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

 Nature of Statutory Criteria/Case Summary:   An enrollee has requested IgG food sensitivity testing (CPT code 86001) for treatment of her allergies and fatigue. Three physician reviewers found that in this case, the patient underwent IgG food testing for possible food allergy and allergic rhinitis. The medical records submitted for review do not demonstrate a diagnosis consistent with a food allergy. The current National Institutes of Health National Institute of Allergy and Infectious Disease expert panel states that IgG food testing is not validated. Moreover, the Joint Task Force on Practice Parameters for the Allergy and Immunology also state that IgG food testing is not validated. As such, the IgG food testing is not the standard of care and was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Final Result: Three reviewers determined that the testing at issue was 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: One reviewer is board certified in allergy and immunology and is actively practicing. Two reviewers are board certified in otolaryngology 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 30-year-old male enrollee has requested a FreeStyle Navigator continuous blood glucose monitoring system (CGMS) and related supplies for the treatment of his type I diabetes mellitus. Findings:  The physician reviewer found that the requested CGMS device and related equipment will maintain the patients health and increase the likelihood of preventing a severe glycemic excursion leading to life threatening conditions or the consequences of them such as permanent disability. The FreeStyle Navigator CGMS is therefore medically necessary in this patient with uncontrolled diabetes mellitus type 1 and hypoglycemia unawareness.
Appeal type: Medical Necessity
Decision: Upheld

A 60-year-old female enrollee has requested anesthesia services to be performed during a colonoscopy for treatment during her colonoscopy. Findings:  The physician reviewer found that monitored anesthesia care is directly provided by anesthesia personnel.  Monitored anesthesia care may include varying levels of sedation, analgesics, and anxiolytics. Per the standards of the American Association of Anesthesiologists, monitored anesthesia care should be provided by qualified anesthesia personnel who must be present continuously to monitor the patient and provide anesthesia care.  The American College of Gastroenterology states that the use of deep sedation is medically necessary when there is documentation by the endoscopist and the anesthesiologist that specific risk factors or significant medical conditions are present. Those risk factors or significant medical conditions include prolonged or therapeutic endoscopic procedures requiring deep sedation, increased risk for complications due to severe comorbidity, and history of anticipated intolerance to standard sedatives. Additionally, patients 12 years of age or younger, patients who are 70 years of age or older, patients who are pregnant, patients with active medical problems related to drug or alcohol abuse, and patients at increased risk for airway obstruction due to anatomic variations may require monitored anesthesia care.  The review of the medical documentation indicates that this patient had no specific medical comorbidity that necessitated the use of monitored anesthesia care for the elective colonoscopy.  She was an acceptable candidate for moderate sedation to be administered by the endoscopist.  All told, the medical necessity of the services at issue has not been established.
Appeal type: Medical Necessity
Decision: Upheld

The parent of an 11-month-old male enrollee has requested a DOC band (cranial reshaping band) for treatment of the enrollees positional plagiocephaly.  Findings:  The physician reviewer found that based on the clinical documentation received and the peer-reviewed medical literature, the requested DOC band (cranial reshaping band) is not medically necessary for treatment of this patients medical condition. According to Xia and colleagues, studies show evidence that molding therapy may reduce skull asymmetry more effectively than repositioning therapy. However, the authors noted that further research is warranted. An additional article from Mortenson and colleagues on orthotic treatment for deformational plagiocephaly also found that more data is needed to better understand the parameters for use, long-term outcomes, and natural history of the impact on caregiving. This patient is noted to have a 7 mm difference in diagonal diameters of the cranium. All told, the need for a DOC band (cranial reshaping band) is not supported as medically necessary for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld

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

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Euflexxa injection series in both knees. Per the medical literature, although viscosupplementation may relieve knee pain in some individuals with osteoarthritis, it is not known as to which individuals will benefit. The current evidence is limited, and guidelines from organizations such as the American Academy of Orthopedic Surgeons indicate that the evidence is not conclusive. In light of the foregoing, viscosupplementation can only be recommended in individuals with a history of lasting benefit from prior injections, and in carefully selected cases where everything else has been tried, and the options are limited. In this case, the patient has tried and failed ibuprofen and tramadol, and is unable to take NSAIDs. Given the patients limited options, with the alternative being bilateral total knee arthroplasties, and based on the current medical literature, the requested services are medically indicated. Therefore, Euflexxa injection series in both knees are medically necessary for the treatment of this patient. 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: Upheld

