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

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the bone density test.Findings:  Three physician reviewers found that there is a lack of support for the services at issue in this clinical setting. As noted by the medical literature, peripheral bone density testing may be used for diagnosing osteoporosis when the hip and lumbar spine cannot be measured or are uninterpretable. According to the International Society for Clinical Densitometry (ISCD), central dual-energy x-ray absorptiometry (DEXA) measurements at the spine and femur are the preferred method for making therapeutic decisions. Per ISCD, peripheral DEXA devices are not clinically useful in monitoring the skeletal effects of presently available medical treatments for osteoporosis. This patient had an established diagnosis of osteoporosis, and she has been treated with bisphosphonates. Per the current medical evidence, peripheral bone density testing may be used for the diagnosis of osteoporosis in patients when the hip and lumbar spine cannot be measured or are uninterpretable, which is not documented in this case. In sum, the bone density test was not likely to have been of greater benefit than other methods of evaluating this patient.Final Result: The reviewers determined that the services at issue 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: Physician reviewers 1, 2 and 3 are board certified in internal medicine with sub-specialty certification in endocrinology, diabetes and metabolism 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 34-year-old female enrollee has requested a viral load test for evaluation of her hepatitis C.  Findings:  The physician reviewer found that there is documentation of the patient having the hepatitis C virus by a polymerase chain reaction (PCR) assay in the past and therefore the diagnosis of hepatitis C is not in question. The patient has minimal liver disease and prohibitive contraindications to therapy at this time. The only reason to repeat a hepatitis C viral load at some point in the future would be if she became a candidate for treatment. The absolute viral level has little prognostic value concerning progression of her liver disease. As noted by the patients provider, the most immediate concern is that the patient complete the chemical dependency program so that she can pursue treatment of her hepatitis C. The medical necessity of a viral load test has not been established.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for gene panel testing. Findings:  The physician reviewer found that  There is a lack of clinical data to support the efficacy of the requested services in this clinical setting. Hereditary ataxia (spinocerebellar degeneration) syndromes are in the differential diagnosis of this patients clinical history and findings.  The medical studies do not identify treatment options which are dependent on the results of the proposed genetic testing.  As such, there is a lack of support in the clinical studies to indicate that the requested gene panel testing for this patient would produce health benefits. Therefore, the requested gene panel testing is not likely to be superior to the available standard treatment options for the evaluation of this patients medical condition.Final Result: The reviewers determined that the requested services are 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: Physician reviewer are board certified in neurology 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: Upheld

Nature of Statutory Criteria/Case Summary:  An enrollee has requested the LINX reflux management system for treatment of his medical condition.   Findings:  Two physician reviewers found that according to the study by researchers, Sphincter augmentation with the LINX Reflux Management System provided long-term clinical benefits as demonstrated by reduced esophageal acid exposure, improved GERD-related quality of life, and cessation of dependence on [proton pump inhibitors] PPIs, with minimal side effects. In this case, the patient has GERD and Barretts esophagus. However, there is a lack of studies in the medical literature demonstrating the safety and efficacy of the LINX procedure in patients with Barretts esophagus. Therefore, the LINX procedure is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Final Result: Two 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:   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 reimbursement for Wound treatment (amniotic membrane allograft skin transplant (CPT 15275 and HCPCS Q4150). The records provided for review document that this patient sustained extensive left lower extremity crush injuries due to a motorcycle accident in 2017. He underwent multiple left foot surgeries and all of his extensive bony and soft tissue injuries have healed. He continued to have a 2 x 1 cm open wound over the lateral calcaneus that would did heal despite more than one year of Silvadene and wet-to-dry dressing changes. He underwent left heel application of skin substitute graft, utilizing dehydrated human amnion/chorion membrane (dHACM). Based on current peer-reviewed medical literature, there is a lack of large volume, long-term outcome studies to support the use of dHACM allograft for this patient (Caporusso, et al.; Kogan, et al.). Zelen and colleagues reported substantial preclinical and clinical evidence supporting the rationale and effectiveness of dHACM as a treatment modality. However, there is a lack of adequate clinical support to establish the value of dHACM for chronic tissue repair and regeneration in lieu of standard of care medical products. For these reasons, the wound treatment (amniotic membrane allograft skin transplant (CPT 15275 and HCPCS Q4150) was 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 wound treatment (amniotic membrane allograft skin transplant (CPT 15275 and HCPCS Q4150) was 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 services at issue were 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 orthopedic surgery 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: Overturned

