Persius/imr-appeals huggingface dataset:
Appeal type: Medical Necessity
Decision: Overturned

A 49-year-old female enrollee has requested a duodenal switch (DS) for the treatment of her morbid obesity. Findings:  The physician reviewer found that the patient meets the criteria set by the National Institute of Health for weight loss surgery.  A weight loss surgery should not only provide resolution of the co-morbid conditions, but should also have reproducible results, with a predictable outcome. An ideal surgical procedure should maximize benefits while reducing side effects and complications. The duodenal switch operation is an appropriate treatment option for this patient. The duodenal switch operation is a better option for this patient; it has a better long term success when compared to other procedures.
Appeal type: Medical Necessity
Decision: Upheld

A 45-year-old female enrollee has requested revisional band over bypass bariatric surgery for the treatment of her post surgical complaints. Findings:  The physician reviewer found that the medical literature shows that 5-10% of patients fail to lose adequate weight (greater than 50% of pre-surgical weight) after LRYGB. In some cases, this is due to a maladaptive behavioral eating disorder. However, it is also possible that poor results are a result of anastomotic failure. In the case of this patient, the submitted documentation does not include definitive proof of anastomotic failure of the previous LRYGB. Furthermore, it does not appear an endoscopy has been performed to evaluate the pouch and the size of the gastrojejunal anastomosis. Until such evidence is obtained, the medical necessity of revisional bariatric surgery is not established.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested Harvoni for eight weeks for treatment of her hepatitis C virus (HCV). Findings:  The physician reviewer found that the submitted documentation establishes the medical necessity of the requested medication. Harvoni carries the highest American Association for the Study of Liver Diseases (AASLD) and Infectious Diseases Society of America (IDSA) recommendation of Class I, Level A recommendation for treatment of HCV patients. Although the documentation submitted for review do not support advanced fibrosis, the medical necessity of HCV treatment as per AASLD/IDSA recommendations, and the medical appropriateness of therapy as proposed for this patient, exists irrespective of fibrosis score. AASLD/IDSA guidelines underscore this position stating Evidence clearly supports treatment in all HCV-infected persons, except those with limited life expectancy (less than 12 months).  Therefore, Harvoni for eight weeks is medically necessary for treatment of the patients HCV. 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 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: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for blood test. Findings:  Three physician reviewers found In this case, Anser IFX was ordered to determine Remicade level, and whether antibodies to Remicade were present. Loss of response to Remicade (infliximab) can occur for many reasons. The presence of antibodies alone does not necessarily result in loss of response to infliximab or infusion reactions, nor have threshold levels been established. Studies have found that anti-infliximab antibodies can be transient, and disappear over time, with many patients who have these antibodies maintaining their response. The current medical literature lacks high-quality controlled studies to define drug level or antibody level thresholds requiring action, compare clinical strategies (such as dose increase or change in medication) based on those thresholds, and then definitively establish that use of Anser IFX improves outcome when used in those treatment pathways. The literature that is available is not sufficient to establish improvement in health outcomes, and studies are contradictory. Thus, the blood test was not likely to have been more effective than other methods of evaluating this patient.Final Result: The reviewers determined that the services at issue were 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 1, 2 and 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 48-year-old male enrollee has requested for pegylated interferon and ribavirin injections for treatment of his hepatitis C.   Findings:  Two physician reviewers found that tt is appropriate in this setting to wait until six months after the patients last dose of medication to determine if the patient had a substantial virologic response. As such, the proposed regimen is not currently clinically indicated, but the patient should be re-evaluated in six months to determine the likelihood of benefit of the requested medications at that time.
