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

A 56-year-old female enrollee has requested nasal irrigation with tobramycin (tobramycin sulfate 40mg/mL, three times daily put 0.3mL in 240mL saline and use as rinse) for treatment of his, history of chronic sinusitis, nasal polyps and asthma. Findings:  Two physician reviewers found that based on the documentation provided, this patient has been tried on tobramycin irrigation without significant improvement in her nasal obstruction, sense of smell or nasal polyposis. Further, there is a lack of scientific evidence demonstrating that nasal irrigation with tobramycin confers additional benefit compared to routine saline irrigation. A study concluded that amphotericin B (antifungal) irrigation did not show superiority to saline irrigations alone in patients who have chronic rhinosinusitis without polyps (Liang and colleagues). Low-level evidence has been cited of benefit from topical antibiotics, but recognized placebo effect and the need for larger and better-designed randomized, double-blind, placebo-controlled trials to evaluate this emerging modality of treatment (Lim and colleagues). A study reported a beneficial effect of nebulizing the nose with saline, but noted that adding antibiotics to local saline is not effective(Videler and colleagues). At this time, further, large, randomized, multicenter studies are needed to arrive at definite conclusions. All told, nasal irrigation with tobramycin (tobramycin sulfate 40mg/mL, three times daily put 0.3mL in 240mL saline and use as rinse) is not likely to be more efficacious than other available treatment alternatives for this patient.
Appeal type: Medical Necessity
Decision: Overturned

A 53-year-old female enrollee has requested Provigil for the treatment of her multiple sclerosis (MS).   Findings:  The physician reviewer found that Provigil has become the prescription medication of choice for treatment of the fatigue often associated with neurologic illnesses such as MS. In this instance, it is known to be effective for the patient and to dramatically improve her quality of life. Continued treatment with Provigil is medically appropriate and in the best interest of the patient.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for an ovarian/pelvic venography with or without embolization. In this case, the records suggest a diagnosis of pelvic venous insufficiency. An ultrasound reported prominent vessels in the bilateral adnexa with PCS. Visit notes reported that computed tomography (CT) imaging showed a dilated 11 mm right ovarian vein, and two dilated left ovarian veins at 11 mm and 9 mm, compatible with reflux. Bookwalter and colleagues note that when pelvic venous congestion syndrome (PVCS) is caused by incompetent gonadal vein valves, treatment typically is performed by means of embolization via a minimally invasive catheter with excellent technical and clinical success rates. Medical and surgical treatments have been shown to be less effective than transvascular embolization in the setting of pelvic venous congestion syndrome due to pelvic venous insufficiency, and percutaneous catheter-directed embolization is a safe and effective procedure with a high percentage of symptom improvement post-procedure. Therefore, the requested ovarian/pelvic venography with or without embolization is likely to be more beneficial for evaluation of the patients condition than any available standard therapy.Findings:  Three of the three physician reviewers found the requested ovarian/pelvic venography with or without embolization is 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 service 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: Physician reviewers 1, 2, and 3 are board certified in diagnostic radiology 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: An enrollee has requested authorization and coverage for bilateral Triluron injections to the knees.An exhaustive review of the current medical literature pertaining to viscosupplementation reveals mixed results. Evidence from eight systematic reviews and six randomized controlled trials indicates that although viscosupplementation may relieve knee pain in some individuals with osteoarthritis, it is not known as to which individuals will benefit. Different studies have tried mixing hyaluronic acid with corticosteroids, platelet rich plasma, and other agents to make it more effective. The current evidence is limited, and guidelines from organizations such as the American Academy of Orthopedic Surgeons indicate that the evidence is not conclusive. In light of the foregoing, viscosupplementation can only be recommended in individuals with a history of lasting benefit from prior injections, and in carefully selected cases where everything else has been tried, and the options are limited. In this case, the patient has a history of prior viscosupplementation, with good results. The patient has also tried other conservative treatments, with the alternative being surgery. Therefore, the requested bilateral Triluron injections to the knees are medically necessary for the treatment of the patients medical condition. Final Result: The reviewer determined that the requested services 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 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: Upheld

