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

SummaryThe patient is a 30-year-old female with a diagnosis of relapsing-remitting multiple sclerosis (MS).  She request authorization of IV rituximab.  The request was denied by the Health Plan based upon a determination that the therapy is not medically necessary.  The reviewing physician concluded that the Health Plan denial should be upheld.  Analysis and FindingsClinical Facts:  The patient has relapsing-remitting multiple sclerosis (MS). She has had a substantial progression of disability since she was diagnosed in 1999, despite treatment with Copaxone and Rebif. The patient has also been treated with courses of steroids for acute flares, but has not regained her baseline status. An evaluation in the MS clinic resulted in a recommendation for more aggressive therapy with Novantrone. The pursuit of this therapy was halted due to the report of an echocardiogram from another hospital showing an impaired left ventricular ejection fraction (LVEF). Novantrone is contraindicated in the setting of cardiac impairment due to its potential for cardiac toxicity. A recommendation was then made for treatment with Rituxan (rituximab). Following that recommendation, a second echocardiogram was performed on July 2006 which was normal, with a LVEF of 60%.  Reviewers Findings:The reviewer concluded that Rituximab has been the subject of some small studies related to the treatment of MS. It appears to be a promising candidate for immunosuppression therapy in patients with MS, however research is on-going and the clinical benefits and safety profile have not been fully established. Novantrone is indeed contraindicated for individuals with low LVEF due to its potential for cardio-toxicity. However, the patient had a normal LVEF when her cardiac status was evaluated in July 2006, and there are presently no apparent contraindications to Novantrone therapy.  Therefore, the physician reviewer found that the Health Plan denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld

A 51-year-old female enrollee requested authorization and coverage of hemorrhoidectomy for the treatment of hemorrhoids.  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 surgery is not medically necessary for treatment of the patients medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for peroral endoscopic myotomy (POEM). The Health Plan has denied this request indicating that the requested procedure is considered investigational for treatment of the enrollee who has been diagnosed with type II achalasia.Findings The American Gastroenterological Association best practice guideline for POEM states that, if the expertise is available, POEM should be considered as treatment option comparable with laparoscopic Heller myotomy for any of the achalasia syndromes. The American Society for Gastrointestinal Endoscopy has recently published a statement based on available evidence, stating that POEM is a potential attractive option for the treatment of achalasia that offers a minimally invasive endoscopic approach to myotomy with the potential for a durable response to therapy . In this patients case, she presents with severe symptoms not improved with proton pump inhibitor therapy. The use of POEM in this clinical setting is supported by current medical literature and guidelines.  For these reasons, POEM is likely to be of greater benefit for treatment of the patients medical condition than any available standard treatment modality.Final Result: All three reviewers determined the requested procedure is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications:  All three reviewers are board certified in internal medicine with sub-specialty certification in 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: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Acessa laparoscopic radiofrequency ablation procedure. Researchers concluded that, laparoscopic radiofrequency ablation therapy is efficacious for small-sized and non-pedunculated symptomatic uterine fibroids. Based on this review, this patient is not a suitable candidate for the Acessa laparoscopic radiofrequency ablation procedure. The patients fibroid is pedunculated and measures 6.9 x 4.8 x 7.1 cm. In addition, the patient previously underwent magnetic resonance guided treatment of her myomas, and there is a lack of data demonstrating that subsequent radiofrequency in this clinical setting is safe and effective. The patient has heavy bleeding and symptoms related to her fibroid uterus. Palpation of the myoma causes pain. The patients heavy bleeding is likely related to the submucosal fibroid. Myomectomy would address the pedunculated fibroid, while hysteroscopic myomectomy can be used to remove the submucosal fibroid. The patient has indicated that she would like to preserve her fertility, and the Acessa procedure is not recommended if a