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

Nature of Statutory Criteria/ Case Summary:  The enrollee underwent a total knee arthroplasty. She then underwent an x-ray of the knee for persistent knee pain.  There was no acute fracture identified.  A request for Revision of Right Knee Surgery and Scanogram of the Right Knee was requested. In regard to the Revision of Right Knee Surgery, scientific literature indicates twice as many patients have pain after revision surgery compared with patients after primary total knee replacement surgery.  Patients after revision total knee replacement have reduced function and poorer quality of life and higher pain intensity compared with patients after primary total knee replacement.  Re-operation may be needed for a variety of problems related to total knee replacement surgery that may lead to implant/joint failure or patient dissatisfaction. The diagnostic studies that were performed included an x-ray, which revealed the alignment was normal and the device was in place.  Therefore, the requested Revision of Right Knee Surgery would not be medically necessary for the treatment of this enrollees medical condition. In regard to the Scanogram of Right Knee, the literature indicates leg-length discrepancy should be assessed with a full-length standing AP radiograph of the lower extremities ideally with use of a magnification marker or three distinct exposures centered over the hip, knee, and ankle (scanogram or orthoroentgenogram).  As bone length discrepancy had already been proven by physical examination, the Scanogram of the Right Knee would not be medically necessary to treat the enrollees medical condition.Final Result: The reviewer determined that the services at issue were not medically necessary for treatment of the patients condition. Therefore, the health plans denial should be upheld. Credentials/Qualifications: The physician reviewer is board certified in Orthopedic Surgery and is actively practicing.
Appeal type: Medical Necessity
Decision: Overturned

A 61-year-old male enrollee has requested Sovaldi with ribavirin for treatment of his hepatitis C genotype 2B.  Findings:  The physician reviewer found that the U.S. Food and Drug Administration (FDA) has recently approved another drug for use in treatment of hepatitis C virus (HCV) infection which is sofosbuvir (Sovaldi), a nucleotide analog polymerase inhibitor. In addition, the American Association for the Study of Liver Diseases (AASLD) and the Infectious Diseases Society of America (IDSA) have crafted a nationally-recognized position paper that provides guidance on the recommended initial treatments for persons with chronic HCV infection who are naive to HCV treatment, as is the case with this patient. The patient has been recommended for HCV treatment, and thus AASLD/IDSA recommendations govern his present treatment alternatives. This treating provider has deemed the patient interferon-ineligible based on his aortic valve calcification. This is consistent with existing AASLD/IDSA guidelines that define a history of preexisting cardiac disease as grounds for interferon-ineligible status. Per AASLD/IDSA guidelines, the recommended regimen for HCV genotype 2 patients who are treatment-naive regardless of eligibility for interferon therapy is daily Sovaldi, and weight based ribavirin. In the absence of any other AASLD/IDSA recommended treatment regimens for this patients HCV genotype 2, the requested Sovaldi with ribavirin is supported as medically necessary for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld

A 34-year-old female enrollee has requested authorization and coverage for labor and delivery services at a facility with a neonatal intensive care unit.  Findings:  The physician reviewer found that the majority of fetal arrhythmias are benign premature atrial contractions (Rasiah, et al). This arrhythmia represents immaturity of the electrical conduction system in the fetal heart and almost always resolves spontaneously either later in the pregnancy or at delivery (Respondek, et al). This arrhythmia does not affect the fetus or the neonate and does not require any change in obstetric or neonatal management. Consistent with the American College of Obstetricians and Gynecologists (ACOG) guidelines, this patient can deliver at any hospital, but the request to deliver at a facility with a neonatal intensive care unit (NICU) is not medically necessary. If the patient desires to deliver at a hospital with more neonatal services, she does not need to deliver at the closest hospital due to her prior rapid delivery, but can be induced at 39 weeks gestation at one of the In-Network hospitals that is 20 minutes away. Therefore, the requested labor and delivery services at a facility with a NICU have not been demonstrated to be medically necessary for management of this patients pregnancy and delivery.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a five-month-old female enrollee has requested Dynamic Orthotic Cranioplasty (DOC) cranial banding for the treatment of the enrollees plagiocephaly. Findings:  The physician reviewer found that DOC banding is considered a reconstructive therapy and not a cosmetic one. There is mounting evidence that it prevents future complications with orbit, temporal jaw, and other bones of the head and face. A recent study demonstrated that a better outcome is achieved with orthotic therapy than with positioning. Conservative interventions have been ineffective and the use of the DOC cranial band is clinically appropriate for this patient.
Appeal type: Medical Necessity
Decision: Overturned

