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

Nature of Statutory Criteria/Case Summary: A patient has requested authorization and coverage for five doses of Supartz injections. The Health Plan has denied this request indicating that the requested medication regimen is not medically necessary for treatment of the patients knee pain. The submitted documentation supports the medical necessity of the requested medication regimen. Researchers conducted a systematic review of overlapping meta-analyses comparing intra-articular hyaluronic acid with other non-operative 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. Evidence based 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 medical literature supports the use of hyaluronic acid injections for the treatment of pain in patients with osteoarthritis of the knee. This patient presents with chronic right knee pain and functional limitations in activities of daily living. The clinical examination findings are consistent with x-ray evidence of severe osteoarthritis with bone-on-bone findings of right knee osteoarthritis. The record indicates that reasonable conservative treatments have failed to provide adequate symptom relief. The medical literature supports the use of viscosupplementation injections for the treatment of pain in patients with osteoarthritis of the knee. Viscosupplementation has been found to be safe and effective and allow for delay of total knee replacement, and more effective than corticosteroid injections. Therefore, the requested five doses of Supartz injections are medically necessary for treatment of this patient.Final Result: The reviewer determined that the requested medication regimen 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 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: The enrollee is requesting authorization and coverage for the medication, Sildenafil six tablets every thirty days. Findings:  The physician reviewer found that according to the record, the enrollee has a history of obesity and erectile dysfunction, testicular hypofunction and sleep apnea. Sildenafil for erectile dysfunction has been prescribed by his current physician for many years. He was seen by his physician and a refill of his sildenafil citrate 100mg tabs was prescribed with instructions to take one half to one tablet, as needed approximately one hour before sexual activity. The medical literature indicates that phosphodiesterase type-5 inhibitors, which include Sildenafil, are considered a first-line treatment for erectile dysfunction (ED) because of their safety and efficacy. The authors also note that obesity increases the risk factors for ED. This enrollee has a diagnosis of erectile dysfunction and sildenafil is medically necessary to treat this condition. Sildenafil is not indicated for daily usage, but for the on-demand treatment of erectile dysfunction. The medication is approved by the FDA for as needed treatment of erectile dysfunction, such as has been requested in this case.Final Result: The reviewer determined that the requested medication is medically necessary for the treatment of the enrollees medical condition.Credentials/Qualifications: The physician reviewer is board certified in urology and isactively 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 43-year-old female enrollee has requested Botox injections for treatment of her temporomandibular joint pain.  Findings:  Two physician reviewers found that the medical literature shows pilot studies supporting the efficacy of Botox to reduce myofascial pain symptoms in bruxers. Ihde and Konstantinovic concluded that, Botulinum toxin appears relatively safe and effective in treating cervical dystonia and chronic facial pain associated with masticatory hyperactivity. Other studies have shown benefit in reducing recurrent dislocation of the disc and some have recommended Botox as first-line treatment for patients with habitual dislocation and systemic or neurological diseases. This patient has history of TMD, with disc dislocation, and a background history of clenching. Her records document that she has tried and failed standard therapies. Since Botox is supported by scientific evidence for the management of her condition, it should not be considered investigational in this clinical setting, and is likely to provide her better results than standard alternatives.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient is a 23-month-old female who has been diagnosed with a CDKL5 gene mutation with infantile spasms, medically refractory epilepsy and global developmental delay.  The patient was described as having developmentally delayed fine motor skills. She was noted to babble and smile. The patient was noted to sustain a hands and knees position with support. The patient was assisted with rolling to a sitting position. In a letter, the provider noted the patient had improved truncal tone and head control since beginning physical therapy with the Anat Baniel Method, and was now able to sit without support for two minutes. The patients parent has requested reimbursement and prospective authorization and coverage for neuromuscular reeducation physical therapy from May 2019 onward. The Health Plan denied the request and reported the services at issue were not and are not medically necessary for the treatment of this patient. At issue in this case is whether neuromuscular reeducation physical therapy from May 2019 onward was and/or is medically necessary for the treatment of the patients medical condition. Studies reported that Some interventions with a task-orientated framework can improve gross motor outcomes in children with developmental coordination disorder or cerebral palsy. These findings are limited by the very low quality of the available evidence. However, in each respect, only a single study has been judged as being of sufficient methodological quality to arrive at this conclusion and all reflect comparatively small sample sizes from single-center studies. The authors noted, To date, no large-scale multisite randomized control trial (with adequately blinded assessors) has been conducted in relation to any motor skills intervention intended to remediate the impact of developmental coordination disorder. There is a lack of evidence supporting the benefits of neuromuscular reeducation physical therapy or the Anat Baniel Method. The current medical evidence does not support the services at issue in this clinical setting. Therefore, neuromuscular reeducation physical therapy from May 2019 onward was not and is not medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested services were not and are 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 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

