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

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for Leukocyte Histamine Release test provided on 11/10/17. The Health Plan has denied this request as investigational for evaluation of the enrollees possible allergies. Findings:  There are insufficient medical notes provided to support the reasoning behind the test for leukocyte histamine release and whether it would be more beneficial in the evaluation and treatment of the patient than standard tests. While the release of histamine from leukocytes upon exposure to an allergen is a valid test for detection of specific IgE to the allergen used in the test, this test is not normally used clinically. It has been used traditionally as a research tool. Quality control studies have shown variability in the measurement of histamine results. Evidence based studies and data supporting its role in the clinical setting are lacking. There is not an established alternative for this test, and the quality and quantity of data in the current peer-reviewed scientific medical literature is inadequate to establish the clinical utility or efficacy of this test. Therefore, Leukocyte Histamine Release test was not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: All three reviewers determined that the services at issue were not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld.Credentials/QualificationsAll three reviewers are board certified in internal medicine with a sub-specialty in allergy and immunology 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 19-year-old female enrollee requested authorization and coverage of gastric bypass using the duodenal switch technique for the treatment of morbid obesity.  The health plan denied the enrollees request indicating that the requested treatment is experimental.Three physician reviewers performed an experimental/investigational Independent Medical Review.  Each of the three physician reviewers concluded that a gastric bypass using the duodenal switch technique  is not likely to be more beneficial for treatment of the enrollees morbid obesity than any available standard therapy.  Because all three physician reviewers concluded that the requested treatment is not likely to be more beneficial for treatment of the enrollees medical condition than any available standard therapy, the review organization upheld the health plans denial.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary:  An enrollee has requested authorization and coverage for endoscopic surgical ablation and concomitant catheter ablation. Findings:  The physician reviewer found that In a study by DeLurgio and colleagues, patients with long-standing persistent atrial fibrillation (AF) were randomized to two groups. One group was treated with minimally invasive epicardial/endocardial approach (hybrid convergent), and the other group was treated with endocardial catheter ablation. The group treated with the hybrid convergent procedure showed a significantly greater efficacy at 12 and 18 months. In a study by Gersak and Jan, 81% of patients with persistent AF were free from AF at four years following the convergent procedure. In this case, the patient has tried conventional approaches, including antiarrhythmic drugs and endocardial catheter ablation approaches. There is sufficient support for the requested services in this clinical setting. Therefore, endoscopic surgical ablation and concomitant catheter ablation are likely to be more beneficial for treatment of the patients condition than any available standard therapy. Findings: Two out of three physician reviewers found that endoscopic surgical ablation and concomitant catheter ablation are likely to be more beneficial for you than any available standard therapy. Final Result: The reviewers determined that the requested services are likely to be more beneficial than any available standard treatment for the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer 1 and reviewer 2 are board certified in internal medicine with sub-specialty certification in clinical cardiac electrophysiology; and reviewer 3 is board certified in cardiovascular disease. All reviewers are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary:   An enrollee has requested continued acute hospital stay for treatment of her medical condition. Findings:  The physician reviewer found that the records do not support continued acute hospital stay services as medically necessary for treatment of this patients medical condition. The Centers for Medicare and Medicaid (CMS) guidelines for acute hospital care require physician certification of the medical necessity that such services be provided on an inpatient basis. This patients physicians have been stating that she is medically stable for discharge. There is no indication for additional inpatient care. Reviewing the records, the patient is ready to transfer to skilled nursing facility level rehabilitation and the requested continued acute care services are not medically necessary.  Final Result: The reviewer determined that the requested services are 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 neuromuscular medicine and physical medicine and rehabilitation and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