Appeal type: Experimental/Investigational
Decision: Upheld

A 35-year-old female enrollee has requested intravenous (IV) antibiotics for treatment of Lyme disease.  Findings:  Three physician reviewers found that there is no peer-reviewed data supporting more than 30 days of treatment for Lyme disease in any form. The submitted materials do not include substantial data supporting use of an extended period of antibiotic therapy. Furthermore, in this case there is no clear objective evidence of ongoing or recurrent infection. Therefore, given the controversy surrounding treatment, long-term antibiotic therapy remains experimental/investigational and is not recommended for this patient.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The enrollees parent has requested authorization and coverage for magnetic resonance spectroscopy. Findings:  Three physician reviewers found the requested MRS is likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Mitochondrial diseases are disorders of mitochondrial respiration resulting in defective energy production which typically manifest in systems with high energy demands, such as the central nervous system. Diagnosis is challenging because symptoms may affect any system and are typically non-specific. Structural magnetic resonance imaging (MRI) and functional brain imaging methods including MRS, diffusion-weighted imaging, and perfusion MRI, have been instrumental in acquisition of knowledge about mitochondrial disorders in a non-invasive fashion. A study reported that clinical diagnosis in children with mitochondriopaties is not easy because of variable clinical symptoms. MRS examination is a noninvasive complementary tool for helping to corroborate the diagnosis. With the current level of knowledge and expertise in this field, the use of MRS in this patient is consistent with the current standard of care, and more likely to be beneficial than other available standard interventions. Final Result: The reviewers determined that the requested MRS is likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Credentials/Qualifications: All three physician reviewers are board certified in pediatrics 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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for laser treatment. Findings:  The physician reviewer found that Multiple small randomized controlled studies do not show a benefit of laser over oral antifungal medications in the treatment of onychomycosis. Studies show some clearance with laser but not significantly better than the U.S. Food and Drug Administration approved oral antifungals, terbinafine and itraconazole. Additionally, long term follow up cure rates are low.  As such, the use of laser therapy to treat onychomycosis is not likely to be more efficacious than standard oral antifungal medication treatments.Final Result: All three reviewers determined the requested services 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:  All three reviewers are board certified in dermatology and are actively practicing. All three reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary:  An enrollee has requested dynamic pelvic magnetic resonance imaging (MRI) for evaluation of her medical condition.  Two physician reviewers found that the requested services are not likely to be superior over other modalities.  The concern for this patient is that her defecatory disorder is either due to dyssynergic defecation or an anatomical abnormality such as a rectocele.  The initial work-up beyond a physical examination and detailed history usually begins with an anal manometry study that incorporates a balloon expulsion test.  If dyssynergia is eliminated as a potential diagnosis, then defecography can be performed to rule out a rectocele.  There is a lack of support for the requested services in this clinical setting.  All told, the requested dynamic pelvic MRI is not likely to be of greater benefit than other methods of evaluating this patient.  Final Result:  Two 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: All three reviewers are board certified in internal medicine with sub-specialty certification in gastroenterology and are actively practicing. All three reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

A 60-year-old female enrollee has requested chemical dependency residential detoxification level of care for treatment of the enrollees substance abuse. Findings:  The physician reviewer found that the American Psychiatric Association guidelines describe the need for residential services as being appropriate for a person that is leaving the hospital, but who remains at high risk for relapse and who lacks the sufficient motivation to continue in outpatient treatment or who has severe co-occurring psychiatric conditions (such as this patient). Similarly, the fact that she is described as having a significant personality disturbance creates a lower likelihood of a successful outcome and complicated her willingness and ability to participate in a lower level of care.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for the Shoemaker Protocol including office visit with qualified provider experienced with the Shoemaker Protocol once every four to six weeks until the Shoemaker Protocol is completed (approximately six months); Welchol 625 mg three tablets daily; liposomal vitamin C 500 mg four times daily; vasoactive intestinal peptide nasal spray, epinastine HCL 0.05% two drops twice daily; neuroquadrant magnetic resonance imaging (MRI) without contrast; macron biofilm analysis; nares culture; Singulair 10 mg once daily; Cromolyn 4 ampules twice daily; and cholestyramine non-saccharine 4 grams. CRIS is a controversial constellation of symptoms, which is not currently accepted as a diagnostic disorder. Mast cell activation syndrome is a recent diagnosis of signs and symptoms related to mast cell release to include urticaria, angioedema, headache, and abdominal pain, as well as fatigue and memory issues. The current recommended therapy includes treatment to inhibit mast cell release and blocking symptoms. Histamine 1 (H1) and histamine 2 (H2) blockers are first-line therapy followed by leukotriene receptor blockers and Cromolyn sodium. This patients records do not document that he has failed treatment, or has a contraindication to H1 and H2 blockers. Thus, the requested Shoemaker Protocol including office visit with qualified provider experienced with the Shoemaker Protocol once every four to six weeks until the Shoemaker Protocol is completed (approximately six months); Welchol 625 mg three tablets daily; liposomal vitamin C 500 mg four times daily; vasoactive intestinal peptide nasal spray, epinastine HCL 0.05% two drops twice daily; neuroquadrant magnetic resonance imaging (MRI) without contrast; macron biofilm analysis; nares culture; Singulair 10 mg once daily; Cromolyn 4 ampules twice daily; and cholestyramine non-saccharine 4 grams are not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the requested services and medications 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 internal medicine with subspecialty certification 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: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested partial hospitalization program (PHP) but if PHP is not medically necessary, the enrollee requests intensive outpatient program (IOP) for treatment of her behavioral health condition. Findings: The physician reviewer found that Ketamine is an N-methyl-D-aspartate (NMDA) antagonizing dissociative drug commonly used as an anesthetic. There are no Food and Drug (FDA) approved medications to treat addiction to ketamine or other dissociative drugs. Per accepted medical guidelines and scientific literature, the treatments of choice in this setting are chemical dependency services and behavior therapy. This patient has a severe substance use disorder with comorbid anxiety and depression. Her addiction dominates her functionality while her co-occurring psychiatric issues hinder her recovery. The records indicate that she has significant interpersonal, occupational, financial, and social impairment. As such, her illness burden demands comprehensive specialty care. A recent clinical evaluation recommended intensive outpatient programming. There is no documentation suggesting an improvement in the patients condition that would support treatment in a less restrictive setting.  Conversely, there is no evidence indicating that services provided by an intensive outpatient program would be inadequate, thus necessitating a higher level of care. Thus, although the requested PHP is not medically necessary, IOP is reasonably expected to improve the patients condition and prevent a more serious episode of illness and therefore is clinically indicated.  Medical literature supports IOP services in this case and these services are recognized as safe, appropriate and consistent with good medical practice.  Thus, the requested IOP services are medically necessary for treatment of the patients behavioral health condition.  Final Result: The reviewer determined that the requested partial hospitalization program (PHP) services are not medically necessary, the requested intensive outpatient program (IOP) services are medically necessary. 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: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for ultrasonic guidance for needle placement of the trigger point injections. There is no proven marginal benefit of trigger point injections into the soft tissues over placebo with respect to health, pain, or functional outcomes in the setting of any musculoskeletal condition, including neck and back pains attributed to myofascial pain or any other underlying etiology.  Dommerholt and colleagues report that most  studies investigating this intervention are inadequately blinded, and that without effective blinding and adequate blinding procedures, the specific effects of the intervention are called in question. The authors further note that while diagnostic testing, such as ultrasound, may be used to identify trigger points, in the clinical setting, palpatory examinations are more commonly performed, and that future studies should investigate if ultrasound is comparable to manual palpation. Trigger point injection therapy remains an empirical option for treatment of pain attributed to myofascial pain, and using ultrasound as an imaging modality to identify trigger points, or to guide dry needling or the administration of injections, is not proven to make this intervention efficacious. Quinter and colleagues report that there is no established difference in the sonographic appearance of trigger points versus normal muscle tissue. In this case, there is a lack of evidence that the service at issue would have been more beneficial than standard therapies for the patients conditions including exercise, independently applied modalities such as heat, and pharmacotherapy as needed. Therefore, ultrasonic guidance for needle placement of the trigger point injections was not likely to have been more beneficial for treatment of the patients condition than any available standard therapy.Findings:  Two of the three physician reviewers found the ultrasonic guidance for needle placement of the trigger point injections was not likely to have been more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the services at issue were not likely to have been 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 reviewer 1 is board certified in physical medicine and rehabilitation and is actively practicing. Physician reviewer 2 is board certified in physical medicine and rehabilitation with sub-specialty certification in neuromuscular medicine and is actively practicing. Physician reviewer 3 is board certified in physical medicine and rehabilitation with sub-specialty certification in pain medicine and is actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested a panniculectomy and abdominoplasty for treatment of her medical condition.  Findings:  The physician reviewer found that this patient presents with evidence of a symptomatic, lower abdominal pannus. She has a complicating factor of an umbilical hernia. Her symptoms have included chronic rashes treated with typical dermatologic medications, including cortisone and antifungal creams. The photographs support that the patient has a significant lower abdominal pannus which is contributing to her functional deficit of chronic rashes. The likely cause of her functional deficit is directly related to the size and overhang of the lower abdominal pannus. However, this is not likely the case with regard to the patients upper abdomen. A panniculectomy would directly address the size of the lower abdominal pannus and likely correct the skin-to-skin overlap. This is not the case for the upper abdomen, as there is a lack of evidence of a significant overlap of the upper abdomen. Her abdominal pain may be related to her history of chronic rashes and open sores, the lower abdominal pannus, as well as the umbilical hernia but it is unlikely related to her upper abdominal excess. Thus, as the patient has a functional deficit related to chronic rashes and possible abdominal pain that would be addressed with lower abdominal panniculectomy, it is considered medically necessary. As the abdominoplasty would not likely address the patients functional deficit it should not be considered functional in nature or medically necessary. The American Society of Plastic Surgeons (ASPS) state that a panniculectomy to eliminate a large hanging abdominal panniculus and its associated symptoms would be considered reconstructive. Further, an abdominoplasty is typically performed for cosmetic purposes, involves the removal of excess skin and fat from the pubis to the umbilicus or above, and may include fascial plication of the rectus muscle diastasis and a neoumbilicoplasty. Manahan and Shermak noted that, the abdominal panniculus may cause disabling rashes, pain, physical limitation, back strain, and cosmetic deformity, and symptoms are more marked the heavier the panniculus for which panniculectomy may be indicated. All told, the requested panniculectomy satisfies the criteria for medical necessity whereas abdominoplasty does not. Final Result: The reviewer determined that a portion of the requested services are 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 plastic 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.