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

The patient is a 49-year-old female who has continuing chronic abdominal pain.  The source of the pain has not been identified despite an aggressive workup including colonoscopy and prior exploratory laparoscopy.  She has also been diagnosed with constipation and IBS. She would like a diagnostic laparoscopy to be performed in the hope that the reason for her pain can be determined and she can be appropriately treated.  The Health Plan has denied authorization for the requested surgery on the basis that it is not medically necessary.The exploratory laparotomy performed in 2003 found no herniations or acute gastrointestinal conditions, and the surgery was limited to lysis of adhesions.  The patients current symptoms do not suggest that a surgical condition now exists, or that there is a need for a second surgical intervention. Diagnostic laparoscopy would not be the recommended treatment for this patient.  Therefore, I have determined the requested surgery 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 52-year-old female enrollee has requested Femara for treatment of endometrial cancer.  Findings:  The physician reviewer found that the utility of hormone therapy in the adjuvant setting for endometrial cancer is unclear. This would also apply to the adjuvant use of Femara for advanced endometrial cancer. Investigation is underway, and Novartis has a phase II study (NCT00171808) for ER/PR positive patients who have measurable disease. Femara is not included in the Health Plans formulary for the treatment of endometrial cancer. As there is no clear evidence that Femara is superior to other hormonal agents, or to no hormonal therapy, it cannot be considered an essential component of the patients treatment.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/ Case Summary:  The enrollee is requesting authorization and coverage for endovenous radiofrequency ablation.  The enrollee has varicose veins with inflammation in both legs. Her symptoms include edema to her ankles, bulging veins and pain. Findings:  The physician reviewer found that literature specifies appropriate candidates for laser ablation for the treatment of lower extremity chronic venous disease are those with persistent symptoms and signs of venous disease after a trial of medical therapy, and documented reflux, as demonstrated by a retrograde flow greater than 0.5 seconds duration, as a source of their symptoms.  This treatment protocol is recommended for treatment of patients with these indications and for patients with symptoms refractory to conventional treatment. 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 Vascular 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 similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

A 39-year-old female enrollee requested authorization and coverage of nasal surgery for the treatment of leftward deviation.  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 overturned the health plans denial on the basis that the requested surgery is 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 reimbursement and prospective authorization and coverage for a series of three alcohol injections. Findings:  Two of three physician reviewers found that the submitted documentation supports the superior efficacy of the services at issue. The alternative therapy is systemic therapy to control the disease. If palliation is necessary, radiation therapy may be used. There is support for alcohol injections in this setting. Alcohol injection is a less invasive procedure which has been shown to be effective.  Therefore, a series of three alcohol injections were and are likely to be more effective than other treatment options in this patients case.Final Result: The reviewers determined that the services at issue were and 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 internal medicine with sub-specialty certification in medical oncology 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 patient has requested authorization and coverage for Norco 5-325 mg. The Centers for Disease Control and Prevention (CDC) guidelines state that, Clinicians should consider opioid therapy only if expected benefits for both pain and function are anticipated to outweigh risks to the patient. If opioids are used, they should be combined with nonpharmacologic therapy and nonopioid pharmacologic therapy. The American Society of Interventional Pain Physicians (ASIPP) have advised patients to Establish appropriate physical diagnosis and psychological diagnosis if available to support an indication for treatment with opioid medication. In this case, the patient has chronic low back pain due to lumbar radiculopathy and spondylosis of the spine. The provider charted that the patient has not demonstrated any aberrant or drug seeking behaviors and that Norco has been effective in managing the patients pain and allowing for the performance of activities of daily living. Based on the available medical records for review, the requested Norco 5-325 mg  is medically necessary for treatment of this patient.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 anesthesiology with subspecialty certification in pain management and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

A 41-year-old female enrollee has requested a duodenal switch for treatment of her obesity.  Findings:  The physician reviewer found that this patient is morbidly obese and has failed supervised weight loss programs in the past. She has completed a thorough multidisciplinary evaluation that did not reveal any obvious barriers to surgery.  A duodenal switch procedure is a standard procedure for the treatment of morbid obesity that is approved by the American Society for Metabolic and Bariatric Surgery. The duodenal switch procedure is a medically appropriate standard primary treatment for morbid obesity. The submitted documentation provides adequate support for the requested procedure in this clinical scenario.  All told, the requested duodenal switch is medically indicated for this patient.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested Norco for treatment of her chronic knee pain and back pain. Findings:  The physician reviewer found that the requested Norco is not medically necessary in this clinical setting.  Current standard of care for chronic pain is treatment using a multi-disciplinary pain management practice to include physical therapy, massage therapy, cognitive behavioral therapy, and injections to help reduce pain. Studies show that patients who are diagnosed with non-malignant chronic pain often worsen or their pain recurs as a result of opioid rebound. Baron and colleagues reported that high dose opiates might contribute to pain sensitization via opioid-induced hyperalgesia, decreasing patient pain threshold and potentially masking resolution of a pre-existing pain condition. In this retrospective study, the majority of patients undergoing detoxification of high dose opiates for chronic pain reported a significant decrease in pain at the end of the study, further supporting the theory of opioid-induced hyperalgesia. The medical literature supports treatment of non-malignant chronic pain by weaning patients off short-acting opiates and having them participate in adjunctive therapy including non-narcotic medications, physical therapy, massage therapy, or cognitive behavioral therapy. Ballantyne and colleagues reported that prolonged use of opiates might induce tolerance, abnormal pain sensitivity, and hormonal effects. The aim of current guidelines is to protect patients from the adverse effects of opioid therapy. For these reasons, the requested Norco is not medically necessary to treat the patients chronic pain. 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 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

