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

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for a CT scan.Findings:  Two of the three physician reviewers found that the CT scan that was performed was likely to be more beneficial for treatment of the patients condition than any other available standard therapy. Medical literature supports the use of CT imaging to screen for malignancy in patients with dermatomyositis. The association between dermatomyositis and internal malignancy is well established. Their data suggests that effective malignancy screening of dermatomyositis patients often requires evaluation beyond a history, physical examination, and age-appropriate cancer screening. An extensive search for malignancy, particularly computed tomographic scans, may be warranted in at least a subset of patients with dermatomyositis and risk factors of malignancy. In this case, the patient had both dermatomyositis and risk factors of malignancy. Accordingly, the CT scan that was performed was likely to be more beneficial for treatment of the patient's condition than any other available standard therapy.Final Result: Two of the three reviewers determined that the services in issue were likely to be more beneficial for the patients medical condition than any other available standard therapy. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications:All three reviewers are board certified in interventional radiology and diagnostic radiology, and all three reviewers 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

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested a Krabat Jockey Plus Chair for treatment of the enrollees medical condition. Findings: The physician reviewer found that the submitted documentation supports the medical necessity of the requested equipment.  This patient has a progressive neurodegenerative disorder characterized by extrapyramidal movement abnormalities, spasticity, cerebellar ataxia, and epilepsy.  It affects strength and coordination, with development of severe dystonia, progressive spasticity, choreoathetosis, ataxia, and rigidity.  It impacts speech and ability to chew and swallow effectively, resulting in dysarthria or anarthria.  This patient requires specialized equipment in order to participate in activities of daily living while minimizing risk of complications. Without adequate support, severe spasticity and poor extremity control prevent him from remaining in proper positioning while sitting.  His condition necessitates specialized equipment to allow for social and therapeutic interactions, optimize functional capacity, and facilitate transition to older childhood and young adulthood.  This chair is designed for dynamic seating to allow for safe feeding, safe positioning for transfers, and for mobility. It has tremendous ability to adjust with the patients positioning needs, and is quite versatile, allowing for dynamic seating and balance control. It allows for social interactions and optimizes patient independence, particularly important for children with physical disabilities that severely limit or mask their cognitive development.  All told, the requested Krabat Jockey Plus Chair is medically indicated for the treatment of this patient.    Final Result: The reviewer determined that the requested equipment is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.  Credentials/Qualifications: The reviewer is board certified in pediatrics 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 female enrollee requested authorization and coverage of testosterone pellet insertion. The Health Plan denied the request indicating that the requested therapy is considered experimental for treatment of the enrollees hormone replacement therapy.Three physician reviewers performed an experimental/investigational Independent Medical Review. Two physician reviewers concluded that the requested therapy is likely to be more beneficial for treatment of the enrollee's medical condition than any available standard therapy. One physician reviewer concluded that the requested therapy is not 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 therapy is likely to be more beneficial for treatment of the enrollee's medical condition than any available standard therapy, the Health Plans denial has been overturned.
Appeal type: Medical Necessity
Decision: Overturned

The patients parent has requested authorization and coverage for intensive in-home feeding therapy including an in-home feeding therapy evaluation. Feeding problems are common in childhood, and may be severe enough to result in failure to thrive, growth failure, and chronic illness. The least restrictive environment for such an approach is in the home, where the provider can directly address the patients behavioral and psychosocial issues. This patient with autism has extremely limited food repertoire and is dependent on infant formula to meet his nutritional needs. The nutritional balance in infant formula is not appropriate for a toddler, but the patient has refused PediaSure. After a thorough work-up, his providers recommended an intensive home-based feeding program to normalize his feeding behaviors and assure appropriate nutrition. This patients health and further development are dependent on this feeding therapy. Given these findings, the requested intensive in-home feeding therapy including an in-home feeding therapy evaluation is medically necessary for treatment of this patient.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 pediatrics with subspecialty certification in pediatric critical care and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for magnetic resonance imaging (MRI). In this case, the records note that the patient has abnormal uterine bleeding. An ultrasound showed an ovarian cyst that was followed with repeat imaging, and further imaging with a computed tomography (CT) scan showed a large myxomatous uterus. Medical literature notes that a pelvic ultrasound is the modality of choice to assess uterine tumors such as leiomyomas and ovarian cysts. While an MRI may be indicated in some circumstances, at the discretion of the provider, for further evaluation of the location, size, or appearance of fibroids, in this case, the submitted documentation does not indicate that the provider has recommended an MRI for further evaluation, for alternative treatments such as uterine artery embolization, or for surgical planning. Therefore, MRI is not medically necessary for the evaluation 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 obstetrics and gynecology 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 57-year-old male enrollee has requested the Saunders Home Lumbar Traction Device for the treatment of his low back pain. Findings:  Two physician reviewers found that the requested Saunders Home Lumbar Traction Device is not likely to be more beneficial than other available standard therapies such as home exercises and over-the-counter medication. While this patient has ongoing back complaints, the medical record does not document objective abnormal physical findings. While the concept of traction to unload the spine sounds appealing, there are no good studies documenting the efficacy of a home traction device to achieve those goals. It takes a tremendous amount of force to distract or unload a lumbar spine, and that amount is clearly greater than can be obtained by a home traction unit. There is a lack of documented studies revealing the efficacy of this type of treatment.
Appeal type: Experimental/Investigational
Decision: Overturned

