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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for bilateral Orthovisc injections. This patient presents with chronic bilateral knee pain that was progressively worsening and is now severe. She is status post bilateral knee anteromedialization osteotomy and medial patellofemoral ligament reconstruction. She reported limited ability to participate in current rehabilitation due to pain. Clinical examination findings are consistent with reported imaging evidence of tricompartmental degenerative changes. Conservative treatment has included physical therapy, activity modification, home exercise, nonsteroidal anti-inflammatory drugs and corticosteroid injections, with limited relief. She reported significant benefit with prior viscosupplementation with Orthovisc. The evidence-based literature supports the use of viscosupplementation injections for the treatment of pain in patients with osteoarthritis of the knee. Repeat viscosupplementation injections have been found to be safe and effective and allow for delay of knee replacement surgery. Given the previous response and age of this patient, repeat Orthovisc injections are indicated. Therefore, bilateral Orthovisc injections 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

A 64-year-old female enrollee requested skilled nursing facility services for medical treatment of her medical condition.  Findings:  The physician reviewer found that for single knee arthroplasty cases, the majority of patients can be discharged safely home following short-term rehabilitation on the acute post-surgical ward, followed by outpatient care.  There are no indications that the patient currently requires active skilled therapy services or skilled nursing care.  There are no documented active medical issues requiring ongoing inpatient care.  There are no indications that care cannot be provided in a custodial level facility or in the community with unskilled supervision and assistance.  All told, the requested continued skilled nursing facility services are not medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Overturned

A fifty-seven year-old female with mixed headache disorder is requesting authorization for treatment with Botox.  Reviewers Findings:  The reviewing physician found that the medical literature includes studies suggesting that Botox is safe and efficacious for treatment of patients such as this patient.  The reviewing physician found that the Health Plan denial should be overturned.
Appeal type: Experimental/Investigational
Decision: Upheld

A 62-year-old female enrollee requested Prolia (denosumab) injections for medical treatment of her osteopenia.  Findings:  Three physician reviewers found that the services are not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The documentation submitted for review does not demonstrate that the patient has osteoporosis, although she does have osteopenia. Denosumab is an effective and approved medication for the treatment of osteoporosis. However, this patient does not have clinical evidence of this condition. Moreover, the patients 10-year fracture risk of 0.6% for hip and 7.2% for major osteoporotic fracture is not severe enough for pharmacologic treatment. As such, the services at issue were not likely to be a more beneficial treatment than standard medical therapy in this clinical setting.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the transcatheter arterial chemoembolization. Transcatheter arterial chemoembolization of the liver is a proposed alternative to conventional systemic or intra-arterial chemotherapy as well as various nonsurgical ablative techniques, to treat resectable and nonresectable tumors. Transcatheter arterial chemoembolization combines the infusion of chemotherapeutic drugs with particle embolization. Tumor ischemia secondary to the embolization raises the drug concentration compared with infusion alone, extending the retention of the chemotherapeutic agent and decreasing systemic toxicity. The liver is especially amenable to such an approach, given its distinct lobular anatomy, the existence of two independent blood supplies, and the ability of healthy hepatic tissue to grow which compensates for tissue mass lost during chemoembolization. For these reasons, the transcatheter arterial chemoembolization rendered was likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.One reviewer found that the transcatheter arterial chemoembolization rendered was not 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 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:  One reviewer is board certified in radiation oncology and is actively practicing. One Reviewer is board certified in radiation oncology and is actively practicing.  One Reviewer is board certified in radiation oncology 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.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for hydrocodone 7.5-325 mg oral tablet and Breg Polar Care Cube Cold Therapy System for treatment of the enrollees right shoulder rotator cuff tear. Findings:  The physician reviewer found that post-operative continuous flow cryotherapy after shoulder surgery has been shown to be of benefit for seven days. It reduces pain, swelling, inflammation, and the need for narcotics after surgery. Based on this patients medical records and recent medical literature with regard to continuous-flow cryotherapy for shoulder surgery, the requested Breg Polar Care Cube Cold Therapy System is supported as medically necessary for seven days postoperatively. With respect to the request for hydrocodone 7.5-325 mg with acetaminophen, weaning is suggested. Thus, the Breg Polar Care Cube Cold Therapy System for post-operative use for seven days and hydrocodone 7.5-325 mg oral tablet for one month are supported as medically necessary for treatment of this patients medical condition. Final Result: The reviewer determined that a portion of the requested services is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be partially overturned. Credentials/Qualifications: The reviewer is board certified in 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

