Persius/imr-appeals huggingface dataset:
Appeal type: Urgent Care
Decision: Upheld

A 65-year-old male enrollee has requested emergency services for treatment of his medical condition. Findings:  The physician reviewer found that the submitted documentation demonstrates the patient had been experiencing ongoing symptoms for about a week prior to his presentation to the ED. During this period, the patient had sufficient time to undergo an evaluation in a clinic or private office. His pain level upon presentation to the ED was 1 out of 10 and there was no physical evidence of infection. While it is understandable that the patient was concerned about this recent development in a wrist that had previously been badly traumatized and surgically repaired, a reasonable and prudent layperson in theses circumstances would have sought evaluation outside of an emergency room setting. Thus, the patients symptoms did not meet prudent layperson criteria for emergency care. A prudent layperson in the patients circumstances would not reasonably expect the absence of emergency care to seriously jeopardize his or her health.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary:  An enrollee has requested authorization and coverage for Xifaxan (rifaximin 550 mg, one tablet twice daily for 30 days; four refills).Xifaxan has proven to be effective for the treatment of irritable bowel syndrome, diarrhea-predominant (IBS-D). The U.S. Food and Drug Administration (FDA) has approved Xifaxan for the treatment of IBS-D, and the medication has been demonstrated to be safe and effective in randomized placebo-controlled trials. In a study by Lembo and colleagues, Xifaxan was demonstrated to be effective, with significant symptom improvement for irritable bowel syndrome. The American College of Gastroenterology guidelines for the treatment of irritable bowel syndrome state that rifaximin (Xifaxan) is effective for the treatment of IBS-D. However, clinical trials and the FDA approval for Xifaxan in the treatment of IBS-D support the use of Xifaxan 550 mg three tablets daily for 14 days, but not daily long-term ongoing use. In this case, the patient has IBS-D. The requested dose exceeds the recommendation from the medical literature. Xifaxan is supported for the treatment of the patients IBS-D, but only for a dose of Xifaxan 550 mg, three tablets daily for 14 days. Therefore, Xifaxan (rifaximin) 550 mg, three tablets daily for 14 days are medically necessary for treatment of the patients medical condition.Final Result: The reviewer determined that the requested medication is partially 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 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 58-year-old male enrollee has requested for a cervical MRI  for evaluation of his neck pain. Findings:  The physician reviewer found that the American College of Radiology, an MRI of the cervical spine is indicated in patients with neurological findings and neck pain. This is true if the radiographs demonstrated spondylosis or were normal. The outcome of the MRI study will assist the physician with appropriate treatment planning.
Appeal type: Medical Necessity
Decision: Upheld

The parent of a nine-year-old male enrollee has requested mental health intensive outpatient treatment for the treatment of the enrollees pervasive developmental disorder, not otherwise specified. Findings:  The physician reviewer found that this patient had been in intensive outpatient treatment for one year. An updated summary from the provider indicates that the patient has made progress in several areas, and his adaptive functioning was described as only moderately impaired. Other documents indicate that his emotional outbursts are less frequent. The school also reports progress and notes that he is able to handle transitions better. A behavior plan is in place. He continues to need ongoing support and redirection, especially with social interactions. He engages in hair pulling and has episodes of anxiety and frustration. The patient has academic difficulties. There is no documentation of ongoing high risk behavior. He continues to have challenges with change in routine, social interactions and flexibility. Goals of treatment from the intensive outpatient program include such goals as increasing relational capacity and social and family functioning. These appear to be ongoing and not specifically related to a major decline in overall functioning. This patient has a supportive environment, a capacity to participate in treatment and a low risk of self-harm. Therefore, current treatment goals could be addressed in regular outpatient therapy. This is consistent with the American Academy of Child and Adolescent Psychiatry practice guidelines and CALOCUS level of care guidelines. Thus, based on the patients level of functioning, continued mental health intensive outpatient treatment was no longer indicated.
Appeal type: Medical Necessity
Decision: Upheld

A 52-year-old male enrollee has requested image-guided radiation therapy (IGRT) with intensity-modulated radiation therapy (IMRT) for the treatment of his prostate cancer. Findings:  The physician reviewer found that the patient has high-risk cancer of the prostate with a rising PSA and rectal and lymph node involvement. Although IGRT may be superior in principle to IMRT, the patients medical status must also be considered. His cancer is no longer confined to the prostate and systemic therapy is needed with radiation used for palliation. IGRT with IMRT is not medically indicated in this setting.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Concerta for treatment of the enrollees attention deficit hyperactivity disorder (ADHD). Findings:  The physician reviewer found that stimulant medication is considered the gold standard pharmacologic intervention for patients with ADHD. Concerta is a methylphenidate based product that was approved by the U.S. Food and Drug Administration (FDA) for the treatment of ADHD in 2000. Concerta is a central nervous system psychostimulant that exert its clinical effect by blocking the reuptake of norepinephrine and dopamine in the prefrontal cortex. The unique extended-release tablet relies on osmotic pressure to steadily deliver methylphenidate resulting in a duration of effect that can approach 12 hours. The typical dose range of Concerta is between 18 mg and 72 mg once a day. This patient was previously treated with a Concerta and has a proven track record of tolerability and efficacy with Concerta. Additionally, upon returning to care for her ADHD, Concerta was prescribed by the treating provider at a safe, appropriate and conservative dose. As such, the requested Concerta is supported as medically necessary for treatment of this patients ADHD. 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 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: Experimental/Investigational
Decision: Overturned

