologists to order a DEXA scan in a postmenopausal woman with risk factors of osteoporosis. A baseline bone density study at onset of menopause is clinically indicated, (especially with risk factors such as family history) in order to counsel and determine whether pharmacological therapy is warranted. For this patient, a DEXA study of the hip and spine is medically necessary determine the proper management of her condition.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has been diagnosed with coronary artery disease, hypertension, and palpitations. Findings:  The physician reviewer found that the records noted that the patient was status post myocardial infarction with right coronary stent placement. The patient endorsed palpitations and chest pain/tightness. The patient was noted to have normal left ventricular function with an ejection fraction of 55%. Within the medical records it was noted the patient had undergone a diagnostic electrophysiology study, showing no inducible or sustained tachyarrhythmias. Cardiac event monitoring showed one event of 20 beats of paroxysmal supraventricular tachycardia (SVT). The patient reported she had no dizziness or syncope. There is no history of a transient ischemic attack or cerebrovascular accident. She underwent implantation of a loop recorder. The patient had requested reimbursement for an implantable loop recorder that was provided. The Health Plan denied the request and reported the device at issue was not medically necessary for the evaluation of this patient. At issue is whether an implantable loop recorder that was provided was medically necessary for the evaluation of the patients medical condition. Current medical evidence does not support the device at issue in this clinical setting. Of note, there is a lack of evidence that the use of implantable loop recorders changes outcomes. In this case, the patient reported palpitations and chest pain/tightness. The patient had external event monitoring which showed non-sustained SVT and sinus rhythm during symptoms. Additional monitoring is not indicated, as an external monitor is adequate to diagnose her symptoms and guide treatment. The medical evidence does not support the requested device at issue in this clinical setting. Therefore, the implantable loop recorder that was provided was not medically necessary for the evaluation of this patient. Final Result: The reviewer determined that the requested device was not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is board certified in internal medicine with sub-specialty certification in cardiovascular disease and clinical cardiac electrophysiology 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

An enrollee has requested authorization and coverage for hypoglossal nerve stimulation (Inspire Upper Airway Stimulation System).Findings:  Two of the three physician reviewers found that there is sufficient support for the requested services in this clinical setting. Although traditional upper airway surgical procedures target the anatomic component of obstruction, upper airway stimulation tackles the twin goals of improving anatomic and neuromuscular pathology. A trial demonstrated that hypoglossal nerve stimulation led to significant improvements in objective and subjective measurements of the severity of obstructive sleep apnea. This trial demonstrated that the hypoglossal nerve stimulator was safe and effective in a small subset of patients with obstructive sleep apnea who had failed CPAP, had nonconcentric airway collapse, an AHI between 20 and 50, and a body mass index less than 32 kg/m2. A recent study supported effective outcome in patients with a higher body mass index and a broader AHI range. The requested services are an effective second-line treatment for moderate to severe obstructive sleep apnea in patients who are intolerant or unable to achieve benefit with CPAP therapy. With a body mass index of 35.35 kg/m2, AHI of 63.2 and nonconcentric airway collapse, this patient meets the expanded criteria for implantation with a hypoglossal nerve stimulator. He has failed CPAP, which is the gold standard treatment for obstructive sleep apnea, and he has failed multilevel sleep surgery. He is at risk for untoward cardiac sequelae of untreated obstructive sleep apnea. Therefore, the requested hypoglossal nerve stimulation (Inspire Upper Airway Stimulation System) is likely to be superior over other available treatment options. Final Result: The reviewers determined that the requested services are 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: Physician reviewers 1, 2 and 3 are board certified in otolaryngology and are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested breast tomosynthesis for evaluation of her medical condition.  Findings: Three physician reviewers found that the addition of three dimensional digital breast tomosynthesis to two dimensional full field digital mammography resulted in a significantly higher cancer detection rate and enabled the detection of more invasive cancers. Thus, although additional studies are needed to confirm these findings, there is adequate data to support the utility of three dimensional digital breast tomosynthesis in this clinical setting. For these reasons, breast tomosynthesis was likely to be more beneficial for evaluation of this patients medical condition than any available standard therapy.  Final Result: Three reviewers determined that the diagnostic procedure at issue was 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 physician 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: Overturned