pregnancy is planned. In addition, Acessa is not suitable for pedunculated fibroids. Accordingly, the requested Acessa laparoscopic radiofrequency ablation procedure (CPT 58674) is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Findings:  Two of the three physician reviewers found the requested Acessa laparoscopic radiofrequency ablation procedure (CPT 58674) 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 services are 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 reviewers 1, 2, and 3 are board certified in obstetrics and gynecology and are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for opioid pain medication for treatment of his chronic low back pain. Findings:  The physician reviewer found that chronic pain that is unable to be cured can be considered palliative in nature and treatment. The stepwise World Health Organization (WHO) ladder for pain relief is considered the reasonable approach to pain control in the palliative setting. However, in this patients case, not all non-opioid treatment options have been optimized or tried. Also, behavior therapy was discussed but not completed despite much research to support its use. Medical literature have shown that continuation of prescribing opioid medications, at higher doses, without proper treatment for the drug use, sets the patient up for higher morbidity and mortality. Moreover, the medical evidence supports consideration of alternatives to opioids and to plan for patients to taper off opioids. In addition, any continuation of opioid medication should be under the direct guidance of a mental health professional, given some documentation that this patient had taken someone elses pain medication. Finally, there was no clear objective functional goals for the additional opioids being requested and there was no evidence provided for using long acting opioids before exhausting the use of short acting opioids. There is sufficient support to offer interventional treatments for this patient's pain. For the reasons stated above, the requested opioid pain medication is not medically necessary for 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 anesthesiology with sub-specialty certification in pain 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: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for gene panel testing. The American College of Obstetricians and Gynecologists (ACOG) has issued recommendations for expanded carrier screening for genetic disorders in all women before and during pregnancy. The ACOG guidelines recommend that each healthcare provider should establish a standard approach for ethnic-specific, panethnic, or expanded carrier screening. Women should be screened for common conditions such as spinal muscular atrophy, cystic fibrosis, hemoglobinopathies and fragile X. The guidelines also recommend expanded carrier screening, which tests for as many as several hundred conditions simultaneously, as an acceptable strategy for prenatal carrier screening. Screened conditions should be able to be diagnosed prenatally and have potential opportunities for antenatal intervention to improve perinatal outcomes, changes to delivery management to optimize newborn and infant outcomes, and parental education about special care needs after birth. Given these findings, the gene panel was likely to have been more beneficial than any available standard evaluation for this patients medical condition.Final Result: One reviewer found that the gene panel was not likely to have been more beneficial than any available standard evaluation for this patients medical condition. Two of the three reviewers determined that the service 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: One reviewer is board certified in genetics with sub-specialty certification in clinical cytogenetics and is actively practicing. One Reviewer is board certified in pediatrics with with sub-specialty certifications in genetics and clinical biochemical genetics and is actively practicing. One Reviewer is board certified in pediatrics with sub-specialty certifications in neurodevelopmental behavioral pediatrics and genetics and is 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 62-year-old male enrollee has requested laparoscopic cryotherapy for the treatment of renal mass.  Findings:  The physician reviewer found that the submitted imaging study confirms the finding of a left renal mass measuring 3.5 cm. This study is sufficient to recommend intervention. The surgical options include a partial nephrectomy or a radical nephrectomy. The proposed option of tumor ablation either through a percutaneous or laparoscopic approach is still being studied. Although there have been favorable findings to date, further studies with long-term follow-up are required before the durability of these techniques is known.
Appeal type: Medical Necessity
Decision: Upheld

