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  hybrid Maze procedure. This patient presents with paroxysmal atrial fibrillation with intermittent palpitations, an EF of 45%, and mild enlargement of left atrium. His provider has recommended a hybrid Maze procedure. The convergent, or hybrid Maze procedure, is a surgical ablation option for patients with atrial fibrillation that is considered when medical therapy and percutaneous ablative options have proven ineffective. When ablation is indicated, current guidelines do not recommend a hybrid surgical approach to ablation over conventional percutaneous ablation (Calkins, et al.). A hybrid approach to ablation has not been shown to be superior to existing accepted approaches in the treatment of atrial fibrillation. Maze procedures are considered when performed in conjunction with other heart surgery that already requires use of a pump, such as valve replacement or coronary artery bypass, neither of which this patient requires based on the records provided for review. Therefore, the requested hybrid Maze procedure 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 hybrid Maze 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 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 reviewer 1 is board certified in internal medicine with subspecialty certification in cardiovascular disease and is actively practicing. Physician reviewer 2 is board certified in internal medicine with subspecialty certifications in cardiovascular disease and cardiac electrophysiology and is actively practicing. Physician reviewer 3 is board certified in cardiovascular disease with subspecialty certification in interventional cardiology 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 44-year-old female enrollee has requested for continued intravenous Rocephin therapy for treatment of the enrollees Lyme disease. Findings:  Two physician reviewers found that there is no clear evidence that the patient has any infectious process to explain her symptoms. With regard to Lyme disease, there is no mention of a tick bite or an erythema migrans eruption.  The clinical symptoms described are all not specific and do not suggest a diagnosis of Borrelia infection. The definitive tests for Lyme disease (IgM and IgG Western Blots) have been equivocal on several occasions, although the positive IgG studies suggest that at some point the patient has been infected with Borrelia burgdorferi.
Appeal type: Medical Necessity
Decision: Upheld

The patient is a 16-year-old male who received treatment for substance abuse at an acute care facility. He had been abusing alcohol, marijuana and crack cocaine prior to his admission to acute care. He reported blackouts prior to admission and conflict with school and family. The patient was diagnosed as having a major depressive disorder but was not treated for such while he was in acute care. He stepped down to an ambulatory status and relapsed on drugs after his discharge from the hospital. In February 2006 the patient was placed at the residential level of rehabilitation. He was admitted to RTC level of care utilizing the ASAM adolescent criteria.  He was started on Wellbutrin with some intolerance of this medication.  The Wellbutrin was lowered and his depression lessened.  The Health Plan determined that as of March 2006 the patient no longer met American Society of Addiction Medicine (ASAM) criteria for the residential level of care and recommended a community based treatment. The patient and his family disagreed and the patient remained at the residential level of care until his discharge in March 2006.  At issue is whether residential treatment services beyond March 2006 were medically necessary.The submitted records from the residential treatment facility report that the patient stated that he had suicidal thoughts on a daily basis in March 2006 but that he would not act on them.  He agreed to sign a safety contract on that date. A progress note dated March 2006 stated that the patient had a bright affect, was smiling and laughing, and attended all groups and activities. The patient had no signs of withdrawal symptoms as of March 2006. Furthermore, there was no indication of symptoms or behavior necessitating 24-hour monitored supervision as of March 2006. Moreover, the patients parents were supportive of his recovery and his home appeared to be conducive to his recovery. Based upon the clinical records provided, the patient was appropriate for step-down to a less intensive level of care as of March 2006. Therefore, I have determined the services at issue were not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Experimental/Investigational
Decision: Upheld

A 52-year-old female enrollee requested electric powered for medical treatment of her skin cancer.  Findings:  Three physician reviewers found that electric powered brachytherapy was not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. In this case, the patient has basal cell carcinoma of skin which can be treated with conventional external beam radiation therapy. Electronic brachytherapy is a novel technique which has been used to treat several malignancies including skin cancers. However, there are few published studies supporting safety and efficacy of electronic brachytherapy for skin cancer. In addition, there is a lack of randomized or large cohort trials supporting long term outcome of this treatment compared to conventional well established treatments. Thus in absence of supporting long term outcome data, the services at issue were 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 52-year-old female enrollee has requested for Synvisc injections for treatment of her knee pain.    Findings:  The physician reviewer found that there is no scientific evidence to support the medical necessity or effectiveness or safety of long-term Synvisc therapy.
Appeal type: Experimental/Investigational
Decision: Upheld

A 39-year-old male enrollee requested authorization and coverage of autologous chondrocyte implantation. The Health Plan denied the request indicating that the requested procedure is considered investigational for treatment of the enrollees chondromalacia of the left patella.Three physician reviewers performed an experimental/investigational Independent Medical Review. Two of the three physician reviewers concluded that the requested procedure is not likely to be more beneficial for treatment of the enrollee's medical condition than any available standard therapy. One of the three physician reviewers concluded that the requested procedure is likely to be more beneficial for treatment of the enrollee's medical condition than any available standard therapy. Because two of the three  physician reviewers concluded that the requested procedure is not likely to be more beneficial for treatment of the enrollee's medical condition than any available standard therapy, the Health Plans denial has been upheld.
Appeal type: Medical Necessity
Decision: Upheld

