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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Gammunex-C Immune Globulin Therapy.Findings:  Three of three physician reviewers found that there is sufficient support for the requested services in this clinical setting. Intravenous immunoglobulin therapy is FDA approved for the immune-mediated peripheral nerve disorders Guillain-Barre syndrome, chronic inflammatory demyelinating polyneuropathy, and multifocal motor neuropathy. Immunoglobulin therapy has been used increasingly with significant efficacy in the treatment of patients with disabling autoimmune forms of dysautonomia, which are most often small fiber (autonomic and/or sensory) polyneuropathies. Small fiber neuropathy is the most common cause of neuropathic pain in peripheral neuropathies. Patients experience excruciating pain, and currently available anti-neuropathic and other pain drugs do not relieve the pain substantially. Several open-label studies have suggested an immunological basis in small fiber neuropathy and have reported efficacy of treatment with intravenous immunoglobulin. In this case, the patient has been diagnosed with small fiber polyneuropathy and is reported to have debilitating neurological symptoms, neuropathic pain, debilitating paresthesia, and sensory and autonomic dysfunction that are progressing. The patient has tried other types of medical therapies without improvement. Under these circumstances, Gammunex-C Immune Globulin Therapy is likely to be more beneficial than any other available standard treatments for the patients medical condition.Final Result: Three of three reviewers determined that the requested services are likely to be more beneficial than any other available standard treatment for the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: Physician reviewers 1, 2 and 3 are board certified in neurology 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

A 66-year-old female has requested a computed tomography (CT) guided needle biopsy of the lungs for treatment of her malignant neoplasm of the liver, primary.  Findings:  The physician reviewer found that the records indicate that the requested CT guided lung biopsy is a prerequisite for enrollment in a clinical trial. Although the requested lung biopsy is not typical, it is required by the clinical protocol that would not routinely be performed as standard practice within five months of a prior biopsy. The patients lesions have already been proven to be metastatic. As the requested CT guided lung biopsy is required by the clinical protocol, the requested services are medically necessary for treatment of this patients medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: A enrollee has requested authorization and coverage for an echocardiogram. The overall yield of positive findings on echocardiogram are low in patients with undifferentiated syncope. However, studies suggest it may be beneficial in this clinical setting. Transthoracic echocardiogram can be useful in selected patients presenting with syncope if structural heart disease is suspected. Cardiac imaging is often used to identify a structural cardiac abnormality, and imaging with transthoracic echocardiogram is widely used for this purpose because it is noninvasive and low risk. Transthoracic echocardiogram can be useful when providers are concerned about the presence of valvular disease. Although an echocardiogram may not be able to establish the immediate cause of syncope, it provides information for a potential disease substrate related to prognosis. Thus, the guideline supports the use of the echocardiogram for evaluation of the cause of syncope. For these reasons, the requested echocardiogram is likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.One reviewer found that the requested echocardiogram is not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Final Result: Two of the three reviewers determined that the requested services are likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications:  One reviewer is board certified in internal medicine with sub-specialty certification in cardiovascular disease and is actively practicing. One Reviewer is board certified in internal medicine with sub-specialty certification in cardiovascular disease and is actively practicing.  One Reviewer is board certified in internal medicine with sub-specialty certification in cardiovascular disease and is 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: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement and prospective authorization and coverage for a wearable cardioverter defibrillator (Zoll LifeVest). Findings:  Two of the three physician reviewers found that there is a lack of support for the device at issue in this clinical setting. There is potential for recovery of left ventricular function over time with medical therapy, and there was no documented indication for immediate placement of a defibrillator, such as sustained or inducible ventricular tachycardia, unexplained syncope or aborted sudden cardiac arrest.  Placement of a prophylactic defibrillator is not recommended until a period of time greater than 90 days where continued left ventricular dysfunction is documented to persist despite appropriate treatment. A prophylactic defibrillator (wearable or implantable) before this time has not been demonstrated to improve outcome. Studies assessing the efficacy of prophylactic defibrillators early after diagnosis of myocardial infarction and reduced ejection fraction less than or equal to 35% before ventricular function has had a chance to recover have not demonstrated improved outcome. Moreover, more recent retrospective trials in patients with newly diagnosed non-ischemic cardiomyopathy have not demonstrated benefit with prophylactic wearable defibrillators. At this time, prophylactic wearable external defibrillator would be indicated only if accepted criteria for an implantable defibrillator were met and an implantable defibrillator could not be placed, needed to be significantly delayed (due to infection, for example) or required explantation. In sum, the wearable cardioverter defibrillator (Zoll LifeVest) was not and is not likely to be more efficacious than other available treatment options.Final Result: The reviewers determined that the device at issue was not and 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.Credentials/Qualifications: Physician reviewers 1, 2 and 3 are board certified in internal medicine with sub-specialty certification in cardiovascular disease 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 male enrollee has requested speech therapy for the treatment of his medical condition. Findings:  The physician reviewer found that the patient was over two years post injury. He continued to have profound cognitive deficits across all domains despite a prolonged course of supervised cognitive linguistic therapy (speech therapy). Although he did show some improvement in pre-functional gains, it was unlikely that additional speech therapy would result in significant functional gains in a reasonable and/or predictable period of time. In fact, significant gains were not achieved as the patients therapist notes that functional communication remains moderately to severely disordered. Available literature supporting the efficacy of cognitive rehabilitation for traumatic brain injury is limited. Standard clinical practice two years post injury would involve transition to a home program and participation in computer-based therapeutic activities. As such, speech therapy services during the period at issue were not medically indicated. Nor is additional speech therapy currently indicated.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary:  An enrollee has requested neuropsychological testing for evaluation of her medical condition. The physician reviewer found that neuropsychological testing is not medically necessary for treatment of the patients medical condition. The documentation submitted for review does not indicate that this patient has any acute neurological deficits that would require neuropsychological testing to diagnose. The neuropsychological testing performed previously indicated a diagnosis consistent with mild intellectual disability and depression, although the testing also revealed that her effort level was lower than expected. The documentation submitted for review does not indicate that she is suffering from a progressive dementia that would require follow-up testing. There also is no indication that she has suffered a stroke, epilepsy or mass lesion that might require neuropsychological testing to aid in the diagnosis. Based on the documentation provided, neuropsychological testing is not medically necessary for evaluation of the patients medical condition. Final Result: The reviewer determined that the requested testing is not medically necessary for evaluation of the patients medical condition. Therefore, the Health Plans denial should be upheld.  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