The parent of an enrollee has requested reimbursement and prospective authorization and coverage for residential treatment center services. The Child and Adolescent Level of Care Utilization System (CALOCUS) provides a framework for determining the clinically appropriate level of care for a child or adolescent in mental health treatment. The records support residential treatment level of care. The six-week treatment course was and is medically indicated. Thus, the residential treatment center services at issue were, and are, medically necessary to treat the patients conditions.Final Result: The reviewer determined that the services at issue and requested services were, and are, medically necessary to treat the patients conditions. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in psychiatry, with subspecialty certification in child and adolescent psychiatry, 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 a 12 week course of Harvoni for treatment of his chronic hepatitis C virus genotype 1a. Findings:  Two physician reviewers found that as per the American Association for the Study of Liver Diseases (AASLD) and Infectious Disease Society of America (IDSA) guidelines, all patients with chronic active hepatitis C are eligible for treatment and should be treated with U.S. Food and Drug Administration (FDA) approved antiviral therapy regardless of fibrosis score. Successful hepatitis C treatment results in sustained virologic response (SVR), which is tantamount to virologic cure, and as such, is expected to benefit nearly all chronically infected persons. Evidence clearly supports treatment in all hepatitis C virus infected persons, except those with limited life expectancy (less than 12 months) due to non-liver-related comorbid conditions. The goal of treatment of hepatitis C virus infected persons is to reduce all liver-related health adverse consequences, including end stage liver disease and hepatocellular carcinoma, by the achievement of virologic cure as evidenced by an SVR. This patient has some advancement of fibrosis. Therefore, as per the FDA recommendation, this patient should be approved for Harvoni for eight weeks, not the requested 12 weeks to prevent further progression of fibrosis due to ongoing hepatitis C virus infection. Thus, an eight week course of Harvoni is supported as medically necessary.  Final result: Two reviewers determined that a portion of the requested medication is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be partially overturned.Credentials/Qualifications: The three reviewers 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: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for onabotulinumtoxinA (Botox) injections. Botox is indicated for the treatment of chronic headaches in patients who have at least 14 headache days per month. In addition, Botox is a U.S. Food and Drug Administration (FDA) approved treatment for the treatment of migraines. The records provided for review document that this patient has been refractory to standard migraine medications. The records document that the patients frequency of migraines has improved from more than 15 headache days per month to five or six days per month with Botox. The patients occipital neuralgia is also likely to exacerbate her migraines. For these reasons, the requested Botox injections are 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 neurology 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 platelet-rich plasma injection (CPT 0232T).Findings:  Two of the three physician reviewers found that this patient presented with persistent left shoulder pain and dysfunction. He was diagnosed with left shoulder impingement syndrome. Imaging demonstrated findings consistent with chronic, severe tendinosis with possible chronic intrasubstance tearing. He underwent left shoulder arthroscopy, debridement of labrum, subacromial decompression with bursectomy, acromioplasty, and Mumford procedure, with insertion of platelet-rich plasma to the left shoulder at the time of surgery. At this time, there is an absence of large well-designed clinical studies to support the safety and efficacy of platelet-rich plasma in the treatment of rotator cuff pathology or to assist in tissue healing. Therefore, platelet-rich plasma injection (CPT 0232T) was not likely to have been more effective than other treatment options. Final Result: The reviewers determined that the services at issue were not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: Physician reviewers 1, 2 and 3 are board certification in orthopedic surgery and are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

A 51-year-old female enrollee has requested brand name Dilantin for the treatment of her seizures. Findings:  The physician reviewer found that Dilantin is now reformulated, and the pharmacokinetics are not identical to the old Dilantin (Dilantin Kapseal 100 mg) in terms of bioavailability. The Taro generic sustained release phenytoin does provide similar bioequivalence studies. Also, the patients treating neurologist believes the generic is as good as or better than the new Dilantin (Dilantin 100 mg extended oral capsules).
Appeal type: Medical Necessity
Decision: Overturned