The patient is a 55-year-old woman with type 2 diabetes mellitus. She has requested coverage for Byetta to be added to her current regimen. She has been taking metformin (Fortamet ER) 500mg a day since at least October 2005. Her A1c, a measurement of blood sugar control, was 6.2% in January 2006 while on this dose of metformin. The patient was started on Byetta by her endocrinologist in February 2006. A subsequent A1c in March 2006 was 5.5%. Her endocrinologist stated the patient was previously unable to tolerate Actos or Avandia due to unspecified side effects. He also stated that she lost a significant amount of weight on the Byetta. However, according to the providers notes the patient lost one pound between February 2006 and April 2006. She lost an additional six pounds on and off Byetta between April 2006 and June 2006. At issue is whether Byetta is medically necessary for treatment of the patients medical condition.This patient with type 2 diabetes appears to have been under good control while taking a small amount (500mg) of metformin. Excellent control is defined by the American Diabetes Association as an A1c of less than 7% and by the American College of Endocrinology as an A1c of less than 6.5%. The patients A1c prior to starting Byetta (while taking the metformin alone) was 6.2%. As such, the medical necessity of Byetta in this clinical setting has not been established.Based upon the information set forth above, I have determined the requested medication is not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld

A 75-year-old male enrollee has requested for continued skilled nursing facility care for treatment of his recovery from multiple injuries and ischemic attack.   Findings:  The physician reviewer found that the patient should be making functional gains and have the potential to continue to functionally improve with his physical, occupational and speech therapy services. The patient was not making those gains, and does not have the potential to make further gains at this time.
Appeal type: Urgent Care
Decision: Overturned

Nature of Statutory Criteria/Case Summary:  An enrollee has requested air ambulance services for treatment of his end stage pulmonary disease. The physician reviewer found that review of the submitted documentation and relevant literature demonstrates the medical necessity of the services at issue. In this case, the patient presented to the hospital with progressive worsening dyspnea and chronic chough. The patient had rapidly deteriorating pulmonary function despite mechanical ventilation. The patients provider recommended the patient be emergently transported via air ambulance due to the need for a higher level care.  Minutes after arrival, the patient underwent ECMO cannulation.  The patients pulmonary dysfunction was an immediate threat to life and as such air ambulance transportation was medically necessary. For the reasons provided, air ambulance services was medically necessary for treatment of the patients medical condition. 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 general surgery and critical care surgery and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld

A 34-year-old male enrollee has requested magnetoencephalogram (MEG) for the evaluation of his epilepsy. Findings:  Two physician reviewers found that although MEG shows great potential promise as a tool for the functional mapping of the brain intraoperatively, it remains an experimental/investigational modality at present. It remains unknown whether MEG is superior to any currently available technologies for surgical planning.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for anesthesia services. The American Society for Gastrointestinal Endoscopy (ASGE) Standards of Practice Committee noted that the combination of an opioid and benzodiazepine is a safe and effective regimen for achieving minimal to moderate sedation for upper endoscopy and colonoscopy in patients without risk factors for sedation-related adverse events. The authors recommended that, Anesthesia provideradministered sedation be considered for complex endoscopic procedures or patients with multiple medical comorbidities or at risk for airway compromise. The guidelines also noted, Minimal and/or moderate sedation can be delivered safely by endoscopists to patients who are American Society of Anesthesiologists (ASA) Class I, II, or III. Other candidates for minimal or moderate sedation include those with a history of previously successful procedures with moderate sedation and an expectation for moderate sedation as well as those undergoing a procedure that is expected to be uncomplicated or routine. In this case, the patient underwent a colonoscopy for polyp removal. She did not have any significant heart, lung, kidney, or liver disease. There was no documentation of a history of alcohol or substance abuse. There was no detailed description of previous history of difficulties with anesthesia or sedation with past colonoscopies documented in the submitted records. The patient had an ASA classification score of 2 and there is no evidence that she presented with a difficult airway. The literature does not support the use of monitored anesthesia care in a patient who does not have significant health conditions or airway concerns. Rather, the guidelines suggest that there is high quality evidence to support the use of mild to moderate sedation in healthy uncomplicated endoscopy procedures, such as in this case. Based on the current medical evidence, the services at issue were not medically indicated. Therefore, anesthesia services were not medically necessary for the treatment of this patient.Final Result: The reviewer determined that the services at issue were 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: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for advanced lipoprotein testing.Findings: Three of the three physician reviewers found that the advanced lipoprotein testing provided to the patient was not likely to be more beneficial for treatment of the patients medical condition than any other available standard therapy. There is a lack of studies in the peer-reviewed medical literature which demonstrate that strategies to correct the residual risk potentially identified by novel lipoprotein testing such as the advanced lipoprotein analysis will further reduce cardiovascular risk. Currently, clinical trial data do not support that advanced lipoprotein testing adds significant information to what is already known from a fasting lipid panel. Although assessment of advanced lipoprotein analysis parameters such as Apo B, LDL particle number and Lp(a) have been advocated by some as reasonable for many intermediate and high risk patients, clinical trial data do not support the superiority of treatment strategies incorporating non-statin lipid modifying agents compared with intensive statin therapy. Additionally, the patient has a low 10 year atherosclerotic cardiovascular disease (ASCVD) coronary risk of 0.3%, for which modifying certain lipid parameters such as LDL particle size or number would not be expected to significantly impact her already existing low risk, despite an elevated CRP. There is insufficient evidence to support the use of advanced lipoprotein analysis in this clinical scenario. Accordingly, the advanced lipoprotein testing performed for the patient was not likely to be more beneficial for treatment of the patients medical condition than any other available standard therapy.Final Result: Three of the three reviewers determined that the advanced lipoprotein testing provided to the patient was not likely to be more beneficial for treatment of the patients medical condition than any other available standard therapy. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: All three reviewers are board certified in internal medicine, with subspecialty certification in cardiovascular disease, 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

