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

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for a transcatheter aortic valve replacement (TAVR) procedure. Mack and colleagues found that among patients with severe aortic stenosis who were at low surgical risk, the rate of the composite of death, stroke, or rehospitalization at one year was significantly lower with TAVR than with surgery. In this case, the patient has severe symptomatic aortic stenosis. He has several comorbid conditions, including obesity and sleep apnea with use of CPAP, that put him at higher surgical risk and would make surgical valve replacement less safe. Therefore, a TAVR procedure is medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested service 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 cardiovascular disease and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld

A 64-year-old male enrollee has requested anterior optical coherence tomography (OCT) for treatment of his glaucoma suspect and narrow angles.  Findings:  Two physician reviewers found that anterior optical coherence tomography was not likely to be more beneficial for treatment of the patients medical condition than any available standard treatment. Anterior optical coherence tomography provides objective high-resolution images of the angle, and these images can be analyzed qualitatively and quantitatively. However, gonioscopy, a recognized method of angle examination, can give sufficient information about the potential for angle closure attack in an eye with narrow angles and is considered the gold standard. Although anterior optical coherence tomography is a promising development in the diagnosis of angle closure, it was not likely to be more beneficial than gonioscopy in this clinical setting. Based on the reasons provided, the anterior optical coherence tomography was not likely to be more beneficial for treatment of the enrollee's medical condition than any available standard therapy.
Appeal type: Experimental/Investigational
Decision: Upheld

A 56-year-old male enrollee has requested reimbursement for Allergen specific blood testing for evaluation of the enrollee, who has a history of fatigue, diarrhea, and pruritus.  Findings:  Two physician reviewers found that the patient has requested reimbursement for Allergen specific blood testing.  Per the submitted documentation, the patient is HIV positive.  The medical records noted diarrhea, and this had worsened over the previous two days.  On this date, the providers assessment included malaise and fatigue, diarrhea, rash and other nonspecific skin eruption, Vitamin D deficiency, and hypothyroidism.  In this case, Allergen specific blood testing performed was not likely to be of greater efficacy than other tools for evaluating this patient.  This patient has been diagnosed with cirrhosis caused by nodular regenerative hyperplasia of the liver.  The medical records noted diarrhea and abdominal tenderness.  Additionally, the patient had a nonspecific rash.  The submitted documentation fails to support the testing at issue in this clinical setting.  This patients symptoms were likely due to his liver disease.  All told, Allergen specific blood testing was not likely to have been of greater benefit than other modalities for evaluating this patients condition.
Appeal type: Medical Necessity
Decision: Upheld

The patient is a 20-year-old female with apparent irritable bowel syndrome. It appears the patient attempted conservative treatment with fiber and stool softeners without success. The patients provider has recommended Zelnorm 6mg twice a day. The Health Plan has denied authorization and coverage for Zelnorm on the basis that it is not medically necessary at this time.The Health Plans denial should be upheld. Upon review of the information provided it does not appear the patient has undergone a complete gastrointestinal workup. The submitted information does not demonstrate the basis for the patients diagnosis. There is no evidence of any imaging studies or laboratory results. Thus, the gastroenterology consultation recommended by the Health Plan is medically reasonable and appropriate. The patient should undergo evaluation by a gastroenterologist with a complete gastrointestinal workup to determine the etiology of her symptoms.Based upon the information set forth above, I have determined that the requested medication is not medically necessary. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned

A 64-year-old male enrollee requested authorization and coverage of a DEXA scan for the treatment of osteopenia.  The Health Plan denied the enrollees request indicating that the requested treatment is not medically necessary.One physician reviewer performed a medical necessity Independent Medical Review.  The physician reviewer overturned the health plans denial on the basis that the requested services are  medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned

A 56-year-old female enrollee has requested a left foot bunionectomy for treatment of her hallux valgus deformity.  Findings:  The physician reviewer found that a bunion deformity is a biomechanical deviation in which the great toe moves laterally towards the second toe. This creates a deviated and sometimes dislocated joint with a prominence of bone to the medial aspect of the first metatarsal head.  This bump of bone can be very painful and can inhibit normal comfortable ambulation in shoes. According to this patient, there are times when she cannot walk or wear shoes, and she has excruciating pain. The only way to correct a bunion deformity is to surgically remove the bump of bone and at times create an osteotomy to realign the first ray. In this case, surgical correction of this patients bunion is medically necessary to treat her painful foot.  Without surgical correction, the deformity may progress and worsen. All told, the requested left foot bunionectomy is medically indicated in this patients case.
Appeal type: Experimental/Investigational
Decision: Upheld

A 32-year-old female enrollee has requested for AxiaLIF (lumbar interbody fusion) for treatment of her low back pain. Findings:  Three physician reviewers found that there is a lack of randomized, controlled, therapeutic studies available to demonstrate safety and efficacy. In addition, there are case specific considerations which likely limit any potential benefit. These case specific considerations include poor definition of pain generators in this patients experience of chronic lumbosacral pain. A more accurate definition of the source of the patients non-radiating or minimally radiating lumbosacral pain is needed.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Otezla tablets.Findings: Based on the psoriasis treatment guidelines, patients who have psoriasis affecting between 3 to 10% (defined as moderate) and greater than 10% (defined as severe) of their body surface area (BSA) are candidates for phototherapy and systemic medical therapy. There are no step therapy guidelines recommended in this context, and the choice of therapy should be made at the discretion of the treating physician with attention paid to patient comorbidities. Otezla is FDA approved and is indicated for the treatment of patients with moderate to severe plaque psoriasis who are candidates for phototherapy or systemic therapy. Otezla has Level `A` evidence to support its efficacy. In this case, the patient has documented evidence of moderate-to-severe disease with difficult to treat areas (nails and scalp). Under these circumstances, the requested medication, Otezla tablets, is medically necessary for this patients medical condition.Final Result: The reviewer determined that the requested medication is medically necessary for the patient's medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in dermatology, with subspecialty certification in dermatopathology, 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

An enrollee has requested an injection of neurolytic substance for treatment of his medical condition. Nature of Statutory Criteria/Case Summary:   Two physician reviewers found that there is sufficient support for the services at issue in this clinical setting.  Helm and colleagues conducted a systematic review with 15 studies identified and selected for review.  The authors concluded that there is fair evidence that percutaneous neurolysis is effective in relieving low back and/or leg pain due to post lumbar surgery syndrome or spinal stenosis.  Amaral and colleagues concluded that the application of morphine sulfate in a single epidural dose was shown to be a good technique for pain therapy following lumbar spinal surgery.  The aggregate of evidence-based medical literature supports this request for analgesia/pain management.  Epidural morphine (Duramorph) for postoperative pain control was medically appropriate as the medication was indicated and use was consistent with current medical standards.  All told, injection of neurolytic substance was likely to have been of greater benefit than other treatment options. Final Result:  two reviewers  determined that the services at issue were likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned.  Credentials/Qualifications:  All three reviewers are board certified in orthopedic surgery 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

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for transforaminal discectomy. Transforaminal endoscopic discectomy is a percutaneous endoscopic method of discectomy. Transforaminal endoscopic discectomy is superior to open microdiscectomy in the length of the associated hospital stay. However, there are no differences in leg pain, functional recovery and incidence of complications between transforaminal endoscopic discectomy and standard open microdiscectomy. In this case, the patient has a history of low back and buttock pain that failed conservative treatment including physical therapy, chiropractic manipulation, and epidural steroid injection. Evidence of L5 radiculopathy is present and the patient had pain that interfered with activities of daily living. A provocative discography/CT scan documented concordant pain at two levels that was associated with annular tears and herniations. There was clinical and imaging evidence of two-level discogenic pain with radiculopathy, and the pain source was identified. Therefore, the decompressive surgery consisting of percutaneous transforaminal endoscopic discectomy at L4-5 and L5-S1 on the left was medically necessary. Accordingly, the transforaminal discectomy services provided to the patient were medically necessary for treatment of the patients medical condition.Final Result: The reviewer determined that the services at issue were 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: Upheld

