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

Nature of Statutory Criteria/Case Summary: An enrollee has requested Norco for treatment of the enrollees medical condition. Findings:  The physician reviewer found that the medical necessity for Norco has not been established. According to Lee and colleagues Because chronic pain affects the whole person (body, mind, and spirit), patient-centered complementary and integrative medicine (CIM) therapies that acknowledge the patients roles in their own healing processes have the potential to provide more efficient and comprehensive chronic pain management. Active self-care complementary and integrative medicine (ACT-CIM) therapies allow for a more diverse, patient-centered treatment of complex symptoms, promote self-management, and are relatively safe and cost-effective. In this case, the patient presents with chronic pain lower back pain. There is a lack of documentation demonstrating that the patient has trialed behavioral therapy for his pain. In addition, not all non-opioid treatment options have been utilized. Given the above, the requested medication is not medically necessary for treatment of the patients medical condition.Final Result: The reviewer determined that the requested medication is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The physician reviewer is board certified in anesthesiology with sub-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 15-year-old female enrollee requested residential treatment for treatment of the enrollees behavioral health conditions.  Findings:  The physician reviewer found that this patient had a concerning affective complex with parasuicidality and contemporaneous anxiety that required two hospitalizations, the second of which occurred while in a therapeutic setting.  Psychodynamically, she demonstrated poor self-esteem, ambivalence and emotional fragility; the patient was sad and anxious, as a result her anxiety medication was  increased.  The patient continued with anxiety and had an episode of cutting at which time her duloxetine was increased to 120mg daily.  Thereafter, the patient struggled with mood symptoms and anxiety, and inattention in the academic setting.  Subsequently the records evidence consolidated treatment gains.  Her insight and emotional regulation had improved.  She had a successful leave of absence with her family and managed stressful issues without significant impairment.  Her psychiatrist noted that things went well with her parents and her irritability had dissipated.  In reviewing the clinical documentation, the residential services were for active treatment delivered in accordance with evidence-based principles.  Additionally, the services facilitated diagnostic clarification and were reasonably expected to improve her condition and prevent a more serious episode of illness.  All told, residential treatment provided initially was medically indicated for the treatment of this patient.  However, the submitted documentation fails to demonstrate the medical necessary of residential treatment at a later date.  A portion of the services were medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld

A 66-year-old male enrollee has requested corrective surgery consisting of surgical removal of bone from femur toward the knee for treatment of his medical condition status post left hip replacement surgery. Findings:  The physician reviewer found that in the medical literature, Clark and colleagues indicate that leg length discrepancy after total hip arthroplasty can pose substantial problems to the orthopedic surgeon, and can be associated with nerve palsy, low back pain, and abnormal gait. In addition, Maloney and Keeney reported that discrepancies of 1 cm or less are common and can be a source of dissatisfaction to the patient. Corbett and colleagues found that uncemented implants may be associated with higher rates of revision regardless of age, although the risk of revision is higher in older arthroplasty recipients. Further, Hallan and colleagues stated that uncemented total hip arthroplasties have poor long-term results, and often times require regular radiographic evaluation to detect osteolysis. The evaluation of a discrepancy requires careful study, and functional problems may be present in the earlier stages of recovery after surgery (Bhave, et al). When a correctable cause of discrepancy can be identified, surgery may be appropriately indicated (Parvizi, et al).    In this case, there is a length discrepancy, but the radiologic evaluation is not detailed in the records provided for review. In addition, there is no documentation of the use of lifts or other conservative mechanical methods of adjusting the length discrepancy to evaluate the response. Overall, there is insufficient data supporting the requested surgical intervention for this patient at this time.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested authorization and coverage for speech therapy sessions (1x a week for 60 minutes)). Findings:  The physician reviewer found that Areas of speech impairment in individuals with Down syndrome involve voice, speech sounds, fluency and prosody, and intelligibility. Vocal and phonatory abnormalities are common. Speech sounds are impaired due to delayed development and errors not seen in typical development. Fluency and prosody are frequently impaired due to stuttering and cluttering, which are seen in 10-45% of children with Down syndrome compared with 1% of the typical population. Intelligibility of speech can be markedly impaired in individuals with Down syndrome. Speech and language development in individuals with Down syndrome is often delayed and/or disordered and speech disfluencies appear to be more common. The achievement of speech intelligibility by persons with Down syndrome facilitates their participation in society. In adolescents with Down syndrome, speech-language therapy during vocational training was found to lead to positive changes in the social behavior of individuals with Down syndrome, as evidenced by an increase in their autonomy and communication.In this case, the patient has Down syndrome, with resultant severe mixed receptive and expressive language disorder. Records indicate that the patient has been receiving speech therapy services by telehealth throughout the pandemic. The patients father notes that the patient makes better progress with in-person therapy, and this is the consistent with the observation that there has been significant regression or slowed progress of speech and language skills in children with Down syndrome who had to change to telehealth during the Covid pandemic. Records reflect that in this case, the patient is making slow but meaningful progress with speech therapy. Under these circumstances, speech therapy sessions (1x a week for 60 minutes) are medically necessary to treat the patients medical condition.Final Result: The reviewer determined that the requested services are medically necessary to treat the enrollees medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in neurology with special qualification in child neurology, with subspecialty certification in neurodevelopmental disabilities, 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