A 52-year-old female enrollee has requested continued Botox therapy for the treatment of her migraine headaches. Findings:  Two physician reviewers found that Botox is approved for use in blepharospasms (which this patient is reported to have). The patient has also had a reduction in her migraines on this therapy thus further justifying its use. She has failed other first-line therapies for migraine including Topamax, Depakote, and narcotics (among others) and is not a candidate for Imitrex use given her prior stroke history. The use of Botox for this patient is both medically reasonable and necessary.
Appeal type: Experimental/Investigational
Decision: Upheld

The mother of a 21-year-old male enrollee requested authorization and coverage of functional electrical stimulation therapy.  The Health Plan denied the request indicating that the requested therapy is considered experimental for treatment of the enrollees spinal cord injury. Three physician reviewers performed an experimental/investigational Independent Medical Review. All three physician reviewers concluded that the requested therapy is not likely to be more beneficial for treatment of the enrollees medical condition than any available standard therapy. Because all CHDR physician reviewers concluded that the requested therapy is not likely to be more beneficial for treatment of the enrollees medical condition than any available standard therapy, the Health Plans denial has been upheld.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for authorization and coverage for injection, immune globulin, Gammagard liquid, non-lyophilized, (e.g., liquid, 500 mg) (CPT J1569). Findings:  The physician reviewer found that there is debate regarding the use of intravenous immunoglobulins (IVIG) in refractory uveitis and a limited number of clinical studies available on its efficacy. Saadoun and colleagues report that biotherapies used in clinical practice for the treatment of ophthalmologic manifestations of systemic diseases include interferons (IFN), IVIG, and monoclonal antibodies (anti-TNF, anakinra, tocilizumab and rituximab). The authors note that tolerance of IVIG is good but their efficacy is transient. Given the lack of randomized, prospective studies available in current medical literature regarding the use of IVIG in refractory/autoimmune uveitis, the requested service is not medically indicated. Therefore, injection, immune globulin, Gammagard liquid, non-lyophilized, (e.g., liquid, 500 mg) (CPT J1569), 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 internal medicine with sub-specialty certification in rheumatology 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 47-year-old male enrollee has requested for a functional neuromuscular stimulator for treatment of his foot drop.   Findings:  Two physician reviewers found that the current medical literature and the current standards of care do not support the need for the requested device in this clinical situation. There is inadequate evidence the Bioness device is likely to be superior to a standard ankle-foot orthotic in this setting.
Appeal type: Medical Necessity
Decision: Upheld

The enrollee has requested reimbursement for full anesthesia sedation that was used during a colonoscopy. The Health Plan has denied the service at issue as not medically necessary.The 2018 guidelines for sedation and anesthesia in GI endoscopy recommend 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. Minimal and/or moderate sedation can be delivered safely by endoscopists to patients who are 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. Colleagues performed a systemic review of moderate versus deep sedation for adult colonoscopy cases. The authors concluded that moderate sedation showed comparable safety and effectiveness to deep sedation with respect to patient satisfaction, physician satisfaction, incidence of recall and recovery time. The patient was assessed with an ASA Class I with no use of medications that would make sedation during a colonoscopy more difficult. Moreover, there was no indication in the providers notes that use of a general anesthetic was required to complete the colonoscopy. Final Result: The reviewer determined that the requested service at issue was 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 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 authorization and coverage for Harvoni for the treatment of the enrollees hepatitis C. Findings:  The physician reviewer found that According to 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 life expectancy less than 12 months due to non-liver-related conditions. This applies regardless of fibrosis stage, and advanced fibrosis is not required for treatment. In non-cirrhotic, genotype 1 patients who have failed Sovaldi and ribavirin, the guidelines recommend re-treatment with Harvoni and ribavirin.  However, when ribavirin has to be discontinued, as in this case, re-treatment with Harvoni monotherapy has been studied and found to be effective. For these reasons, the requested therapy with Harvoni to complete therapy is medically indicated.  All told, the requested extension of the medication, Harvoni is medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested medication regimen 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