The parent of a 17-year-old male enrollee has requested an out-of-network referral for CyberKnife radiosurgery for the treatment of the enrollees Ewings sarcoma. Findings:  The physician reviewer found that this 17-year-old boy has a Ewings sarcoma in the left aspect of his sacrum with pulmonary metastasis. All conventional modalities, including surgery, chemotherapy and radiation therapy, have been exhausted. Radiosurgery by CyberKnife has been denied by two experts from a major academic cancer center on the basis of no significant benefit and increased risk to permanently damaging skin.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has been diagnosed with cervical intervertebral disc degeneration, cervical spondylosis, cervical radiculopathy, lumbar facet arthritis, and myofascial muscle pain. The provider noted that Suboxone is not appropriate for the patients condition and that the purpose of the Belbuca is to provide longer lasting baseline pain relief without drastically increasing her daily opioid morphine equivalent daily dose (MEDD) and to reduce the use of hydrocodone for breakthrough pain. The provider noted that Belbuca is being added to the patients current regime of Vicodin to provide better pain control and to prevent further escalation of her opioid MEDD. The patient has been treated with cervical and lumbar epidural steroid injections and cervical facet joint blocks. The patient has also been treated with medications, including gabapentin and Vicodin. The patient reported low back pain with radiation to bilateral lower extremities. Per the provider, magnetic resonance imaging (MRI) of the lumbar spine obtained revealed multilevel disc bulging and bilateral L4-5 and L5-S1 facet joint hypertrophy. The provider also noted a MRI of the cervical spine obtained revealed multilevel degenerative disc bulges with facet arthropathy from C4-5 through C6-7. There is no indication in any of the medical records that the patient demonstrated behavior consistent with opioid use disorder or that there were any inconsistent urine toxicology screens. The patient has requested authorization and coverage for Belbuca 75 mcg buccal film. The Health Plan denied the request and reported the requested medication is not medically necessary for the treatment of this patient. At issue in this case is whether Belbuca 75 mcg buccal film is medically necessary for the treatment of the patients medical condition. In this case, the patients provider noted prescribing Belbuca is to improve the patients pain control with a longer acting medication without increasing the total daily opioid requirements, which is consistent with the stated guidelines published by the CDC. The medical evidence supports the requested medication in this clinical setting. Therefore, Belbuca 75 mcg buccal film is medically necessary for the 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 anesthesiology with sub-specialty certification in pain 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: Overturned

The parent of a four-year-old male enrollee has requested PediaSure with fiber and benecalorie for treatment of the enrollees cerebral palsy and spastic quadriplegia.  Findings:  The physician reviewer found that based on review of the available records, the requested PediaSure with fiber and benecalorie are medically necessary as enteral therapy. This patient is dependent upon fortified PediaSure with fiber for his nutritional needs. Because of his neurodevelopmental deficits, he is not able to tolerate anything but small amounts of pureed foods. PediaSure was originally developed for children who were unable to maintain intake of nutrients adequate to meet their needs for growth and development by other means. According to the initial safety and efficacy studies, PediaSure is both safe and efficacious in the maintenance of nutritional status and the promotion of growth in chronically disabled children who require specialized nutritional support. PediaSure, supplemented with benecalorie, provides the nutrients that this patient needs in a way that he can tolerate. The requested PediaSure with fiber and benecalorie is therefore medically necessary for this patient because it is his primary source of nutrition.
Appeal type: Medical Necessity
Decision: Overturned