The patient has requested authorization and coverage for lumbar home traction device. The current data from peer-reviewed, published studies do not support mechanical lumbar traction as clinically effective in the management of chronic low back pain. While data suggest some short-term pain and functional benefits, the data in favor of these findings have also cautioned that these improvements are temporary. Researchers found that compared to no traction or sham treatment, lumbar traction exhibited significantly more pain reduction and functional improvement in the short-term, but not in the long-term. This patient presents with left hip and buttock pain that has been resistant to medications and physical therapy. However, there is a lack of medical literature demonstrating that lumbar traction is appropriate for treatment of this patients symptoms. All told, the requested lumbar home traction device is not medically necessary for treatment of this patient. Final Result: The reviewer determined that the requested device 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 physical medicine and rehabilitation and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

The enrollee is requesting reimbursement for intensity-modulated radiation therapy (IMRT) services. This enrollee has a diagnosis of glioblastoma multiforme of the right temporal lobe, World Health Organization grade IV.  At a follow-up visit, the records indicate the enrollee underwent gross total resection of the right temporal lobe lesion. He had recovered from surgery quite well.  The enrollee does have a small left visual field deficit that has persisted. However, he reported his balance has improved.  He was not having seizures and there were no significant neurologic deficits.  The enrollee was alert and oriented with 5/5 strength to the upper and lower extremities. Clinically and radiographically, the enrollee was stable. Multiple published studies on IMRT for glioblastoma multiforme (GBM) have demonstrated that IMRT provides significantly improved radiation dose distribution to the tumor with sparing of adjacent normal brain tissues over a Three Dimensional (3D) conformal radiation therapy plan. With superior dose conformity to target volume and sparing of adjacent normal brain tissues with potential of decreasing risks of radiation related complications, such as brain necrosis, damage to optic nerve/chiasm and brain stem, IMRT has been accepted as a standard of care for enrollees with primary brain tumor in a clinical practice guideline for CNS (central nervous system) tumors. The record detailed this enrollees diagnosis of GBM and the literature supports conformal radiotherapy techniques including three-dimensional conformal radiation therapy and IMRT partial brain irradiation are recommended.  Final Result: The reviewer determined that the requested service is medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The physician reviewer is board certified in radiation oncology 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: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for bilateral custom shoe inserts. Neville and Lemley note that while data are limited on the various orthotic devices available for patients with stage II posterior tibial tendon dysfunction, custom devices were associated with greater hindfoot inversion and forefoot plantarflexion compared to walking with only a shoe, and that the off-the-shelf device was associated with forefoot plantarflexion but no change in hindfoot motion. Richie notes that in the management of adult acquired flatfoot deformity resulting from posterior tibial tendon dysfunction, ankle-foot orthoses may arrest the progression of deformity and help the patient avoid debilitating surgery. In this case, the patient has right posterior tibial tendonitis and has tried and failed treatment with over-the-counter orthotics. Given that custom shoe inserts and orthotics may control the abnormal biomechanics of the foot and alleviate excessive pressure from the posterior tibial tendon insertion, the requested equipment is medically indicated. Therefore, bilateral custom shoe inserts are medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested equipment is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is a licensed D.P.M., board certified in podiatry, 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 substance abuse intensive outpatient program services for treatment of her behavioral health conditions.   Findings:  The physician reviewer found that the submitted documentation supports the medical necessity of the services at issue.  This patients pattern of substance use was unlikely to change with outpatient and community resources alone.  The treatment team outlined a reasonable rationale supporting continued intensive outpatient program treatment.  The patient had made progress but had not yet consolidated the treatment gains necessary to succeed in the outpatient setting as she continued to experience craving and act impulsively in the context of a poorly developed sense of self, affective symptoms and anxiety.  The treatment provided was, and remains, reasonably expected to improve the patients condition while preventing a more serious episode of illness via relapse.  Further, the duration of care for a case of this complexity falls within typical community standards.  In sum, substance abuse intensive outpatient program services were and are medically indicated for the treatment of this patient. Final Result: The reviewer determined that the services at issue were and 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 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: Upheld

Nature of Statutory Criteria/Case Summary:  The parent of an enrollee has requested Alinia for treatment of the enrollees bacterial overgrowth.  The physician reviewer found that small intestinal bacterial overgrowth is a difficult condition to reliably diagnose and treat. There have been several studies showing some effectiveness of broad-spectrum or poorly absorbed antibiotics, such as metronidazole, trimethoprim-sulfamethoxazole, and rifaximin, in this condition. However, there is a lack of evidence that Alinia has a role in the management of small intestinal bacterial overgrowth. Alinia is useful in the treatment of intestinal infection with pathogens such as Giardia lamblia, Cryptosporidium parvum, and a variety of other intestinal parasites. Alinia is also being actively studied as a treatment for viral infections, including some which affect the gastrointestinal tract. This patients records do not include documentation of Giardia lamblia, Cryptosporidium parvum, or other intestinal parasites that are considered indications for Alinia. For these reasons, the requested Alinia 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 pediatric 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 64-year-old female enrollee has requested for biofeedback therapy for treatment of her pelvic floor tension myalgia.   Findings:  Three physician reviewers found that the study by Cornel, et al. regarding the effect of biofeedback physical therapy in men with chronic pelvic pain syndrome concluded that biofeedback physical therapy had a significant effect on pelvic floor muscles. All told, there is sufficient evidence supporting the efficacy of biofeedback for treatment of pelvic floor tension myalgia to support its use by this patient, particularly since standard therapies have been ineffective.
Appeal type: Medical Necessity
Decision: Overturned

The patient is a 26-year-old female with a body mass index (BMI) of 40. She has comorbid conditions of back and joint pain. She has requested authorization for gastric bypass surgery. The Health Plan has denied the patients request. She has undergone a psychological evaluation and is considered an appropriate candidate for weight loss surgery.With a BMI of 40 the patient meets nationally accepted medical necessity criteria for consideration of weight loss surgery. In addition, the patient has undergone a psychological evaluation and is considered an appropriate candidate for weight loss surgery. Furthermore, scientific evidence does not show that structured weight management plans consisting of diet and exercise have been successful in the treatment of the morbidly obese. The study referenced above demonstrates that surgery has the best long-term outcome for the morbidly obese. Therefore, I have determined that the requested procedure is medically necessary for treatment of the patients medical condition. The Health Plans denial should be overturned.