Nature of Statutory Criteria/Case Summary: An enollee has requested reimbursement for the inpatient continuous positive airway pressure (CPAP) titration study performed. Findings:  The physician reviewer found that Based on the current medical literature and the presented clinical records, the CPAP titration study was medically necessary for evaluation of the patients medical condition. The member's home sleep study for her AHI was 15.6  and the member met the medical necessity criteria for treatment with CPAP. The CPAP titration study was medically necessary to document the optimal setting for treatment with CPAP. The patients optimal setting was CPAP of 8 cm H2O, which normalized the AHI to 1.5 (normal AHI is 0 to 5) and also treated the hypoxia. For the reasons provided, the CPAP titration study performed on the date of dispute was medically necessary for evaluation of the patients medical condition. Final Result: The reviewer determined that the service at issue was medically necessary for evaluation of the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in in internal medicine with sub-specialty certification in pulmonary disease and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

The patient is a 44-year-old woman has been treated with Elidel for severe prurigo nodularis with good results. Prior treatment with topical corticosteroids and oral antihistamines was ineffective. The Health Plan denied coverage for Elidel on the basis it is not medically necessary for treatment of the patients medical condition.Prurigo nodularis is a form of atopic dermatitis. The patients treatment history demonstrates Elidel has been successful for this patient whereas a trial of steroids was not successful. Furthermore, chronic topical steroid use may result in permanent atrophy and telangiectasis of the skin. Given the proven efficacy and greater safety of Elidel, its continued use is medically appropriate and indicated for treatment of the patients severe prurigo nodularis. Therefore, I have determined that the requested medication is medically necessary for treatment of the patients medical condition. The Health Plans denial should be overturned.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: A patient has requested authorization and coverage for LINX Reflux Management System for the treatment of the enrollees medical condition. Findings:  The physician reviewers found that the requested procedure is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. There is a lack of randomized controlled trials with long-term follow-up demonstrating that LINX is safer or more effective than Nissen fundoplication or other surgical anti-reflux procedures. One evidence review concluded that the long-term safety and efficacy of LINX, both alone and in comparison to current GERD therapies remains to be determined. Another best-evidence review concluded that long-term comparative outcome data past one year are needed in order to further understand the efficacy of magnetic sphincter augmentation. Adverse events, such as erosion through the esophagus have been reported in the period after the U.S. Food and Drug Administration approval. One peer-reviewed journal published a letter stating that there are 11 reports of endoscopically confirmed LINX erosion through the esophagus in the publicly accessible U.S. Food and Drug Administrations Adverse Events database. Additionally, LINX (more than surgical fundoplication) is associated with severe dysphagia requiring endoscopic intervention. In this case, the available peer-reviewed literature does not definitively support the conclusion that LINX is more likely to be beneficial than standard treatment, surgical fundoplication. The American College of Gastroenterology guidelines for the management of reflux disease also state that more evidence is needed before LINX can be recommended. For these reasons, LINX Reflux Management System is not likely to be more beneficial than any available standard therapy for the treatment of this patient.Final Result: The 2/3 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 reviewers all 3 are board certified in internal medicine with sub-specialty certification in gastroenterology 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

A 21-year-old female enrollee has requested the remote heart monitor for evaluation of her heart palpitations.  Findings:  Two physician reviewers found that based on the records provided, the patient has a history of palpitations in the setting of a normal ECG, essentially normal ECHO, and no symptoms during Holter monitoring. In this circumstance, self-activated non-real time and non-continuous monitoring devices (event recorders) should be effective at recording potential dysrhythmias during symptoms that are not frequent enough to be identified on continuous 24-48 hour Holter monitoring. In cases of infrequent asymptomatic dysrhythmias that require identification, non-real time (off-line) monitoring devices with auto-triggering capability should be sufficient. This patients records offer no documentation to indicate that she is unable to effectively manage these standard monitoring devices and or that these have been previously obtained to evaluate the patients symptoms. The current expert consensus guidelines endorsed by several national organizations also consider Holter monitoring and patient activated event recorders appropriate initial tests for evaluation of supraventricular dysrhythmias. Consistent with these guidelines, the continuous real-time monitoring with the CardioNet device was not medically indicated in this case since off-line analysis with a patient activated device should be sufficient to identify symptomatic dysrhythmias without jeopardizing the patients safety. Immediate recognition and reporting of dysrhythmias through a call center provided by CardioNet real-time mobile telemetry remains investigational in this circumstance and has not been shown to improve health outcomes compared to standard monitoring techniques.