A 23-year-old female enrollee has requested approval for termination of pregnancy services for treatment of her medical condition.   Findings:  The physician reviewer found that the patients pregnancy was diagnosed at 21 weeks gestation apparently due at least in part to menstrual-like bleeding which the patient has experienced during the pregnancy. The pregnancy has been complicated by this bleeding as well as pain and reported fainting spells. The patient has pregnancy risk factors of symptomatic fibroids, obesity, diastolic hypertension, and a prior Cesarean section. Review of the medical literature demonstrates that fibroids in pregnancy are associated with potential complications including pain and bleeding. In addition, the American Congress of Obstetricians and Gynecologists Technical Bulletin regarding obesity and pregnancy states:  Obese women are at increased risk for several adverse perinatal outcomes, including anesthetic, perioperative, and other maternal and fetal complications. Furthermore, according to Shulman and Ling, second-trimester extraction is as safe for the woman as having a normal pregnancy and delivery. Overall, elective abortion at any gestational age is safer for the mother than carrying a pregnancy to term. Moreover, the American Congress of Obstetricians and Gynecologists notes:   abortions are necessary in a number of circumstances to save the life of a woman or to preserve her health. In this case, the patient does not have a normal pregnancy and also has a history of a prior Cesarean section. The risk of complications related to a trial of labor (i.e., ruptured uterus) or a repeat Cesarean section are greater than the risk of complications from a mid-trimester pregnancy termination. Furthermore, the requested pregnancy termination is clinically justified to preserve the patients health in light of her clinical history and current symptomatology. All told, the requested termination of pregnancy is medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned

A male enrollee requested Viekira Pak for medical treatment of his hepatitis C.  Findings:  Three physician reviewers found that according to the joint guidelines issued by the American Association for the Study of Liver Diseases and the Infectious Diseases Society of America, all patients with chronic hepatitis C, regardless of fibrosis, should be treated, except for those with limited life expectancy less than 12 months due to non-liver-related comorbid conditions.  Viekira Pak is medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary:  An enrollee has requested ambulance transport services on an emergent or urgent basis.  Findings:  The physician reviewer found that review of the submitted clinical documentation demonstrates that a prudent layperson would not have sought ambulance transport on the date in question. In this case, emergency medical services were dispatched due to intermittent abdominal pain. His vital signs were normal. He was in mild distress. He was able to ambulate with assistance to the ambulance stretcher. There is no documentation that the patient suffered from a condition that risked placing the patients health in serious jeopardy, causing serious impairment to bodily functions, or serious dysfunction of any bodily organ or part. All told, the services did not meet prudent layperson criteria for emergency care.  Further, it has not been established that criteria for urgently needed services were met on the date in question. In this case, the patient presented with intermittent abdominal pain and constipation with no nausea or vomiting. His vital signs were normal and his level of distress was mild. The documentation submitted for review fails to demonstrate signs or symptoms of infection or injury that would require immediate treatment. There is no documentation to suggest a prudent layperson would believe that the absence of immediate medical attention would result in serious impairment to bodily function. Based on the documentation submitted for review a prudent layperson in a similar situation would not have believed immediate medical attention was necessary to prevent serious deterioration of ones health. In sum, based on the patients clinical presentation on the date in question, the patient did not meet prudent layperson criteria for urgently needed services. As such, the Health Plans denial should be upheld.  Final Result: The reviewer determined that the patients symptoms did not meet prudent layperson criteria for emergency care or urgently needed services. Therefore, the Health Plans denial should be upheld.  Credentials/Qualifications: The reviewer is board certified in emergency 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: Experimental/Investigational
Decision: Overturned

A 34-year-old male enrollee requested an insulin pump (E0784), continuous glucose monitoring system (CGMS) transmitter (A9277) and CGMS sensors (A9276) for medical treatment of his type 1 diabetes.  Findings:  Two physician reviewers found that the requested services are likely to be more effective for this patient than other available options. A continuous glucose monitoring system (CGMS) is a U.S. Food and Drug Administration (FDA) approved device that records blood sugar levels at repeated intervals throughout the day and night. The main advantage of continuous glucose monitoring is that it can help identify fluctuations and trends that would otherwise go unnoticed and can thereby help maintain tight glycemic control and prevent hyperglycemia and hypoglycemia. As this system is likely to benefit the patients health, the requested services are likely to be more beneficial than other available therapies for this particular patient.