A 44-year-old female enrollee has requested a wireless capsule endoscopy for an evaluation of her abdominal pain.  Findings:  Two physician reviewers found that wireless capsule endoscopy (WCE) is a major advance in visualization of the small intestine. Since the introduction of WCE, the indications for the procedure have expanded to include Crohn's disease, celiac disease, polyposis syndromes, monitoring of patients after small-bowel transplantation and monitoring for obscure gastrointestinal bleeding (OGIB). WCE has been particularly successful in finding the cause of OGIB and evaluating patients with inflammatory bowel diseases. WCE has been shown to improve the diagnosis of Crohns disease in a significant number of patients who would have otherwise remained undiagnosed. It offers the potential to directly visualize the entire mucosal surface of the small bowel, and it has the ability to detect subtle superficial lesions not evident on traditional contrast radiographs. WCE is less invasive than conventional endoscopy, and it does not require sedation or anesthesia. At the present time, WCE is approved for the evaluation of patients with OGIB, iron deficiency anemia with negative EGD and colonoscopy, and patients with suspected Crohn's disease. It is also approved for patients with other small bowel diseases, such as small bowel tumors, family polyposis syndrome and arteriovenous malformation.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for a L4-L5 artificial disc replacement surgical procedure (CPT 22857). The U.S. Food and Drug Administration (FDA) approves for the ProDisc-L total disc replacement for spinal arthroplasty in skeletally mature patients with degenerative disc disease (DDD) at one or two consecutive levels from L3 to S1. The FDA further notes that the patient should have no more than grade 1 spondylolisthesis at the involved level(s) and have failed at least six months of conservative treatment. The FDA notes that contraindications include active systemic or site infection, osteopenia or osteoporosis, bony lumbar spinal stenosis, isolated radicular compression syndromes especially due to disc herniation, and pars defect. In a follow-up at the five-year mark of 236 patients who underwent either ProDisc-L total disc replacement (TDR) or fusions, Zigler and colleagues noted that the TDR group had significantly better improvement on some scales, and while TDR patients avoid the stiffness of fusion and are more satisfied than fusion patients, both fusion and TDR were reasonable surgical options in this specific patient population. In this case, the patient is being treated for low back pain. Diagnostic imaging demonstrates moderate degenerative hypertrophic facet arthropathy at the requested surgical level, with a normal intervertebral disc. There is no documented evidence of significant DDD, which is typically the primary indication for artificial disc replacement. Given that current medical literature does not support artificial disc replacement in the lumbar spine in this clinical setting, the requested service is not medically indicated. Therefore, a L4-L5 artificial disc replacement surgical procedure (CPT 22857) is not medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested service 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 orthopedic surgery and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned

A 47-year-old male enrollee has requested speech therapy for treatment of his brain injury. Findings:  Two physician reviewers found that the services that were provided to this patient appear to have utilized cognitive rehabilitation techniques as they were intended to address the patients short term memory deficits, decreased executive function and deficits in attention and concentration. The provider indicated that the patient was treated with this therapy to aid the patient in compensating for these deficits. Review of the scientific literature indicates that some studies have shown cognitive rehabilitation results in superior benefit for patients with traumatic brain injuries compared to standard modalities. Such methods have been implemented in acute and sub-acute conditions followed by periodic courses of outpatient therapy. As this patient has experienced decreased functional capacity secondary to traumatic brain injury, it was and is medically reasonable and appropriate to employ periodic courses of the disputed therapy to improve his level of functioning.
Appeal type: Medical Necessity
Decision: Upheld