Nature of Statutory Criteria/Case Summary: The patient had been diagnosed with right knee osteoarthritis. A right knee x-ray revealed mild to moderate tricompartmental osteoarthritis. The patient reported right knee pain. Physical examination findings included right knee medial and lateral joint line tenderness. The patient reported that prior cortisone injections were not beneficial. The patient has requested authorization and coverage for a Synvisc-One (hyaluronan) injection for the right knee. The Health Plan denied the request and reported the requested service is not medically necessary for the treatment of this patient. At issue in this case is whether a Synvisc-One (hyaluronan) injection for the right knee is medically necessary for the treatment of the patients medical condition. Review of the current medical literature pertaining to viscosupplementation reveals mixed results.  Although viscosupplementation may relieve knee pain in some patients with osteoarthritis, it is unknown which patients will benefit. Viscosupplementation can only be recommended in patients with a history of lasting benefit from prior injections and in carefully selected cases where the options are limited. A clinical trial by Campos and colleagues found that viscosupplementation increased functional scores in patients with severe osteoarthritis of the knee, especially within three months of injection. In this case, the patients options are limited. The patient has tried and failed other conservative treatments. The medical evidence supports the requested service in this clinical setting. Therefore, a Synvisc-One (hyaluronan) injection for the right knee is medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested services 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 orthopedic surgery and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

A 61-year-old female enrollee has requested Flector patch for treatment of her sprain syndrome.   Findings:  The physician reviewer found that Taylor and colleagues presented a systematic review on the evaluation and management of elbow tendinopathy. The authors concluded that NSAIDs and corticosteroid injections yield moderate symptomatic relief in short-term but do not demonstrate benefit in long-term follow-up. Platelet-rich plasma injections may be advantageous in cases of chronic pain due to injury or sprain. If 6 to 12 months of non-operative treatment fails, then surgical intervention can be undertaken.While it is appropriate to avoid oral NSAIDs in combination with anti-platelet medications, the Flector 1.3% patch is not medically necessary for this patient. Overall, the treatment efficacy of the Flector patch for chronic pain and inflammation due to arthritis or sprain injury is not proven in the medical literature. Tylenol and intermittent short-acting opioids are considered safe for patients with contraindication to NSAIDs and are also efficacious as topical NSAIDs in treating inflammatory pain. All told, the requested Flector 1.3% patch twice per day is not medically necessary for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Synvisc One injection in the left knee. Per the medical literature, although viscosupplementation may relieve knee pain in some individuals with osteoarthritis, it is not known as to which individuals will benefit. The current evidence is limited, and guidelines from organizations such as the American Academy of Orthopedic Surgeons indicate that the evidence is not conclusive. In light of the foregoing, viscosupplementation can only be recommended in individuals with a history of lasting benefit from prior injections, and in carefully selected cases where everything else has been tried, and the options are limited. In this case, the patient has tried and failed other conservative treatments including physical therapy and corticosteroid injections have been tried without lasting benefit. In the absence of mechanical symptoms, arthroscopy is not indicated. Given the patients limited options and based on the current medical literature, the requested services are medically indicated. Therefore, Synvisc One injection in the left knee is medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested service 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 orthopedic surgery and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

The patient is a 31-year-old female who reports a long-standing history of panic attacks, anxiety disorder, and minor depression. Since the birth of her child, the patient reports her panic attacks, anxiety disorder, and depression have increased. She reports experiencing approximately three episodes a day. The patients physician attributes the increase in part to increased hormone levels as well as low-level depression. The patient has requested authorization and coverage for acupuncture as an alternative to medications as she is breast-feeding her child and also plans on becoming pregnant in the near future.This patient has requested acupuncture for treatment of her panic attacks, anxiety disorder, and minor depression. She states she has tried other types of treatments without any long-term benefit. Because the patient is a nursing mother and also plans on becoming pregnant again in the near future she does not at this time want to take any medication because of concerns the medication could have an adverse affect on the baby and also on her ability to become pregnant. Acupuncture is a medically reasonable and appropriate alternative for treatment of anxiety and depression and is commonly used for the treatment of these conditions. In light of the patients concerns regarding the use of medication, a trial of six acupuncture treatments is medically appropriate as an alternative to pharmacologic treatment. Therefore, I have determined that 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