A 31-year-old female enrollee has requested substance abuse sub-acute residential treatment for the treatment of her behavioral health condition. Findings:  The physician reviewer found that no medical records have been provided to aid in the determination of the medical necessity of this patients treatment for the dates of service in question. Due to the absence of medical record documentation, there is no supporting evidence that this patient required further treatment, that such treatment may have benefitted her, or that she could not have been safely and effectively treated at a less restrictive setting. As a result, the medical necessity of the services at issue has not been established at this time.
Appeal type: Urgent Care
Decision: Upheld

A 26-year-old female enrollee has requested reimbursement for a gastroenterologist consultation and a diagnostic CT enterography scan performed on different dates.  The Health Plan has denied this request indicating the services at issue were not required on an urgent basis. Findings:  The physician reviewer found that the patient underwent a gastrointestinal consultation and computed tomography (CT) enterography scan of the abdomen about a month later for the evaluation of abdominal pain while outside of her plans service area. The patient has a history of appendectomy with lysis of adhesions. The pain was described as a deep pain and had been present for several months prior to evaluation. During the exam, it was noted that the patient had a tender subcutaneous nodule in the right lower quadrant as well as diffuse mild tenderness of the whole right lower quadrant. The provider ordered a CT scan. The CT scan only showed post-operative changes. The patient has requested reimbursement for the services. The Health Plan has denied coverage for these services indicating that they were not urgent in nature.  At issue in this case is whether a prudent layperson in the patients circumstances would have sought immediate medical attention on the dates in question. Urgently needed services are those services necessary to prevent serious deterioration of the health of an enrollee, resulting from an unforeseen illness, injury, or complication of an existing condition, including pregnancy, for which treatment cannot be delayed until the enrollee returns to the plan's service area.  The patients gastroenterologist noted that recurrent adhesions or even a mild flare of irritable bowel disease (IBD) was possible. The patient did not present with symptoms that would cause a reasonable layperson to believe that immediate medical attention was required. The patients symptoms were ongoing and had been present for several months prior to evaluation. The submitted evidence does not demonstrate that the patient was experiencing a complication of an existing condition for which treatment could not be delayed until she returned to the Plan's service area. A gastroenterology work-up could have been deferred until the patient returned to the Plans service area. All told, a prudent layperson in this situation would not have sought immediate medical attention.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for gel injections. Findings: The physician reviewer found that there is sufficient support in the medical literature for the requested services in this clinical setting. The patient has clinical and radiographic evidence of osteoarthritis of both knees with failed treatment with NSAIDs and corticosteroid injections. Treatment algorithm recommends intra-articular hyaluronic acid for management of knee osteoarthritis as second-line treatment in patients who remain symptomatic despite use of NSAIDs. This recommendation is based upon accumulating evidence that intraarticular hyaluronic acid provides a significant benefit in knee osteoarthritis. There is adequate evidence that intraarticular hyaluronic acid injections reduce pain and increase function in knee osteoarthritis. Additionally, the evidence also shows that the benefits from these injections are long lasting when compared with intraarticular corticosteroids. The current evidence suggests that intraarticular hyaluronic acid is a viable option for knee osteoarthritis where improvement with knee pain and function persisted for up to 26 weeks. Therefore, gel injections for treatment of this patients bilateral knee pain has been established as medically necessary. 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: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for a gastroenterology consultation at a tertiary level facility. Findings:  The physician reviewer found that the records provided for review document that this patient has gastrointestinal disease consistent with inflammatory bowel disease, specifically fistulizing Crohns disease, although this has not been formally diagnosed. His course has been complicated by multiple surgeries and a need for intravenous antibiotics. Diagnosis and management of complicated inflammatory bowel disease, both medical and surgical, requires specialized expertise beyond that of a general gastroenterologist, which has been shown to result in better medical and surgical outcomes. Inflammatory bowel disease specialists at referral centers are associated with a lower risk of surgery. For these reasons, the requested referral to a gastroenterologist for consultation at a tertiary level facility is supported as medically necessary for the evaluation of this patients medical condition. Final Result: The reviewer determined that the requested service is 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 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: Upheld