A 51-year-old female enrollee has requested a virtual colonoscopy for a screening of her for colon cancer. Findings:  Three physician reviewers found that the Food and Drug Administration approved virtual colonoscopy (VC) technology in 1995. VC is being proposed as a method for non-invasive evaluation of the colon for colon cancer screening. Conventional colonoscopy remains the best test and gold standard technique for the detection of colon polyps and colon cancer. However, VC is a useful tool for evaluation of patients who are at high risk for anesthesia/sedation due to their compromised cardiopulmonary status or other co-morbidities, or when the conventional colonoscopy fails due to either redundancy of the colon or obstructive lesion in the colon, or scarring and adhesions. In the case of this patient, although there are some inconsistencies in the submitted operative report, it states that the colon examination was complete and fully examined, and the cecum, ileocecal valve and appendix were identified, and the rest of the colon including ascending colon, transverse, descending, sigmoid colon and rectum were examined and were essentially normal. Therefore, there is no indication for VC in this case, and thus the request for authorization should be denied.
Appeal type: Medical Necessity
Decision: Upheld

A 77-year-old male enrollee has requested authorization and coverage for a third series of Orthovisc injections for treatment of the enrollees osteoarthritis. Findings:  The physician reviewer found that the value of viscosupplementation in the treatment of osteoarthritis of the knee has been generally accepted.  It is most suitable in patients with mild to moderate involvement, and is less effective in patients with more severe involvement. Although the efficacy of further courses of therapy has been suggested, there is an increased reported incidence of local adverse events. The available evidence is insufficient to reach firm conclusions of the effect of multiple courses of treatment on outcomes.  At this time, additional, high-quality, randomized studies are needed to define the role of intra-articular hyaluronate injections in the treatment of osteoarthritis.  The current medical evidence does not support the requested services in this patients case.  All told, a third series of Orthovisc injections is not medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld

A sixty-four year-old male who underwent a total knee replacement is seeking reimbursement for use of a cold pump therapy unit.  Reviewers Findings:  The reviewing physician found that the literature does not support the medical necessity of a cooling device after total knee replacement.  The reviewing physician found that the Health Plan denial should be upheld.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/ Case Summary:  The enrollee requested authorization and coverage for hyperbaric oxygen therapy. The enrollee has a history of ulcerative colitis since age 16. He was evaluated at the wound care center due to complaints of an ileal pouch sinus. He had a total colectomy with ileal pouch anastomosis performed approximately 30 years ago; after failing outpatient treatment with prednisone, Entocort and 5-aminosalicylic acid (5-ASA). He recently started Entyvio for continued pouchitis. A pouchoscopy showed a sinus tract in the ileal pouch. The gastroenterologist recommended a hyperbaric oxygen evaluation to determine if the pouchitis could be placed in remission. A magnetic resonance imaging (MRI) scan showed a small fluid-filled sinus tract extending from the anterior anus. Given his concomitant diabetes, this tract is at high risk for infection and may be an atypical diabetic ulcer. The gastroenterologist believed the enrollee may benefit from hyperbaric oxygen. A systematic literature review demonstrated the need for well-controlled, blinded, randomized trials in order to understand the benefit of hyperbaric oxygen for this condition. A study designed to trial hyperbaric oxygen therapy for ulcerative colitis was terminated early due to small enrollment. The use of hyperbaric oxygen is not considered a scientifically proven treatment for this enrollees condition. Medical literature notes hyperbaric oxygen therapy (HBOT) has been shown to be efficacious in treating various conditions; including perianal Crohn's disease. While it is hoped that hyperbaric oxygen therapy would place the enrollee in remission and decrease the chance of infection, larger clinical studies are needed to determine the safety and efficacy of hyperbaric oxygen therapy for patients with ulcerative colitis and pouchitis. There are multiple articles detailing how hyperbaric oxygen therapy is well-tolerated and effective for ulcerative colitis; however, the majority of articles relate to hospitalized patients treated for moderate to severe flares.  Therefore, while the literature does indicate this may be a promising treatment in the future, additional studies are needed to define long-term safety and efficacy.  Final Result: Three of the three reviewers determined that the requested services are not likely to be more beneficial than any available standard therapy for treatment of the enrollees medical condition. Credentials/Qualifications: Three reviewers are board certified 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: Medical Necessity
Decision: Upheld