A 51-year-old female enrollee has requested a PET scan for an evaluation of her breast cancer. Findings:  Three physician reviewers found that according to the Medicare guidelines, a PET scan is medically indicated for staging of patients with distant metastasis, or restaging patients with locoregional recurrence or metastasis as an adjunct to standard imaging modalities. PET is also indicated for monitoring response to treatment of locally advanced and metastatic breast cancer when a change in therapy is contemplated as an adjunct to standard imaging modalities. This patient has locally advanced disease, with 18 out of 19 lymph nodes positive. She has had abnormal laboratory values, including an elevated tumor marker. Conventional imaging has been negative. In this patients case, a PET scan is likely to be more clinically useful for evaluation of this patient than alternative methods of evaluation.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for intravenous immunoglobulin injections every two weeks. Stiff person syndrome is a neurological disorder characterized by muscle rigidity primarily in the truncal muscles and is commonly associated with autoantibodies to the GAD 65 receptor. The pathophysiology of the disease is caused by the decreased level of the glutamic acid decarboxylase (GAD) activity due to an autoantibody against GAD that decreases the level of gamma-aminobutyric acid (GABA). Most patients require treatment with immunotherapy with intravenous immunoglobulins, oral or intravenous steroids. The records provided for review document that this patient has experienced significant clinical improvement with the use of IVIG. Treatment has reportedly yielded a 60-70% clinical improvement in the patients symptoms. Given this support, the requested intravenous immunoglobulin injections every two weeks 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

A 46-year-old male enrollee has requested surgery (CPT code 29916) for treatment of his hip pain. Findings:  Two physician reviewers found that in this case, the services at issue were not likely to have been of greater benefit than other available treatment options.  Surgical treatment for femoroacetabular impingement syndrome is supported in patients who have minimal degenerative changes of the hip, no other explanation for pain, and whose radiographs or testing document cam impingement.  In this patients case, there was another explanation for pain in light of his buttock pain and positive straight leg raise with possible radicular complaints associated with his L5-S1 degenerative changes.  Additionally, on the date indicated, a magnetic resonance (MR) arthrogram of the right hip documented moderate degenerative changes of the right hip.  In this clinical setting, the superior efficacy of the services at issue has not been established.
Appeal type: Experimental/Investigational
Decision: Overturned

A 35-year-old male enrollee has requested for bilateral implantation of corneal ring segments for treatment of his keratoconus. Findings:  Three physician reviewers found that most patients improved after undergoing the procedure at issue for the treatment of keratoconus, and very few suffered any ill effect. One should generally try to improve the condition of an existing organ with minimal risk before transplanting that organ from an unrelated donor, even if only to postpone the transplantation.
Appeal type: Medical Necessity
Decision: Upheld

An 18-year-old female enrollee has requested coverage for Dry Eye Light Intense Therapy for treatment of  her chronic severe dry eyes.  Findings:  The physician reviewer found that the submitted documentation fails to establish the medical necessity of the requested services in this patients case.  There is a lack of medical evidence demonstrating the safety and efficacy of the requested treatment for this patients medical condition.  In this case, the patient has history of severe dry eyes and meibomian gland dysfunction.  Prior treatment has included topical medications, punctual plugs and environmental/dietary adjustments.  Intense pulsed light therapy was prescribed for additional treatment.  In the medical literature, there is a lack of controlled studies of intense pulsed light treatment for dry eyes or meibomian gland dysfunction.  There are a number of well-established and available treatments for dry eyes beyond the patients current therapies, such as systemic anti-inflammatory, or other local agents.  All told, the requested Dry Eye Light Intense Therapy treatments are not medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Overturned

The patient is a 54-year-old female with a history of documented right atrial tachycardia, tachycardia induced cardiomyopathy and status post atrial ablation in February 2004. The patient has reported continued symptomatic palpitations during follow-up evaluation. The patient was not offered repeat ablation at that time. Thereafter, the patient underwent repeat Holter monitoring demonstrating recurrent symptomatic supraventricular tachycardia at 127-130 bpm. Despite these findings, there is no report from the patients treating electrophysiologist of any new recommendations or plans for additional therapy. The patient has sought a second opinion from another electrophysiologist. The second opinion has recommended attempting a repeat ablation. The patient is requesting authorization for a repeat electrophysiologic study and catheter ablation.Treating atrial tachycardia is challenging. This patient has had an abnormal Holter monitor and was not offered any additional therapy other than a follow up visit. Based upon the patients history and abnormal testing the repeat electrophysiologic study and catheter ablation are medically indicated and within the standard of care for this patients condition. Therefore, I have determined that the requested services are medically necessary for the treatment of the patients medical condition. The Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Upheld