The parent of an eleven-year-old female enrollee has for a continuous blood glucose monitoring system for treatment of her Type I diabetes.   Findings:  Three physician reviewers found that continuous glucose monitoring systems have proven to be useful tools in finding unexpected hypoglycemia and hyperglycemia in insulin treated patients not in good control.  Recent reports of monitoring up to six months have shown improvement in hemoglobin A1c levels.
Appeal type: Medical Necessity
Decision: Upheld

A thirty-eight year-old morbidly obese female diagnosed with a metatarsal stress fracture is now requesting authorization for an electric wheelchair.  Reviewers Findings:The reviewing physician found that there is no documentation demonstrating that the patient is confined to a wheelchair or is unable to walk. Nor is there evidence that the patient is unable to propel a manual wheelchair.  The physician concluded that the Health Plan denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for Orthovisc injections (J7324) in both knees. Evidence from systematic reviews and randomized controlled trials indicate that although viscosupplementation may relieve knee pain in some patients with osteoarthritis, data has not established which patients will benefit. Guidelines from the American Academy of Orthopedic Surgeons (AAOS) indicate that the data on safety and efficacy of viscosupplementation remain inconclusive. As such, the AAOS does not currently recommend viscosupplementation as routine treatment for osteoarthritis of the knees. Viscosupplementation is reserved for patients with a history of lasting benefit from prior injections and in cases where the remaining options are limited. In this case, the patients treatment options are limited. The patient has been treated with and failed medications and physical therapy. As noted in the current peer-reviewed medical literature, viscosupplementation can promote production of endogenous hyaluronic acid, thereby relieving the symptoms of osteoarthritis. As such, the Orthovisc injections (J7324) in both knees at issue were medically necessary to treat this patient. 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: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Lyrica 50 mg capsules for treatment of the enrollee who has a history of myofascial muscle pain, fibromyalgia, and lumbago. Findings:  The physician reviewer found that The medical literature supports the requested medication in this clinical setting. Specifically, the patients WPI score was noted to be greater than 10 without Lyrica. The American College of Rheumatology recommends a symptom severity score of at least a 5. This patients symptom severity score was a 6. Moreover, the provider noted failure with gabapentin, amitriptyline, and nortriptyline for eight months. Additionally, the medical literature supports Lyrica as a treatment option for fibromyalgia and is approved for such an indication. All told, Lyrica 50 mg capsules are  medically necessary for treatment of this patient. Final Result: The reviewer determined that the requested medication is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in 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: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for implantation of an Inspire Hypoglossal Nerve Stimulator System.Findings: Two out of three physician reviewers found that the requested implantation of an Inspire Hypoglossal Nerve Stimulator System is likely to be more beneficial than any other available standard treatments for the patients medical condition.There is a plethora of sufficient evidence in the peer-reviewed literature to support the safety, efficacy, and long-term outcome in the treatment of obstructive sleep apnea with hypoglossal nerve stimulation or Inspire airway stimulation. The STAR (Stimulation Treatment for Apnea Reduction) trial showed that upper airway stimulation (UAS) provides significant improvement in sleep-related quality of life outcome measures with effects maintained across a 5-year follow-up. Studies demonstrated clinically significant decreases in observed mean apnea-hypopnea index (AHI), oxygen desaturation index (ODI), and Epworth sleepiness scale (ESS), combined with improvements in quality-of-life scales. Studies showed that improvements in sleepiness, quality of life, and respiratory outcomes are observed with 5 years of UAS with implantable hypoglossal nerve stimulation. Serious adverse events were uncommon. UAS was determined to be a nonanatomic surgical treatment with long-term benefit for individuals with moderate to severe OSA who have failed nasal continuous positive airway pressure. The American Academy of Otolaryngology-Head and Neck Surgery considers UAS via the hypoglossal nerve to be a safe and effective second-line treatment of moderate to severe obstructive sleep apnea in adult patients who are intolerant or unable to achieve benefit with positive pressure therapy. In this case, the patient has been diagnosed with obstructive sleep apnea (OSA) by polysomnogram on 2/11/17 with an apnea-hypopnea index (AHI) of 52.3 events per hour and a lowest oxygen saturation of 90%. Records indicate that the patient failed CPAP therapy because of claustrophobia which did not improve after trying several different masks and machines. Therefore, the requested implantation of an Inspire Hypoglossal Nerve Stimulator System is likely to be more beneficial than any other available standard treatments for the patients medical condition.Final Result: The reviewers determined that the requested services are likely to be more beneficial than any other available standard treatments 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 otolaryngology and are actively practicing. All three reviewers are experts in the treatment of the enrollees medical condition and are 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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for  right breast lumpectomy intraoperative radiation therapy (IORT) (CPT 77424 and 77469). Findings:  The physician reviewer found that recent National Comprehensive Cancer Network (NCCN) guidelines endorse the use of IORT in the treatment of well-selected patients with breast cancer. Moreover, phase 3 studies have shown equivalent outcomes in patients who undergo standard radiation therapy and IORT. The American Society for Radiation Oncology (ASTRO) recommends the use of IORT for breast cancer patients as well as counseling patients regarding the higher risk of ipsilateral breast tumor recurrence with IORT compared with whole breast irradiation, the need for prospective monitoring of long-term local control and toxicity with low-energy radiograph IORT given limited follow-up, and restriction of IORT to women with invasive cancer considered suitable (Correa, et al.).  Based on the ASTRO consensus statement, this patient falls into the suitable category and meets the criteria for the use of IORT. Therefore, the requested right breast lumpectomy IORT (CPT 77424 and 77469) is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Findings:  Three of the three physician reviewers found the requested right breast lumpectomy IORT (CPT 77424 and 77469) is 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 are 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: Physician reviewer 1 is board certified in radiation oncology and is actively practicing. Physician reviewer 2 is board certified in radiation oncology and is actively practicing. Physician reviewer 3 is board certified in radiation oncology 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: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for an Intracept procedure at L5-S1. Current medical literature supports the use of the requested procedure in leading to statistically significant improvement over standard therapies including physical modalities and injections. Fischgrund and colleagues report that patients treated with radiofrequency ablation of the basivertebral nerve for the treatment of chronic back pain maintained benefits at two years following treatment in both Oswestry Disability Index (ODI) and Visual Analog Scale (VAS). The  authors concluded that basivertebral nerve ablation is a durable, minimally invasive treatment for vertebrogenic chronic low back pain. Truumees and colleagues report that in patients with chronic low back pain and Modic type 1 or type 2 vertebral endplate changes, treatment with minimally invasive radiofrequency ablation of the basivertebral nerve resulted in significant improvement in pain and function. In this case, the patient has Modic endplate changes on MRI and axial low back pain. In this clinical setting, the requested procedure is likely to be superior to continued conservative care. Therefore, an Intracept procedure at L5-S1 is likely to be more beneficial for treatment of the patients condition than any available standard therapy.Findings:  Two of the three physician reviewers found the requested Intracept procedure at L5-S1 is 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 service is 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: Physician reviewers 1, 2, and 3 are board certified in orthopedic surgery 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