An 18-year-old male enrollee has requested ultraviolet light therapy for the treatment of his cystic acne. Findings:  Three physician reviewers found that although there are many light services commonly derived from lasers that are used today for the treatment of acne they are currently considered of unproven efficacy in the treatment of acne. There are no well-controlled studies that have proven light therapy is equal to or more beneficial than standard medical therapy for treatment of acne or sebaceous gland disease. As such, there is inadequate evidence that ultraviolet light therapy was likely to be more efficacious for treatment of this patients condition than standard modalities.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary:   An enrollee has requested Xifaxan for treatment of her medical condition.  Findings:  The physician reviewer found that Xifaxan is U.S. Food and Drug (FDA) approved for the treatment of irritable bowel syndrome with diarrhea. The patient is requesting for Xifaxan to treat small intestinal bacterial overgrowth (SIBO). In this clinical setting there are multiple other antibiotics, alone or in combination, which can be used rather than Xifaxan. These antibiotics, while not compared directly to Xifaxan, are of equal efficacy. In sum, the patients request for Xifaxan for the treatment SIBO has not been established as medically necessary.   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/Qualification:  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: Experimental/Investigational
Decision: Overturned

A 57-year-old male enrollee has requested a microprocessor controlled lower limb prosthesis for the treatment of his status post amputation. Findings:  Two physician reviewers found that the microprocessor controlled lower limb prosthesis is appropriate for this patient with a transfemoral amputation and the functional level described. Though data on computer-based prostheses is still being gathered, they are routinely prescribed for patients such as this patient. Some studies find improved performance with the microprocessor controlled prosthesis. Improved mobility with decreased oxygen consumption may be critical for this patient with COPD and CAD. As such, there is sufficient evidence of the benefits of the microprocessor controlled prosthesis to support its use in this setting.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Botox for treatment of the enrollees trigeminal neuralgia.Findings: The physician reviewer found that trigeminal neuralgia (TN) is characterized by recurrent short occurrences of unilateral facial pains, abrupt in onset and termination, in the distribution of one or more divisions of the trigeminal nerve that can be triggered by stimuli involving touching or moving the face. The annual incidence of TN is 4 to 13 per 100,000 people. TN can be caused by compression of the trigeminal nerve root via various mechanism. However, it is not uncommon for the mechanism to remain idiopathic. The medical literature indicates that carbamazepine is the best studied treatment for classic TN and is established as effective in various trials. However, other medications such as phenytoin, valproic acid, pregabalin, clonazepam, and topiramate have also shown benefit. The records appear to indicate that this patients trial of oral medication was limited to carbamazepine and gabapentin. However, there are several other options with positive data for treatment of this patients TN prior to initiating Botox.  Botox therapy data is limited and at best equal to the other available standard oral medications yet to have been tried by the patient. For these reasons noted above, Botox therapy is not medically necessary for treatment of this patients medical condition. 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 neurology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for the laparoscopic anti-reflux surgery (LINX procedure). Overall, there is a lack of randomized controlled trials with long-term follow-up demonstrating that LINX is safer or more effective than standard surgical anti-reflux procedures. One evidence review concluded that the long-term safety and efficacy of LINX - both alone and in comparison to current GERD therapies - remains to be determined. Additionally, LINX more than surgical fundoplication is associated with severe dysphagia requiring endoscopic intervention. The currently available peer-reviewed literature does not support the conclusion that LINX is more likely to be beneficial in this case than standard treatment including surgical fundoplication. Further, the American College of Gastroenterology (ACG) guidelines for the management of reflux disease state that more evidence is needed before LINX can be recommended. Therefore, the requested laparoscopic anti-reflux surgery (LINX procedure) is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Findings:  Three physician reviewers found the requested laparoscopic anti-reflux surgery (LINX procedure) is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the requested laparoscopic anti-reflux surgery (LINX procedure) is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Credentials/Qualifications: Physician reviewers 1, 2 and 3 are board certified in internal medicine with sub-specialty certification in gastroenterology and are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.