The patient is a 43-year-old male who has a PSA of 6.55. In June 2005 he had an ultrasound-guided prostate biopsy, which revealed a Gleason score total of 6 (3+3) adenocarcinoma extensively present on both sides of the prostate. The patient wishes to undergo robotic-assisted laparoscopic radical prostatectomy. The Health Plan has denied coverage for the requested procedure but has offered radical prostatectomy, including the alternative of laparoscopic radical prostatectomy. The Health Plans denial should be upheld. The robotic-assisted laparoscopic procedure is relatively new, and while short-term results are comparable, long-term data especially with regard to survival is not yet available. While there is no medical objection to the robotic-assisted laparoscopic approach, to date there is insufficient data to demonstrate its superiority to other procedures. The open surgical approach is a well-established treatment with good long-term results regarding survival and complications and is considered standard of care for treatment of the patients prostate adenocarcinoma. Therefore, I have determined that the requested procedure is not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned

The patient is a 56-year-old male who utilized an electronic controlled thermal therapy device after knee surgery as prescribed by his surgeon. A request has been made for reimbursement for the device. The Health Plan has denied this request on the basis that a thermal therapy unit was not medically necessary for treatment of the patients medical condition. Thermal therapy units are extremely useful postoperatively to diminish pain and swelling. Use of cold therapy is an established modality and is generally accepted as beneficial in this clinical setting. It is superior to ice packs and patients achieve significant relief with its use. In the case of this patient, he clearly experienced a benefit from use of the device following his surgery. Therefore, I have determined the device at issue was medically necessary for treatment of the patients medical condition. The Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Upheld

The parent of a six-year-old male enrollee has requested speech therapy for the treatment of the enrollees autism. Findings:  The physician reviewer found that several interventions are available to improve communication in individuals with autism, and interventions are based on an assessment of needs. A review of the medical documents reveals no previous or current assessment/evaluation of speech and language needs. The progress notes provided are brief, and include limited details regarding the patients deficits and functional status. The documentation indicates that major identified goals have been met. Overall, the documentation submitted does not support medical necessity for speech and language services.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for allergy testing laboratory services performed . Findings: The physician reviewer found that : there is a lack of support for the services at issue in this patients case.  Testing of food-specific IgG/IgA levels does not predict true food hypersensitivity, and may actually be a marker of earlier development of food tolerance.  Food-specific IgG tests typically yield multiple positive results and may represent a normal immune response to foods.  Researchers  performed a study of children with atopic dermatitis and egg and/or milk allergy.  The authors noted that those who had higher levels of IgG4 to milk and egg proteins were more likely to tolerate these foods by 4.5 years of age compared with children with lower IgG4 levels. Per the medical evidence, food-specific IgG should not be used as a tool to diagnose food allergy, and the positive food should not be eliminated from the diet based upon results of these tests. The standard evaluation of food allergy consists of blood IgE level for foods and skin testing.  Immunoglobulin E (IgE) immunoassays are in vitro assays used to identify food-specific IgE in the serum. These tests are widely available and have demonstrated very high positive predictive accuracy for several of the major food allergens. Values have been established for egg, milk, peanut, tree nuts, and fish that correspond to a positive predictive accuracy of 95 percent. Skin testing for food-specific IgE is used in the diagnosis of IgE-mediated food allergies. A positive skin test to a particular food indicates the possibility that the patient has true allergy to that food.  A negative skin test result indicates the absence of an IgE-mediated allergy upon subsequent challenge with a 90 to 95 percent predictive accuracy. All told, allergy testing laboratory services performed were not medically necessary for the evaluation of this patient. Final Result: The reviewer determined that the services at issue were not medically necessary for evaluation of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: Physician reviewer is board certified in allergy and immunology 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: An enrollee has requested reimbursement and prospective authorization and coverage for buprenorphine HCL 8 mg for treatment of the enrollee who has a history of ankylosing spondylitis. Findings:  The physician reviewer found that the documentation provided does not support the medical necessity of the requested buprenorphine in this clinical setting. The records do not mention counseling, despite research and recommendations to support its use in opioid dependency and abuse. It is unclear what the plan is for this patient since the notes state she is taking Nucynta and buprenorphine. Moreover, there is no clear objective functional goals for the additional buprenorphine being requested. Buprenorphine is only U.S. Food and Drug administration approved and indicated for opioid dependence. However, this patient does not acknowledge she has an opioid dependency. The patient does not state she is taking the medication to be free from opioids but rather she is requesting the medication for pain control. Furthermore, per the provider, Suboxone was effective therapy for this patient. As such, given the patient has a history, Suboxone should be sufficient. It is unclear why this patient believes Suboxone will be problematic due to future surgeries. Finally, multiple minimal requirements for opioid prescribing have not been performed. The need to use buprenorphine alone or alongside another opioid for an indefinite basis as the primary medication treatment strategy for pain or opioid dependency has not been established. Final Result: The reviewer determined that the requested medication was not and 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-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.