Findings:  The physician reviewer found that The patient has requested authorization and coverage for Euflexxa injection to the left shoulder. Per the medical literature, although viscosupplementation may relieve shoulder 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 is a 45-year-old male severe osteoarthritis of the left shoulder confirmed on X-rays and MRI. The records note that the patient has tried and failed cortisone injections. The patient has reported benefit from viscosupplementation on two occasions, with the benefits from the first injection lasting seven months and the benefits from the second injection lasting four to five months. Given the patients limited options and based on the current medical literature, the requested services are medically indicated. Therefore, an Euflexxa injection to the left shoulder 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.
Appeal type: Medical Necessity
Decision: Upheld

A 43-year-old female has requested coverage for past and future acupuncture visits at a frequency of two sessions per week provided for treatment of her complex regional pain syndrome/neuralgia.  Findings:  The physician reviewer found that based on the documentation provided, the patient underwent 20 acupuncture sessions. While undergoing such care, the patient continued taking oral medication and additional neuroma shots were performed, evidencing an overlap of therapies. Despite reports from the acupuncture provider of range of motion improvements, no measurements were offered to verify these claims. Also, the provider noted the patients initial pain severity was rated as an 8 out of 10 at treatment number 1, which was reduced to 7 out of 10 at treatment number 14, which is not a significant improvement. Additionally, the peer reviewed medical literature emphasizes the documentation of significant, objective, measurable improvements in order to support additional care as medically necessary. The records reviewed did not include documented evidence of any functional improvement which is essential to establish the reasonableness and necessity of additional care. Specifically, there is no evidence of the benefits obtained with the previous acupuncture rendered such as increased endurance, increased body mechanics, increased ability to perform job-related duties and activities of daily living, reduction of pain medication, improved sleep or reduced pain behaviors. Without baseline measurements from the initial treatment session for later comparison, including: functional scales, Pain Disability Index (Vernon-Minor) forms, Oswestry Pain questionnaires or other tools documenting the improvement obtained, the disputed past and future acupuncture treatment is not supported as medically necessary.