The patient is a 53-year-old female with back pain and a diagnosis of scoliosis and segmental somatic spinal dysfunction with her cervical and lumbar spine. She requests additional chiropractic care of six treatments over three months. The treating record reveals x-ray findings of scoliosis at her thoracic and lumbar spine. A review of the submitted records does not reveal a developed and practiced home program of concurrent self-care. The Health Plan has denied further chiropractic care recommending referral to a physical therapist. The patient finds the chiropractic care to be helpful and has requested reconsideration of her authorization request. At issue is whether the requested chiropractic services are medically necessary for treatment of the patients medical condition.The patients diagnosis is one that is treatable by both physical therapy and chiropractic. The patient has benefited from chiropractic and wishes to continue receiving treatments. The requested chiropractic care of six treatments over three months is medically reasonable and necessary for the patients diagnosis and her current status. It is also appropriate for the patient to receive concurrent physical therapy given her diagnosis. The treatment goals should be similar but the physical therapy sessions should focus on home program development. Based upon the information set forth above, I have determined the requested services are medically necessary for treatment of the patients medical condition. The Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Cialis 5 mg for treatment of his enlarged prostate with lower urinary tract symptoms. Findings:  The physician reviewer found that the records provided for review document that this patients irritative lower urinary tract symptoms and erectile dysfunction were improved substantially with Cialis. His urinary tract symptoms have been treated with multiple medications including alpha blocker therapy and finasteride. His symptoms have been resistant to treatment. However, his urinary tract symptoms have responded to daily Cialis. Although this is considered a third-line therapy, it is has been successful for this patient following failure of first- and second-line therapies. Furthermore, daily Cialis has reportedly helped his erectile dysfunction. 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 urology 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 Xifaxan for treatment of his irritable bowel syndrome.  The physician reviewer found that Xifaxan has proven effective for eradication of bacterial overgrowth and for symptom relief in randomized and retrospective studies at high dose. Eradication was demonstrated in 80% versus 54% for placebo. The medication had greater effectiveness with fewer side effects than alternatives such as metronidazole and levofloxacin. Xifaxan has also proven effective to alleviate symptoms in patients with irritable bowel syndrome with positive lactulose breath test. This improvement was observed for a period of three months after two weeks of treatment with rifaximin 800 mg daily. In addition, a prospective trial of patients with IBS and a positive breath test found that 86% responded to rifaximin, and IBS symptoms were reduced as well. For these reasons, the request for Xifaxan is supported as medically necessary for the treatment of the patients irritable bowel syndrome with bacterial overgrowth. Final Result: The reviewer determined that the requested medication is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.  Credentials/Qualifications: The reviewer is board certified in internal medicine with sub-specialty certification in gastroenterology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

A 60-year-old female enrollee has requested  for Hyalgan injections for treatment of her osteoarthritis and chondral tear.       Findings:  The physician reviewer found that this patient does not require treatment with Hyalgan injections at this time.  She should undergo a documented trial of at least two different non-steroidal anti-inflammatory drugs before pursuing Hyalgan injections. The submitted clinical evidence does not establish that treatment with Hyalgan is clinically indicated at this time.
Appeal type: Medical Necessity
Decision: Upheld

A 46-year-old female enrollee requested authorization and coverage of a Stretta procedure. The Health Plan denied the request indicating that the requested procedure is not medically necessary for the treatment of the enrollees gastroesophageal reflux disease (GERD).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: Experimental/Investigational
Decision: Upheld