The patient is a 37-year-old woman who was referred for physical therapy (PT) in March 2004. At that time she was experiencing left hip abductor strain and scapulothoracic upper back pain. She continued to receive PT through July 2004. The Health Plan has denied coverage for PT as of June 2004 on the basis that continued PT was not medically necessary for treatment of the patients condition.Review of the records from June 2004 through July 2004 shows resolution of pain with keyboarding on July 2004. PT notes from July 2004 show increased pain with bike riding. In June 2004 a 75% overall improvement was documented compared to 50% in April 2004. In July 2004 it was noted the patient tried playing tennis and experienced tightness but no pain. Notes from July 204 show no complaints of pain. The patient continued to be pain free through July 2004. The focus of therapy as of June 2004 was strengthening. The patient made some gains in trapezius and external rotation strength. The submitted notes show ongoing improvement with attainment of goals by July 2004. The patient was pain free in mid-July 2004 and was appropriate for discharge from PT at that time. Based upon the information set forth above, I have determined that physical therapy was medically necessary for treatment of the patients medical condition through July 2004. Therefore, the Health Plans denial should be partially overturned.
Appeal type: Medical Necessity
Decision: Upheld

A 46-year-old female enrollee has requested for Nuvigil 150mg for treatment of her fibromyalgia. Findings:  The physician reviewer found that fibromyalgia shares many features with chronic fatigue syndrome, including an increased frequency among women between 20 and 50 years of age, absence of objective findings, and absence of diagnostic laboratory test results.  Treatment with a multidisciplinary approach is most effective, and cognitive behavioral therapy is often beneficial.  Medications for this condition include amitriptyline, fluoxetine, duloxetine, milnacipran, chlorpromazine, cyclobenzaprine, pregabalin, or gabapentin.  The current medical literature does not support the use of the requested medication in this clinical setting.  All told, Nuvigil 150mg is not medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Overturned

A 52-year-old female enrollee has requested tendoscopy procedure to debride the peroneal tendons for treatment of her osteoarthritis of the right ankle. Findings:  The physician reviewer found that the submitted documentation establishes the medical necessity of the requested procedure. The requested tendoscopy procedure to debride the peroneal tendons is both medically necessary and likely to be beneficial for treatment of this patients medical condition. The requested procedure would have less morbidity than an open surgical incision and would be an appropriate technique to address the complications of this patients multiple prior ankle surgeries. Moreover, this approach is consistent with standards of care per the American Academy of Orthopaedic Surgeons. Therefore, for the reasons provided above, the requested procedure is medically necessary for treatment of the patients medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned

A 64-year-old male enrollee requested sofosbuvir/ledipasvir (Harvoni) for medical treatment of his hepatitis C genotype 1a.  Findings:  Two physician reviewers found that the overall positive and negative predictive value for liver biopsy and non-invasive markers of fibrosis for providing an accurate total liver fibrosis score are about 70%. In this case, the biopsy specimen appears to have been inadequate to provide an accurate stage. Thus, the FibroSure study assessment is likely more reliable. Given that this patient likely has significant underlying liver disease, he is likely to benefit from treatment with Harvoni over treatment with standard available therapies.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/ Case Summary:  The enrollee requested authorization and coverage for Cornea Collagen Crosslinking. The scientific literature noted improvement in visual acuity after undergoing the collagen crosslinking procedure. It was concluded that the collagen crosslinking procedure is a safe and effective method for halting the deterioration of keratoconus. The Food and Drug Administration (FDA) approved corneal crosslinking for the treatment of patients with progressive keratoconus in 2016. This procedure was effective in improving vision in eyes with progressive keratoconus 1 year after treatment, with an excellent safety profile. Corneal collagen crosslinking provides the keratoconic patient with an important new option to decrease progression of this ectatic corneal processFinal Result: Three of the three reviewers determined that the requested service is likely to be more beneficial than any available standard therapy for treatment of the enrollees medical condition. Therefore, the health plans denial is overturned.Credentials/Qualifications: Three reviewers are board certified in Ophthalmology 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 34-year-old female enrollee requested authorization and coverage of endovenous laser therapy. The Health Plan  denied the request indicating that the requested therapy is not medically necessary for treatment of the enrollees varicose veins.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: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patients parent has requested authorization and coverage for Zolgensma. Spinal muscular atrophy (SMA) is an autosomal recessive neuromuscular disorder characterized by degeneration of spinal motor neurons (Kolb and Kissel). SMA is caused by low levels of the survival motor neuron (SMN) protein due to deletions or mutations of the SMN1 gene. SMA results in profound weakness in the limbs and the respiratory muscles. An almost identical gene, SMN2 is present on the same chromosome and produces a smaller, truncated protein. The number of copies of the SMN2 gene in the patient is a major factor in the severity of disease. Zolgensma is indicated for the treatment of patients less than two years of age with SMA with bi-allelic mutations in the survival motor neuron 1 (SMN1) gene. Currently, the peer-reviewed published medical literature supports a clinical role of Zolgensma for infantile-onset or SMA type 1, and pre-symptomatic patients with a diagnosis of SMA and less than three copies of SMN2 gene. There are ongoing clinical trials on other indications for Zolgensma, but no available published data to support an indication for patients with more than two copies of SMN2. This patient has three copies of the SMN2 gene, which does not meet the current criteria for treatment with Zolgensma.  All told, Zolgensma is not medically necessary for treatment of this patient. 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 reviewer is board certified in pediatrics and neurology with special qualification in child neurology 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 Synvisc injections for treatment of the enrollees osteoarthritis, left knee. Findings:  The physician reviewer found that evidence based medical peer reviewed literature supports the use of Synvisc injections for the treatment of pain in patients with osteoarthritis of the knee. Colleagues concluded that hyaluronic acid was the best pharmacologic intervention for knee osteoarthritis in their meta-analysis of 137 studies with 33,243 participants. Hyaluronic acid was found to be better than injected placebo or injected corticosteroids. Colleagues conducted a systematic review of overlapping meta-analyses (total 20,049 patients) comparing intra-articular hyaluronic acid with other nonoperative treatment modalities for knee osteoarthritis. They reported that the current highest level of evidence suggests that intra-articular hyaluronic acid is a viable option for knee osteoarthritis. Nationally recognized evidence based medical guidelines state that hyaluronic acid injections in the knee are recommended as a possible option for patients with significantly symptomatic osteoarthritis who have not responded adequately to recommended conservative treatments for at least three months, including failure to adequately respond to aspiration and injection of intra-articular steroids. The American Medical Society for Sports Medicine (AMSSM) recommends hyaluronan acid for appropriate knee osteoarthritis patients, based on a large network meta-analysis. Viscosupplementation has been found to be safe and effective and allow for delay of total knee replacement, and more effective than corticosteroid injections. This patient presents with worsening left knee pain with associated swelling and slight giving way. He was status post left knee arthroscopic partial medial meniscectomy. There was reported radiographic evidence of left knee medial compartment osteoarthritis, and operative findings of chondromalacia patella. The patient failed to improve with recent and prior corticosteroid injections and medications. Pain precluded participation in postoperative rehabilitation for functional restoration. Therefore, Synvisc injections are medically necessary for treatment of this patients left knee osteoarthritis. Final Result: The reviewer determined that the requested services are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in orthopedic surgery and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Vemlidy 25 mg one tablet daily for the duration of one year for treatment of the enrollees hepatitis B virus. Findings:  The physician reviewer found that guidelines for the treatment of hepatitis B from the American Association for the Study of Liver Disease (AASLD) recommend entecavir and tenofovir compared with alternatives for the treatment of chronic hepatitis B. In comparison with tenofovir disoproxil fumarate (Viread), which the patient is taking, the Vemlidy formulation of tenofovir is effective for hepatitis B, but is associated with lower incidence of side effects such as osteopenia and renal disease. For this reason, the request for Vemlidy 25 mg one tablet daily for the duration of one year is medically necessary for the treatment of the patients chronic hepatitis B.  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 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: Experimental/Investigational
Decision: Overturned