The parent of a 12-year-old male enrollee has requested blepharoplasty, blepharoptosis repair and eye photography for treatment of the enrollees congenital ptosis. Findings:  The physician reviewer found that the medical necessity of the proposed procedures is not established. The submitted photographs do not demonstrate that the patients left upper lid is causing functional visual problems. Additionally, the visual field tests do not document a significant superior visual field loss that is corrected by taping the upper lids. Furthermore, the amount of astigmatism in the patients left eye is 0.50 diopters, which is not visually significant. Moreover, the patients astigmatism cannot be attributed to his ptosis with certainty. All told, the documentation provided does not establish that the patient meets clinical indications for the proposed surgical intervention.
Appeal type: Medical Necessity
Decision: Upheld

The patient is a 42-year-old female with head posterior fossa development with Chiari malformation. In June 2002, the patient underwent suboccipital craniectomy, C1 laminectomy, and duraplasty. The patient has now been diagnosed with cerebellar ptosis. It has been recommended the patient undergo re-exploration of her posterior fossa decompression with possible replacement of her dural graft and partial posterior fossa cranioplasty.  The Health Plan indicates the recommended procedure is not medically necessary for treatment of the patients medical condition.The patient has a history of post fossa decompression and duraplasty. A cranioplasty and repeat duraplasty has now been proposed. The patients providers have not made a definitive diagnosis. As such, the proposed surgery is not medically indicated at this time. The Health Plan has offered to provide further workup and evaluation of the patients condition. The services offered by the Health Plan are medically reasonable and appropriate. 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: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement and prospective authorization and coverage for laser treatment (CPT 17108).Findings:  Three physician reviewers found that rosacea is a common chronic disorder characterized by periods of exacerbation, remission and possible progression. The nonpharmacologic approach to therapy includes adequate skin care, trigger avoidance and photoprotection. In addition, there are several topical, herbal, systemic and light-based therapies available. U.S. Food and Drug Administration (FDA) approved treatments include topical metronidazole and azelaic acid. Combinations of azelaic acid or topical metronidazole with anti-inflammatory doxycycline appears to have a synergistic effect. The standard approach for the treatment of patients with rosacea is to combine the systemic anti-inflammatory effect of tetracycline antibiotics with topical anti-inflammatory and bactericidal treatments. In this case, the records do not document that this patient has failed standard treatments. Laser treatment is not supported in this setting. Therefore, laser treatment (CPT 17108) was not and is not likely to have been of greater benefit than other treatment options. Final Result: The reviewers determined that the services at issue were not and are not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: Physician reviewers 1, 2 and 3 are board certified in dermatology 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

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for anesthesia service rendered during the flexible sigmoidoscopy with biopsies on 5/23/17. The Health Plan has denied this request indicating that the requested service was not medically necessary for treatment of the enrollees Crohns disease.At issue in this case is whether the anesthesia service rendered during the flexible sigmoidoscopy with biopsies on 5/23/17; was medically necessary for treatment of this patients medical condition.The patient was given an ASA preoperative physical status classification score of two. Intravenous sedation performed by a non-anesthesiologist and non-certified registered nurse anesthetist is well supported in both clinical practice; and in the research, given a low preoperative physical status classification score. This level would be appropriate in this case given the low ASA score. Therefore, the requested anesthesia service rendered during the EGD with flexible sigmoidoscopy along with biopsies on 5/23/17, was not medically necessary for treatment of the patients medical condition.Final Result: The reviewer determined that the requested service 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 Orthovisc injections. The submitted documentation supports the medical necessity of the requested services. The current literature continues to support the use of viscosupplementation for osteoarthritis of the knees. Per medical literatures, there is good evidence that intraarticular hyaluronic acid injections reduce pain and increase function in knee osteoarthritis, and the benefits are long-lasting as compared with intraarticular corticosteroids. Evidence from real-life studies of repeat courses of intraarticular hyaluronic acid demonstrates an improvement in pain or function lasting up to 40 months, a reduction in use of concomitant analgesia by up to 50%, and suggests that there may be a delay in the need for total knee replacement of around 2 years. The researchers performed a systematic review of overlapping meta-analyses comparing viscosupplementation with other nonoperative treatment modalities for knee osteoarthritis. Their review found that that the current highest level of evidence suggests that intraarticular hyaluronic acid is a viable option for knee osteoarthritis and that its use results in improvements in knee pain and function that can persist for up to 26 weeks. Viscosupplementation has a good safety profile, and its use should be considered in patients with knee osteoarthritis. There is sufficient support for the requested services in this clinical setting. Therefore, Orthovisc injections are medically necessary for 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.