A 53-year-old female enrollee has requested coverage for LAP Band surgery for treatment of her obesity and obesity related medical conditions.  Findings:  The physician reviewer found that the patient reportedly has a BMI of 34. Although the LAP Band adjustable gastric banding (LAGB) system is now no longer off label for use in low BMI patients, general guidelines including the National Institutes for Health (NIH) Consensus Guidelines do not currently recommend bariatric surgery for individuals with a low BMI (less than 35).  With a BMI less than 35, this patient does not meet generally accepted criteria for morbid or clinically severe obesity at this time. Low BMI bariatric surgery is still undergoing clinical trials. While studies involving small numbers of patients have been performed, no society or governmental guidelines are currently available for the use of bariatric surgery in patients with a BMI less than 35. All told, there is a paucity of medical literature indicating the requested procedure is safe and efficacious in this patient population. Therefore, the requested surgery is not medically necessary.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary:  An enrollee has requested inpatient hospital services for treatment of his atrial fibrillation.  The physician reviewer found that according to Ganz, patients with atrial fibrillation and a rapid ventricular response who are symptomatic but not unstable, initial therapy usually involves intravenous rate control medications. Patients who are chronically managed with a rhythm control strategy can undergo cardioversion if they have been adequately anticoagulated or are considered to have a low thromboembolic risk. In this case, the patient was admitted with COPD and cor pulmonale. The patient was initially noted to have atrial fibrillation with rapid ventricular response. He required an intravenous drip of diltiazem for rate control.  Adequate control was not immediately obtained on oral medications. Subsequently, the patient could have been discharged to a lower level of care. As such, initial inpatient hospital services were medically necessary for treatment of the patients medical condition. Final Result: The reviewer determined that a portion of the services at issue were 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 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 has requested reimbursement and prospective authorization and coverage for  Duexis 800 mg-26.6 mg tablets. The guidelines from the American College of Gastroenterology (ACG) regarding non-steroidal anti-inflammatory drugs (NSAIDs) in patients at high risk for gastrointestinal toxicity recommend co-therapy with misoprostol, histamine type-2 receptor antagonists or proton-pump inhibitors (PPIs) and/or the use of cyclooxygenase-2 selective inhibitors. The records provided for review document the presence of shoulder pain with confirmation of a partial rotator cuff tear. The patient has undergone cortisone injections in the shoulder without significant benefit as well as physical therapy with improvement in range of motion. However, she has found Duexis to be more helpful than single agents. However, the peer-reviewed medical literature has not demonstrated that use of a one-pill agent is superior to a two-pill combination of the same agents. Currently, there is a lack of data in the medical literature demonstrates that using Duexis is superior to using ibuprofen 800 mg with famotidine 80 mg in combination as single agents. For these reasons, Duexis 800 mg-26.6 mg tablets were not and are not medically necessary for treatment of this patient. Final Result: The reviewer determined that the medication at issue was not and is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in anesthesiology with subspecialty certification in pain management and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

A 61-year-old female has requested coverage for bilateral upper blepharoplasty (ptosis repair) for treatment of her bilateral eyelid ptosis.  Findings:  The physician reviewer found that as noted by the American Society of Plastic Surgeons (ASPS), when reconstructive blepharoplasty is performed, indications for surgery should be documented by the surgeon in the history and physical and reiterated in the operative note. The ASPS further states that, If the patient is experiencing visual impairment, formal visual field testing by an optometrist or ophthalmologist is recommended. A complete eye exam may also be appropriate in certain cases. Applying the ASPS requirements for blepharoplasty, quality photographs and visual field testing demonstrating the severity of the condition need to be provided for review in the medical documentation. Further, there must be supporting evidence to adequately define the severity of the patients condition. In this patients case, the provider documents that the condition is present but does not clearly describe it or define it. In addition, the photographs do not demonstrate the severity of the condition. Further, there is no documentation of visual field testing with taped and untapped eyelids. The surgeon documents that there is a visual field defect, but does not describe the specifics of the deficit. Overall, the documentation provided by the patient does not satisfy the criteria from the ASPS and American Academy of Ophthalmology (AAO) for blepharoplasty for a reconstructive or medically necessary procedure.