A 42-year-old male enrollee has requested orthotics for the treatment of his Achilles tendonitis and plantar fasciitis. Findings:  The physician reviewer found that custom triplanar orthotic therapy has been used to treat heel pain for many decades. Orthotic treatment is well established in the podiatric and orthopedic communities. Orthotic therapy for the treatment of plantar fasciitis and Achilles tendonitis is appropriate and necessary for the treatment of this patient. Orthotic therapy is within standards of good medical practice within the organized medical community and should be authorized in this case.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for ivabradine (Corlanor). Based on the records provided for review, this patient has a history of postural orthostatic tachycardia syndrome (POTS) and she is being treated with low dose carvedilol without any documented trial or intolerance to higher dose beta-blocker therapy. A recent clinic note did not document any tachycardia or hypotension, at baseline or after standing, despite symptom occurrence. Studies evaluating Corlanor for the treatment of patients with POTS have demonstrated lower heart rate and reduced symptoms in some patients. However, the available studies are small and without comparison control groups. The patient has not reported any tachycardia during symptoms while on low dose carvedilol and there is no documented contraindication to higher dose carvedilol therapy. For these reasons, the requested ivabradine (Corlanor) 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 internal medicine with subspecialty 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: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for residential treatment center (RTC) and partial hospitalization program (PHP) services. Per the American Society of Addiction Medicine (ASAM) criteria, this patient meets Level 3.5 criteria for Clinically Managed High-Intensity Residential Services. ASAM criteria focuses on six dimensions to determine the appropriate level of care including: (1) intoxication and withdrawal potential; (2) biomedical conditions; (3) emotional, behavioral and cognitive conditions; (4) readiness to change; (5) relapse, continued use, or continued problem potential; and (6) recovery environment. The patient met the criterion for dimension 1, given her prior withdrawal symptoms included tremors, body aches, and increasing suicidal ideation. For dimension 2, the patient was noted to have spinal compression and obesity. Dimension 3 was satisfied due to the presence of comorbid depression, anxiety and PTSD. The patient demonstrated self-harming behavior and suicidal ideation. For dimension 4, the patient appeared motivated, but lacked insight into the amount of effort required to maintain sobriety. For dimension 5, the patient was at high risk of relapse, considering her poor judgment, lack of impulse control, and lack of sober support. The records report the patient had low frustration tolerance and was unable to avoid or prevent relapse. She continued to use despite consequences of withdrawals and blackouts as well as impaired functioning. For dimension 6, the patients living environment did not include any sober supports. The patient was not stable enough to maintain sobriety without a highly structured 24-hour therapeutic environment. The patient presented with severely limited coping skills, including a pattern of self-medication and required 24-hour supervision in a sober setting to treat presenting problems and improve coping skills. The patient required a safe and stable living environment in order to develop her recovery skills. The patient qualified for ASAM Level III treatment, which is similar to what the patient received at the RTC and PHP. Given the severity of the patients illness, RTC and PHP were in accordance with generally accepted standards of medical practice. All told, the RTC services and PHP services were medically necessary for treatment of 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 psychiatry with expertise in addiction 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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for the medication Clobetasol Shampoo.Superpotent topical steroids are a first line therapy for mild/localized psoriasis per the joint AAD-NPF guidelines. Furthermore, treatment of the scalp can be difficult given penetration issues with various vehicles/formulations. Clobetasol (Clobex) shampoo is a very reasonable therapy for the treatment of scalp psoriasis given a favorable vehicle/formation to allow for enhanced skin contact in hair bearing areas in comparison to creams, lotions, gels. The guidelines allow for the selection of a vehicle that is most suitable for the patients circumstance. In this case, the patient was diagnosed with seborrheic dermatitis, which has similar treatment considerations as psoriasis. There can also be clinical overlap. Moreover, topical steroids are effective based on multiple studies and are generally considered part of the standard of care management. Therefore, the requested medication, Clobetasol Shampoo, is medically necessary for this patients medical condition.Final Result: The reviewer determined that the requested medication is medically necessary for this patients 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: Upheld