A 57-year-old female enrollee has requested ritixumab (Rituxan) for the treatment of her progressive multiple sclerosis. Findings:  Two physician reviewers found that this patients disease is progressing despite Rebif therapy. A number of immunomodulatory and immunosuppressive therapies have been tested for efficacy in the treatment of primary progressive MS and none have shown to be effective. Rituxan has recently been studied (Hawker and colleagues). In that study, while there was a subclass of younger patients (less than 51 years of age) who may have had some positive response to the treatment, Rituxan showed no effect on overall accumulation of disability in patients as compared with placebo. Furthermore, the article by Hauser and colleagues submitted with this appeal pertains to patients with relapsing forms of MS. In summary, the medical literature does not reveal that Rituxan has utility in the treatment of primary progressive MS. In addition, Rituxan therapy carries risk of infection and side effects such as progressive multifocal leukoencephalopathy.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Myoelectric elbow-wrist-hand orthosis. The Health Plan has denied this request, indicating that the requested device is not medically necessary for treatment of the enrollees left middle cerebral artery (MCA); and posterior cerebral artery (PCA) stroke.At issue in this case is whether the requested Myoelectric elbow-wrist-hand orthosis is medically necessary for treatment of the enrollees medical condition.The medical literature regarding this type of device is limited to preclinical work, developmental work and small anecdotal reports reporting potential for benefit (Ren et al; Maciejasz et al; Proietti et al.), some of which is industry-sponsored work. While the device can provide some functional benefits theoretically, it is not known whether users will adopt the device for regular functional use in the long-term; beyond the short-term as a novelty device. Also not known is if the device itself causes injuries with long-term use at the shoulder due to the devices significant weight. Current commercially available iterations of this type of device remain heavy; bulky; difficult to don; and difficult to use on a practical basis.Further study of an unbiased nature is required in order better understand the adoption of the device into actual functional use outside of research settings, and to establish safety. Although the enrollee in the current case has severe impairments that are not expected to improve with any further conventional management; the device in question is not reasonably expected to favorably affect the enrollee's long-term clinical or functional outcomes in a practical manner while worn. It is not reasonably expected to stimulate or promote any underlying neurological recovery beyond the limited recovery that has occurred to date. Therefore, the Myoelectric elbow-wrist-hand orthosis is not medically necessary.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: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement and prospective authorization and coverage for biofeedback. As this patient has failed first-line therapies to improve mixed urinary incontinence, she is a candidate for pelvic floor therapy assisted by biofeedback. This treatment may improve the patients pelvic floor strength and competence of external sphincter. Treatment with pelvic floor therapy with biofeedback is standard protocol with decades of supporting documentation regarding minimizing risk with statistically significant symptom relief in patients who have failed to improve after surgery. For these reasons, the biofeedback was and is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.One reviewer found that the biofeedback was not and is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: Two of the three reviewers determined that the services at issue were and are 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 urology and is actively practicing. One Reviewer is board certified in urology and is actively practicing.  One Reviewer is board certified in urology 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: Experimental/Investigational
Decision: Overturned

A 45-year-old female has requested genetic testing for breast cancer gene for evaluation of her risk for developing breast cancer.  Findings:  Two physician reviewers found that the patient is a 45-year-old female with a significant family history of breast cancer. Her mother had breast cancer at 80, as did her maternal grandmother at 60 years of age, and her maternal aunt at 65. The patient does not have a diagnosis of breast cancer. BRCA testing is important in clinical oncology because bilateral mastectomy would eliminate a patients chance of developing breast cancer. Likewise, closer surveillance for ovarian cancer can be enacted, or the patient may choose salpingo-oophorectomy, which would reduce the probability of developing this cancer. The U.S. Preventive Services Task Force indicates that genetic testing is not applied universally, but rather to patients that exhibit family histories that are suggestive of inherited predispositions. A large study by Frank and colleagues performed BRCA testing in 10,000 patients and related the presence of mutations to the family history. The authors reported that family history included at least one first or second degree relative with breast or ovarian cancer. This study is impressive for its size and for its separate analysis of patients of Ashkenazi and non-Ashkenazi descent. Similarly, this patients pedigree may not be obvious since there are two second degree relatives with breast cancer, and one first degree relative with breast cancer diagnosed over age 45. Genetic testing is commonly applied to familial cancer syndromes. The National Cancer Institute (NCI) guidelines stipulate that BRCA testing is reasonable in this clinical setting. All told, there is sufficient evidence to test this patient for BRCA1 and BRCA2 mutations.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for the Prevena negative pressure wound therapy placed on 6/19/17 for treatment of the enrollees breast reconstruction. Findings:  The physician reviewer found that This patient had a fresh dry surgical wound following breast implant placement in breast reconstruction. There is no report of obesity, diabetes, drainage, infection, or conditional negatively affecting wound healing. The current peer-reviewed medical literature on the use of the Prevena negative pressure wound management device present case reports or small series reports without controls. No randomized control trials could be found for review. Gorgulu noted that negative pressure wound therapy is routinely utilized in plastic surgery for the treatment of open wounds. However, a newer system, known as closed-incision management (CIM), may minimize the likelihood of open wounds. CIM is designed for use after primary surgical skin closure. The authors reported on a 2 cm area of superficial skin necrosis that followed the use of the Prevena device in an abdominoplasty. Overall, the published articles do not document that the use of the Prevena negative pressure wound management device placed was likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Final Result: The reviewers determined that the device at issue was 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 number one is board certified in plastic surgery and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.Physician reviewer number two is board certified in plastic surgery and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.Physician reviewer number three is board certified in plastic surgery and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.