The parent of a 12-year-old male enrollee has requested vagus nerve stimulator (VNS) implantation for treatment of the enrollees seizures.   Findings:  Three physician reviewers found that although there is a lack of multi-institutional clinical trials assessing the positive and negative effects of VNS on treatment of intractable epilepsy, in this patients particular situation that should not be an obstacle to him receiving this device. Based on the refractory nature of this patients seizure disorder, VNS represents the most appropriate next step and best practice in improving this patients quality of life and decreasing his complications from intractable epilepsy. The benefits of VNS in this patients case outweigh any potential adverse effects associated with VNS implantation and maintenance.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for the medication armodafinil. The Health Plan has denied this request indicating that the requested medication is not medically necessary for treatment of the enrollees multiple sclerosis (MS). At issue in this case is whether the requested medication armodafinil is medically necessary for treatment of the enrollees medical condition.Armodafinil is not FDA approved for fatigue management in relation to multiple sclerosis. There is no indication of mitigating circumstance. The records report fatigue in condition of MS. Findings noted multiple therapeutic treatments for MS related fatigue, but armodafinil is not supported as having peer reviewed literature in support of treatment. Findings note that armodafinil has not shown benefit in treatment of fatigue related to MS. Armodafinil is not medically necessary for treatment of the patient. 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 reviewer is board certified in neurology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for a stress echocardiogram. Findings: The American Society of Echocardiography guidelines note that stress echocardiography is generally considered as the initial coronary disease screening test in clinical scenarios where the baseline electrocardiogram is abnormal. Stress echocardiography is the preferred test for women with an indication for noninvasive imaging for known or suspected coronary artery disease and is a reasonable option for asymptomatic adults with a strong family history and an elevated coronary calcium score. In this case, given that the records noted a family history of coronary artery disease and a coronary calcium score greater than 200, the service at issue was medically indicated. Therefore, the stress echocardiogram was medically necessary for the evaluation of this patient.Final Result: The reviewer determined that the service at issue was medically necessary for evaluation of the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in internal medicine with sub-specialty certification in 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: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for residential treatment center services for treatment of the enrollees behavioral health condition. Findings:  The physician reviewer found that the documentation submitted does not support the medically necessity of the services at issue in this clinical setting. The records do not show post-acute withdrawal symptoms. The patient was not a danger to self or others and she showed no self-harming urges or behaviors.  There were no emotional, behavioral, or cognitive issues at play to warrant further residential care. Her activities for daily living were intact.  She was not manic and had no hallucinations or delusions in any modality.  Her medical condition was stable and did not require residential level of care for management. The records did not show that significant medication changes were made to her regimen. She was psychiatrically stable. She had not been placed on any psychotropic medications. She was medication compliant.  The patient was aware of triggers and able to identify coping mechanisms and utilize skills to improve impulse control, which provided her a better chance of lowering her risk of relapse.  She lived with her mother.  She had improved and no longer required the structure of the residential setting.  She received a Vivitrol injection, which she could have received as an outpatient. She could have been stepped down to an ambulatory level of care such as intensive outpatient services. For the reasons stated above, the residential treatment center services were not medically necessary for treatment of this patient. Final Result: The reviewer determined that the services at issue were 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 psychiatry with sub-specialty certification in addiction 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.