A female enrollee requested weekly individual therapy sessions with a therapist for medical treatment of her social anxiety disorder, bipolar disorder type 2, obsessive compulsive disorder, and depression.   Findings:  The physician reviewer found that this patient is complex and symptomatic with depression and anxiety and probably PTSD. It is noted that the facility keeps changing her providers, which has made it very difficult for her to form a therapeutic bond with a therapist. Given these findings, the patients current treatment plan has been ineffective. Therefore, it is reasonable for this patient to begin receiving weekly psychotherapy sessions by a consistent provider. All told, the records support the medical necessity of the requested weekly individual therapy sessions with a therapist.
Appeal type: Experimental/Investigational
Decision: Overturned

A 53-year-old male enrollee has requested allogeneic hematopoietic stem cell transplantation (HSCT) for treatment of his multiple myeloma.  Findings:  Three physician reviewers found that this patients disease has very low probability of any significant benefit from further standard therapies. While allogeneic HSCT has had variable results in the treatment of multiple myeloma, there is evidence that some patients significantly benefit from this therapy. Given this patients treatment history, the requested allogeneic HSCT is likely to provide him with a superior health outcome when compared to standard available therapies.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for ThyraMir gene test. Findings:  The physician reviewers found that the Bethesda System recommends a repeat thyroid biopsy. Moreover, the newest 2015 American Thyroid Association's guidelines state that for nodules with AUS/FLUS cytology, after consideration of worrisome clinical and sonographic features, investigations such as repeat fine needle aspiration (FNA) or molecular testing may be used to supplement malignancy risk assessment in lieu of proceeding directly with a strategy of either surveillance or diagnostic surgery. Informed patient preference and feasibility should be considered in clinical decision-making. The American Thyroid Association also recommends taking the patients history, ultrasound appearance and other clinical factors, including the institutions rate of malignancy, in consideration in order to make medical and surgical decisions. In this patients case, the provider after consideration of this patient's condition and in consultation with the patient, made the decision to repeat the biopsy and order genetic testing, specifically, the ThyraMir test. The gene test proved helpful in the management of this patient. A review noted that for thyroid lesions with indeterminate cytology, the detection of any mutation translated into a malignancy risk for AUS/FLUS, FN, and SMC of 88%, 87%, and 95% respectively, compared to 6%, 14%, and 28% in mutation-negative lesions. The guidelines recommend oncologic thyroidectomy based on this positive results, as opposed to observation or diagnostic lobectomy. All told, ThyraMir gene test performed was likely to have been superior over other methods of evaluating this patients medical condition. Final Result: 3 of 3 reviewers determined that the services at issue were 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 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: Overturned

Nature of Statutory Criteria/Case Summary: The enrollee has requested authorization and coverage for Nutropin AQ NuSpin 10 mg/2mL for treatment of the enrollee who has been diagnosed with idiopathic short stature. Findings:  The physician reviewer found that the documentation submitted supports the medical necessity for the requested medication in this clinical setting. According to  the Pediatric Endocrinology Society guidelines, a trial of GH therapy should be approved for children with otherwise unexplained short stature who pass GH stimulation tests but who meet most of the following criteria: height more than 2.25 standard deviations below the mean for age or more than 2 standard deviations (SD) below the mid-parental height percentile; growth velocity is less than 25th percentile for bone age; (3) bone age more than 2 SD below the mean for age; (4) low serum IGF-1 and/or IGFBP-3; and/or (5) other clinical features suggestive of GH deficiency.  The submitted records indicate that this patient meets most of the above criteria. Recent predicted adult height is more than 2 SDs below the mean for adult females in the United States and below her genetic potential. Her height prediction of 55 inches qualifies for treatment of idiopathic short stature based on the U.S. Food and Drug criteria. As such, Nutropin AQ NuSpin 10 mg/2mL is medically necessary for the treatment of this patients medical condition. Final Result: The reviewer determined that the requested medication is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in pediatrics with sub-specialty certification in pediatric endocrinology 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.