Nature of Statutory Criteria/ Case Summary:  The enrollee is requesting authorization and coverage for the medication, Tramadol for chronic back pain. A magnetic resonance imaging scan showed congenital spinal canal stenosis, with moderate spinal canal stenosis with core deformity, no edema. The enrollee indicates the pain is constant and radiates down her right arm and into her hand.  There is numbness and tingling in her right arm and stiffness in her neck. The enrollee has tried gabapentin but discontinued it because she believed it was causing increased bladder incontinence. She tried duloxetine, which made her stomach burn. The records indicate the enrollees pain medicine specialist prescribed nortriptyline but the enrollee did not want to try it. The enrollee reports multiple medication trials, with very uncomfortable side effects. Her physician indicated the symptoms appeared consistent with cervical radiculitis. The enrollee received a cervical epidural steroid injection. The physician ordered Meloxicam, 7.5mg, once or twice daily as needed and topical lidocaine as needed.  The enrollee indicates she has tried anti-depressants and anti-epileptics. These medications resulted in multiple side effects. She received no benefit from acupuncture. She is requesting authorization of Tramadol for short-term relief of flare-ups. She indicates Relafen and Robaxin are not effective for acute severe back pain. Governmental agency guidelines do not support the chronic use of opiates for non-malignant pain.  Literature indicates though these guidelines have been criticized and misapplied in some cases, the risks of long-term oral opiate use in non-malignant pain are substantial.  The requested medication is not medically reasonable in this case.Final Result: The reviewer determined that the requested service is not medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The physician 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 similar medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned

A 50-year-old male enrollee has requested for a Meniett device for treatment of his Menieres disease. Findings:  Two physician reviewers found that review of the medical literature reveals multiple articles supporting the use of the Meniett device in the treatment of Menieres disease. Although the Meniett device is a more recent development in the treatment of Menieres disease, its success rate and low adverse effect/risk rate are impressive. To date, there continue to be many otolaryngologists who question the efficacy of surgical endolymphatic procedures. In addition, the invasiveness of vestibular nerve and labyrinthine surgeries limits the patient population in which they may be useful. The Peterson review strongly indicates that the Meniett device as a second-line treatment for Menieres disease may become standard of care.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for hypoglossal nerve stimulator implantation. The submitted documentation supports the requested services in this clinical setting. The patient has severe obstructive sleep apnea and has not been able to tolerate the CPAP device. He has undergone septoplasty to address the nasal obstruction without substantial improvement. Per the records, this patient is an appropriate candidate for hypoglossal nerve stimulator implantation. Therefore, the requested hypoglossal nerve stimulator implantation is medically necessary for the treatment of this patient. 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 otolaryngology 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

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Sovaldi with RibaPak for 12 weeks. Findings:  The physician reviewer found that according to joint guidelines issued by the American Association for the Study of Liver Diseases (AASLD) and the Infectious Diseases Society of America (IDSA), all patients with chronic hepatitis C should be treated except those with life expectancy less than 12 months due to non-liver-related conditions. This applies regardless of fibrosis stage, and advanced fibrosis is not required for treatment. Per the guidelines, Epclusa and Vosevi are recommended as first-line therapy for treatment naive genotype 2 patients, based on clinical trials which showed the superiority of Epclusa to Sovaldi with ribavirin. Therefore, the use of Sovaldi and ribavirin is no longer supported by the guidelines for genotype 2. Delay in treatment may result in decreased survival. For these reasons, although treatment of hepatitis C is needed, the request for Sovaldi and Ribasphere is not supported as medically necessary for the treatment of this patients hepatitis C infection. Final Result: The reviewer determined that the requested regimen 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 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

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for fertility preservation services (fertility testing, chemistry procedures, diagnostic ultrasound, measurement of human chorionic gonadotropin (HCG), gonadotropin-follicle stimulating hormone (FSH), oocyte retrieval, cryopreservation of oocytes) for treatment of the enrollee who has a history of breast cancer. Findings:  The physician reviewer found that there is support in the medical literature for the services at issue. With current technology, sperm and embryo as well as oocyte cryopreservation, are considered standard practice and are widely available. In this case, the patients fertility status after breast cancer treatment was uncertain. The submitted documentation indicates that the plan for this patient would be to undergo fertility treatment as soon as the cancer diagnosis was confirmed and prior to the initiation of the chemotherapy. Although there was no specific treatment plan, treatment options were considered that included chemotherapy. Because of the unpredictable nature of a cancer diagnosis and future treatments, the American Society of Clinical Oncology and the American Society for Reproductive Medicine guidelines recommend immediate fertility treatment so that the opportunity is not lost and cancer treatment is not delayed. Such treatment is considered the standard of care by these societies. Additionally, the current evidence appears to indicate that these fertility treatments have been shown to be successful.  Therefore, in order to preserve this patients fertility, it was medically necessary for this patient to undergo fertility sparing treatment.  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 obstetrics and gynecology 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