The parent of an enrollee has requested authorization and coverage for a portable automated external defibrillator (AED).The 2016 study by Ackerman and colleagues evaluated sudden death in the young and found that home AEDs are important for these patients. Most pediatric cardiologists recommend that families obtain AEDs for their children with long QT and carry them, as AEDs are not always readily available in public. AEDs have been proven to save lives. Survival is greatest when the AED is placed within three minutes of a witnessed collapse. McLeod and colleagues have stated that prescribing an AED should be considered for children at increased risk of sudden arrhythmic death, especially when the risk/benefit ratio of an implantable defibrillator is unclear or delay to defibrillator implantation is deemed necessary.In this case, the submitted documentation supports that the requested portable AED is medically necessary. The patient has a genetic mutation which causes long QT syndrome type 2. Although the patient is currently asymptomatic on beta blocker medication, he is at risk of sudden death from this condition. Other than an implantable cardioverter defibrillator (ICD), there is no treatment to prevent sudden death if this arrhythmia should develop. The patient does not currently meet the criteria for an ICD, as he has not had an aborted episode of sudden death or documented ventricular arrhythmia. Furthermore, an ICD in active patients at this age carries increased risks of inappropriate shocks and lead fractures. A portable AED is necessary to be immediately available in the event that the patient does have a life-threatening arrhythmia. Under these circumstances, the requested portable AED is medically necessary to treat the patients medical condition.Final Result: The reviewer determined that the requested device 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 subspecialty certification in pediatric cardiology, 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 reimbursement for residential treatment. The submitted documentation supports the medical necessity of a portion of the services at issue. This patient was struggling with identity formation. The patient had poor self-esteem and self-defeating coping strategies in context of anxiety, depression, alcohol abuse and poor motivation. As such, a conservative treatment course was to be expected. On 2/07/18, there was no discharge plan in place. The patient felt self-hatred and was engaged in all-or-none thinking while struggling with urges to drink alcohol. On 2/09/18, the patient had visions of drinking and starving upon discharge. The patient needed staff support during lunch. The provider increased the patients anti-craving medication, naltrexone, discontinued the prazosin, and changed the dose and timing of the trazodone. On 2/10/18, the patient was eating meals, but doing so slowly. On 2/12/18, the patient completed an outing and was looking forward to continuing treatment in a less restrictive setting.  In this patients case, discharge on 2/07/18 would have resulted in an unnecessary risk for prompt relapse and possible need for readmission. The patient was still having mood symptoms, anxiety and craving. The patient feared social situations and relapsing. The patient had not embraced a discharge plan. The patient was not fully motivated for recovery. Based on the records, residential treatment center services were safe, appropriate and consistent with good medical practice through 2/11/18, but not thereafter. By 2/12/18, there was no evidence to suggest that residential programming would further improve the patients condition or prevent a more serious episode of illness superiorly to well-coordinated services delivered in a less restrictive setting. Therefore, residential treatment provided from 2/07/18 through 2/11/18 was medically necessary for the treatment of this patient.Final Result: The reviewer determined that a portion of the services at issue was medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be partially overturned.Credentials/Qualifications: The reviewer is board certified in psychiatry 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

The patient is a 45-year-old female with chronic neck pain due to disc disease. Her orthopedist prescribed a neuromuscular stimulator to help manage her pain. Previous treatment with cortisone injections, medications and chiropractic therapy has not resolved her symptoms. The patient reports the neuromuscular stimulator has provided significant pain relief and improved her range of motion. She has requested reimbursement and continued authorization and coverage for the device. The Health Plan denied her request based upon a determination that the neuromuscular stimulator was/is not medically necessary.The patient has chronic neck pain that is not muscular in origin, but more likely due to degenerative disc disease. The efficacy of a neuromuscular stimulator for the treatment of discogenic pain remains unproven at this time. No prospective study has been conducted to warrant its general use. The risks, benefits and long-term results of such therapy remain unknown. Therefore, I have determined the device at issue was/is not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned

A 41-year-old female enrollee requested authorization and coverage of left breast mastopexy. The Health Plan denied the request indicating that the requested procedure is not medically necessary for treatment of the enrollees bilateral breast pain.One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer overturned the Health Plans denial on the basis that the requested procedure is medically necessary.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary:  An enrollee has requested Harvoni for treatment of his hepatitis C virus.  Findings:  The physician reviewer found that based upon the most 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. This applies regardless of fibrosis stage or viral load. Per the guidelines, non-cirrhotic genotype 1 patients who have failed peg-interferon and ribavirin should be treated with Harvoni for 12 weeks. This guideline recommendation is based on multiple randomized clinical trials, and the medication is U.S. Food and Drug Administration (FDA)-approved for all patients with chronic hepatitis C genotype 1 regardless of fibrosis stage . For these reasons, the request for a 12-week course of Harvoni is supported as medically necessary for treatment of this patients hepatitis C infection. 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.