Nature of Statutory Criteria/Case Summary: The enrollee has requested authorization and coverage the LINX device and LINX procedure for treatment of the enrollees gastroesophageal reflux disease (GERD). Findings:  The physician reviewer found that the requested procedure is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. According to the documentation provided for review the patient had a negative pH. On Day 2 of the ambulatory monitoring the patient had essentially no reflux. The patient was positive for the second day at 6.9% but this is not a high value. Manometry shows no hiatal hernia and a normal lower esophageal sphincter (LES) pressure. In addition, there is a lack of documentation indicating the patients medications tried and failed. Based on the clinical information provided for review, the LINX device and LINX procedure cannot be deemed likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Final Result: All three reviewers determined that the requested procedure is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: Physician reviewer number one 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.Physician reviewer number two 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.Physician reviewer number three 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 and prospective authorization and coverage for residential treatment center services. Findings:  The physician reviewer found that the submitted documentation supports the medical necessity of a portion of the services at issue. During her stay, the patient was noted to be cooperative in treatment. She was engaged in family and individual therapy and was noted to have some issues with difficulty interacting with peers. Throughout the first portion of her stay, the patient described suicidal ideation. The progress notes do not indicate that the patient made any suicide attempts or self-harm attempts during her stay. During her stay, the patient gained more insight into her behaviors and it appears that she made significant progress. In this patients case, residential treatment was initially medically necessary because she was endorsing suicidal ideation on a frequent basis. However, this suicidal ideation resolved, and the patient was documented to have shown improved coping skills. After the resolution of her suicidal ideation, the patient could have transitioned to a less restrictive setting. Based on the records, residential treatment center services provided from certain dates were medically necessary, but not thereafter. Final Result: The reviewer determined that a portion of the services at issue was medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be partially overturned.Credentials/Qualifications: The reviewer is board certified in psychiatry with sub-specialty certification in child and adolescent psychiatry and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

The patient is a 58-year-old obese woman with a fracture to her right ankle. She has had some progress with physical therapy, particularly with bed mobility. However, the patient has not progressed with transfer and still requires two-person transfer. Based upon the submitted information, the patients progress with parallel bars is not clear. The patient has requested authorization and coverage for continued daily inpatient skilled therapy. The Health Plan has denied her request on the basis the requested therapy is not medically necessary.The submitted documentation does not provide compelling evidence the patient has reached her skilled rehabilitation plateau. Although the patient did not progress with transfer ability, there is evidence she progressed slowly but consistently with occupational therapy. There is potential for continued benefit in this case, particularly if the patient has been able to progress with parallel bars. In the absence of evidence the patient has plateaued with occupational therapy, continued daily inpatient skilled therapy is medically indicated. Therefore, I have determined that the requested therapy is medically necessary for treatment of the patients medical condition. The Health Plans denial should be overturned. The patient should be fully re-evaluated in two weeks to determine if continued daily skilled inpatient rehabilitation therapy is indicated.
Appeal type: Medical Necessity
Decision: Upheld

A 35-year-old male enrollee has requested for bilateral custom knee braces supplied for treatment of his knee condition. Findings:  The physician reviewer found that the bilateral custom knee braces were obtained to be used prophylactically during motorcycle riding and other physical activities. They were not medically necessary for treatment of the acute right knee sprain. There is no medical evidence demonstrating there was a medical need for the knee braces.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for sensory integration occupational therapy. Sensory integration occupational therapy is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Various forms of sensory stimulation are often combined with purposeful muscle activities, with the goal of improving how the brain process and organizes sensory information. Sensory integration therapy has been a popular treatment for children with neurodevelopmental disorders such as autism and developmental delay but there is significant controversy regarding its effectiveness. In the medical literature, researchers noted that sensory integration therapy remains a controversial treatment method supported by limited scientific data. At present, there is insufficient evidence in the medical literature to support the use of sensory integration occupational therapy in this clincial setting. Thus, the requested sensory integration occupational therapy is not likely to be more beneficial for treatment of the patients medical condition than any standard available therapy.One reviewer found that the requested sensory integration occupational therapy is likely to be more beneficial for treatment of the patients medical condition than any standard available therapy.Final Result: Two of the three reviewers determined that the requested services are not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications:  One reviewer is board certified in pediatrics, neurodevelopmental behavioral pediatrics, and genetics and is actively practicing. One Reviewer is board certified in pediatrics and neurology with special qualification in child neurology and is actively practicing.  One Reviewer is board certified in pediatrics with expertise in developmental and behavioral pediatrics 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.