Nature of Statutory Criteria/Case Summary:  An enrollee has requested a power wheelchair for treatment of her medical condition.  Findings:  The physician reviewer found that the records forwarded for review do not establish that the patients mobility-related activities of daily living needs could not be sufficiently resolved with an optimally fit manual wheelchair at this time.  The records do not establish that the patient would be bed or chair confined without a power mobility device.  Based on the available records, a power mobility device is not medically necessary for this patient given that her mobility deficits in the home can be addressed by other means (i.e., an optimally fit manual wheelchair), which would be more health beneficial than a power mobility device.  Ongoing exercise through ambulation (aided with an appropriate assistive device) would be expected to provide significant health benefits use over power wheelchair use.  Manual wheelchair use has been shown to provide significant health benefits use over power wheelchair use for persons with mobility impairments.  All told, the requested power wheelchair is not medically indicated for the treatment of this patient. Final Result: The reviewer determined that the requested equipment 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 physical medicine and rehabilitation and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/ Case Summary:  The enrollee has requested authorization and coverage for suction assisted lipectomy. The enrollee underwent mastectomy for gynecomastia.  At a post-operative follow up visit, the right side of his chest had a thicker layer of subcutaneous fat and the impression was asymmetry following gynecomastia excision. The surgeon states that there is a noticeable difference between the right and left chest. The enrollee states that the mastectomy was incomplete and this it is now difficult to go jogging. He is requesting coverage for suction assisted lipectomy. The medical records fail to demonstrate the medical necessity of the requested suction assisted lipectomy. The enrollee complains of irritation while jogging, but there is no documentation of symptoms, chronic rashes or failed treatment in the records.  Photographs do not demonstrate the alleged abnormality constitutes an abnormal structure of the body that is a major variation from normal. They show slight fullness of the right breast without ptosis. Findings: the physician reviewer found that the doctor describes the fullness as secondary to subcutaneous tissue; that is, fatty tissue, and not breast tissue. The requested suction assisted lipectomy is not likely to improve function or create a normal appearance to the extent possible. The variance in symmetry is minimal and would not provide more than a minimal improvement in the appearance of the enrollee.  Therefore, this procedure is not reconstructive in nature. Final Result: The reviewer determined the requested service is not medically necessary and is not reconstructive for the treatment of the enrollees medical condition. Credentials/Qualifications: The physician reviewer is board certified in plastic and reconstructive 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 similar medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld

A 56-year-old male enrollee has requested CyberKnife radiosurgery for the treatment of his prostate cancer. Findings:  Three physician reviewers found that this patient has clinically localized curable prostate cancer. He was given various treatment options. CyberKnife radiosurgery has been used at several institutions for curative treatment. There is a lack of long-term data showing superiority of CyberKnife radiosurgery over other established treatment.
Appeal type: Medical Necessity
Decision: Overturned

A 50-year-old female enrollee requested authorization and coverage of gamma knife radiosurgery. The Health Plan denied this request indicating that the requested therapy is not medically necessary for treatment of the enrollees brain metastases.One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer overturned the Health Plans denial on the basis that the requested therapy is medically necessary.
Appeal type: Experimental/Investigational
Decision: Upheld

A 53-year-old male enrollee has requested authorization and coverage for Supartz injections to the bilateral hips for treatment of the enrollees hip osteoarthritis. Findings:  Three physician reviewers found that the patient is has a several year history of hip pain. No radicular symptoms, paresthesias or sensory changes were reported. The patients pain reportedly caused awakening at night and occurs with sitting, walking on stairs and when putting on shoes and socks. The provider recommended treatment with oral medications and Supartz injections. The patient has requested authorization for Supartz injections, which have been denied by the Health Plan. The use of intra-articular injections of viscosupplementation (Supartz) has been demonstrated to be efficacious in the treatment of osteoarthritis in the knee joint and for the treatment of TMJ. However, there is a paucity of data demonstrating the safety and efficacy of treating osteoarthritis in other joints in the body with viscosupplementation. Additionally, the use of viscosupplementation is approved by the Food and Drug Administration (FDA) only for treatment of the knees and TMJ. It has not yet been approved for use in the hip joints. Given the lack of proof regarding the efficacy and safety of Supartz in the treatment of hip pain, the Health Plans denial was appropriate and should be upheld.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: A 44-year-old female enrollee has requested authorization and coverage for surgery (embolization of bilateral gonadal veins)for treatment of the enrollees pelvic congestion syndrome. Findings:  The physician reviewer found that There is sufficient support in the medical literature supporting embolization of bilateral gonadal veins in the clinical setting of pelvic congestion syndrome. The medical literature indicates that treatment with embolotherapy demonstrates significant improvement in pain levels in patients with chronic pelvic pain caused by pelvic venous congestion. The medical literature supports embolization of gonadal veins as a safe and successful treatment option for this patient. As such, the request for surgery (embolization of bilateral gonadal veins) is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: Two of the three reviewers determined that the requested surgery is 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 interventional radiology and diagnostic radiology and is actively practicing. One Reviewer is board certified in diagnostic radiology and is actively practicing.  One Reviewer is board certified in surgery and vascular surgery 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.