The patient is a 52-year-old male with no history of previous psychological evaluation or treatment. He reports experiencing anger, anxiety, decreased concentration and depressed mood. The patient has not been tried on medications and/or psychotherapy for behavior modification. He consulted a provider who recommended further evaluation. The provider has requested authorization for a total of 14 hours of psychological testing. The Health Plan indicates five hours of psychological testing are sufficient to complete the workup. At issue is whether the additional nine hours of testing are medically necessary.The Health Plans denial should be upheld. There is no evidence the proposed testing cannot be completed within five hours. Administration and analysis of the tests can be performed within the authorized five-hour timeframe and will allow the provider to establish the patients diagnosis and/or baseline. Nine additional hours of testing related services are beyond the community standard of practice in this setting and are not medically warranted. Accordingly, I have determined the requested services are not medically necessary for evaluation of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Mavyret 100 mg-40 mg tablets for eight weeks. The Health Plan has denied this request indicating that the requested medication is not medically necessary for treatment of the enrollees hepatitis C virus, genotype 2b.According to the recent joint guidelines issued by the American Association for the Study of Liver Diseases (AASLD) and the Infectious Diseases Society of America (IDSA), all patients with chronic hepatitis C should be treated except those with limited life expectancy due to non-liver-related conditions. The guidelines recommend that all patients should be treated, regardless of fibrosis stage. The guidelines recommend that non-cirrhotic treatment naive genotype 2 patients should be treated with Mavyret for eight weeks. These recommendations apply regardless of fibrosis stage. The SURVEYOR-2 trial showed a 99% cure rate with eight weeks of treatment.  AASLD/IDSA guidelines cite data showing reduced survival with delayed treatment. For these reasons, the requested treatment with Mavyret is supported as medically necessary for the treatment of this patients hepatitis C infection. For these reasons, the requested treatment with Mavyret 100 mg-40 mg tablets for eight weeks to treat hepatitis C is supported as medically necessary. 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: Overturned

A 24-year-old male enrollee has requested inpatient acute detox services for the treatment of his polysubstance dependence and amphetamine abuse. Findings:  The physician reviewer found that while the patient was indeed beginning to improve this improvement was not fully established until the following day. The patient continued to require acute inpatient care. His symptoms of diaphoresis, anxiety, agitation and nausea were beginning to improve but remained sufficiently present to require acute inpatient care that day. Inpatient acute detox services were medically necessary and fully indicated from the time of admission through the initial date in question. On the following day, the patient was sufficiently improved and no longer required this level of care.
Appeal type: Urgent Care
Decision: Overturned

A 30-year-old female enrollee has requested emergency services for the treatment of her headache. Findings:  The physician reviewer found that the patient complained of headache in the occipital area for one week that had increased in severity. She also reported nausea and vomiting on one occasion. The patients symptoms met prudent layperson criteria for emergency care. A prudent layperson with an average knowledge of medicine and severe, worsening headache pain and vomiting would reasonably expect the absence of emergency care to jeopardize their health. The patient presented in distress with 9/10 pain and required multiple doses of narcotic pain medications to control her symptoms.
Appeal type: Experimental/Investigational
Decision: Upheld

Physician 1: The patient is a 47-year-old male with degenerative disc disease. He is seeking authorization for multi-level artificial disc replacement utilizing the Prodisc implant. The Health Plan has denied this request because it considers artificial disc replacement experimental.The use of cervical artificial disc replacement has no prospective evidence of superiority over cervical fusion. Additionally, the proposed advantage of reduced adjacent level disease has not been shown to be effective for patients such as this patient. At this time, there is insufficient data demonstrating the proposed procedure is likely to result in a superior clinical outcome to standard treatment modalities. Therefore, I have determined the requested procedure is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Plans denial should be upheld.Physician 2: The patient is a 47-year-old male with degenerative disc disease. He has significant degenerative disc disease at C5-6 and C6-7. His provider has recommended two-level artificial disc replacement with the Prodisc. The Health Plan considers this procedure experimental.The Health Plan is correct that the proposed procedure is considered experimental. There is no evidence to support disc replacement surgery at two levels. There are no known outcomes at two years or more. The long-term success rate and safety profile remain unknown. Because there is no evidence supporting the safety and efficacy of a two-level disc replacement, I have determined the requested procedure is 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.Physician 3: The patient is a 47-year-old male with two-level degenerative disc disease at C5-6 and C6-7. The patient has tried and failed conservative therapy. A two-level disc replacement has been recommended. The Health Plan has denied authorization for the requested procedure.The proposed procedure is experimental with no established efficacy. There are no studies supporting a two-level disc replacement. The safety profile is unknown. There is no clinical indication for the proposed procedure. There are other treatments available. For these reasons, I have determined the requested procedure is 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.
Appeal type: Medical Necessity
Decision: Upheld

The patient has requested authorization and coverage for lumbar spinal fusion and vertebral body resection. Medical literature supported consideration of lumbar fusion for patients with degenerative disease of the lumbar spine, with disc herniations and radiculopathy, when a herniation is associated with evidence of spinal instability, chronic low-back pain, and/or severe degenerative changes, or if the patient participates in heavy manual labor. Researchers found no added benefit from lumbar fusion for patients with degenerative disc disease and stenosis without spondylolisthesis and concluded that in the absence of deformity or instability, the inclusion of a fusion was not recommended. In assessing functional outcome following lumbar fusion, Researchers found that recent studies suggested a patients pretreatment psychological state was a major independent variable that affected the ability to detect change in functional outcome. In this case, the patient has worsening low back pain with intermittent radiation into the right lower extremity to the ankle and minimal radiation into the left lower extremity. Imaging shows degenerative disc disease with spondylosis from L3/4 to L5/S1 with mild to moderate central canal stenosis. There is no evidence of any focal neurologic deficit to support a diagnosis of lumbar radiculopathy. There is no imaging evidence of nerve root compromise or severe degenerative disc disease. There is no radiographic evidence of spondylolisthesis or spinal segmental instability on flexion and extension x-rays. There is no discussion supporting the need for wide decompression that would result in temporary intraoperative instability and necessitate fusion. There is a significant history of anxiety which has not been addressed with psychological clearance or by the neurosurgeon. The records show the provider did not recommend surgery prior to significant weight loss, and instead recommended a spinal cord stimulator prior to consideration of surgery. Therefore, lumbar spinal fusion and vertebral body resection are not medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld

The patient is a 59-year-old male who is requesting reimbursement for a continuous positive airway pressure (CPAP) machine. The patient previously had a diagnosis of obstructive sleep apnea based on a polysomnography with an apnea index of 7. The submitted records indicate the patient had a polysomnography study with a full-face mask CPAP at pressure of 5 to 9 cm in December 2004. The patient had an apnea index of 0 with CPAP at 9 cm H2O. The submitted documentation does not include the patients preceding symptoms and/or signs that led to the polysomnography. There are no comorbidities noted in the submitted records. At issue is whether a CPAP machine was medically necessary for treatment of the patients medical condition.Upon review of the submitted clinical documentation, the patient did not meet medical necessity criteria for CPAP therapy. There is no mention in the submitted documentation of the patients preceding symptoms and/or signs that led to the polysomnography. Furthermore, there is no documentation of symptomatic improvement after intervention with CPAP. In fact, there is no evidence of any associated comorbidities. Though the subsequent titration study suggests an ablation of the apneic events, there was no clinical indication for CPAP therapy based on the information provided. Moreover, there is no evidence of a trial and failure of conservative sleep hygiene therapy prior to the initiation of CPAP therapy. Therefore, I have determined the equipment at issue was not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.