A 56-year-old female enrollee requested authorization and coverage of physical therapy twice a week for ten weeks. The Health Plan denied the request indicating that the requested therapy is not medically necessary for treatment of the enrollees shoulder and clavicle problems.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 female enrollee requested Otezla 30mg tablets for medical treatment of her Behcets syndrome.  Findings:  Two physician reviewers found that the current medical evidence has not established the superior efficacy of the requested medication.  There is a lack of high-quality studies that support the use of Otezla in the treatment of Behcets Syndrome.  The safety and efficacy of this medication in the treatment of Behcets has not been determined.  In sum, the requested Otezla 30mg tablets are not likely to be of greater benefit than other options in this clinical setting.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee who has requested authorization and coverage for EpiPen two pack for treatment of the enrollee, who has allergies to nuts. Findings: The physician reviewer found that the medical evidence show that epinephrine administration is a critical component of individualized emergency action plans for patients at risk for anaphylaxis. The auto injector should be portable, identifiable, safe, and effective. In this patients case, the history and laboratory data indicate that the patient had a significantly elevated IgE level to multiple food items.  Her laboratory testing showed a class 4 reaction to walnuts, and a class 3 reaction to soybean, wheat, sesame seeds, hazelnuts and almonds. She had multiple positive results to respiratory allergens such as pollen, dust mites, and animal dander. 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 allergy and immunology 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: An enrollee has requested authorization and coverage for cooled radiofrequency denervation for treatment of the enrollees low back pain. Findings: Three physician reviewers found that Lumbar medial branch radiofrequency ablation or neurolysis is a well-documented procedure which helps with chronic low back pain due to lumbar facet pain. Son and colleagues noted that repeated radiofrequency ablation for lumbar facet syndrome does provide successful pain relief for about 10 months in more than 85% of carefully selected patients. The procedure is successful in treating lumbar spine pain in repeated fashion. However, there is not significant literature for the use of cooled radiofrequency denervation.  While there is support for lumbar radiofrequency ablation using traditional technique, the superior effectiveness of the requested cooled radiofrequency denervation has not been established.Final Result: The 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: All three physician reviewers are board certified in anesthesiology with sub-specialty certification in pain medicine 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: Upheld

The mother of a two-year-old male enrollee requested authorization and coverage of 126 hours per week of continued home nursing care. The Health Plan denied the request indicating that the requested services are not medically necessary for treatment of the enrollees congenital central hypoventilation.One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer upheld the Health Plans denial on the basis that the requested services are not medically necessary.
Appeal type: Experimental/Investigational
Decision: Upheld

A 27-year-old female enrollee has requested Hyalgan injections for the treatment of her knee pain. Findings:  Three physician reviewers found that Hyalgan injections are not indicated for meniscal pathology. The requested therapy is not medically indicated or appropriate for this patients condition. Hyalgan injections are not likely to be more efficacious than alternate standard therapies.
Appeal type: Medical Necessity
Decision: Overturned

A 60-year-old female has requested coverage for double discectomy, laminectomy, insertion of spinal fixation device, and surgical/additional IP procedure for treatment of her lumbar stenosis, lumbar radiculopathy, and lumbar spondylolisthesis.   Findings:  The physician reviewer found that based on review of the available records, this patient has had spinal stenosis with radiculopathy for at least five years. In addition, her MRI scan shows severe stenosis at L4-5 with instability, or spondylolisthesis. She has been undergoing various forms of treatment, without long lasting relief of her symptoms. The medical literature demonstrates that spinal stenosis is a progressive condition that does not improve with time and never goes away. Watters and colleagues support the necessity for fusion in the surgical treatment of stenosis with degenerative lumbar spondylolisthesis following adequate attempts at conservative treatment without long-term relief of symptoms. Therefore, the requested decompression and instrumented fusion at L4-5 is clinically indicated for management of this patients medical condition and is medically necessary.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has advanced lipoprotein testing for evaluation of her heart disease. Findings: Two reviewers found that in current evidence-based practice, there is insufficient data to support the use of advanced lipoprotein analysis in this clinical setting. While some researchers have advocated use of the advanced lipoprotein analysis for evaluation of cardiovascular risk to help make treatment decisions for patients with hyperlipidemia, the guidelines of the American College of Cardiology Foundation (ACCF) do not support the use of advanced lipoprotein analysis. There is insufficient data, according to the ACCF, to document benefit for the advanced lipoprotein assay above the basic lipid profile. Therefore, the advanced lipoprotein testing performed was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Final Result: Two reviewers determined that the service 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: All three physician reviewers are board certified in internal medicine with sub-specialty certification in cardiovascular disease 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: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for genetic testing for evaluation of the enrollees risk for cancer. Findings:  The physician reviewer found that the records indicate that the patient had her family history interrogated by a genetics counselor who did not recommend genetic testing at this time. Many of the cancers appeared too sporadic since they occurred at older age of onset. Her provider has not recommended genetic testing. Although the patients family history and patient history may be suggestive of Lynch syndrome or a BRCA mutation, several of the cancers occurred in older relatives suggesting sporadic rather than familial predisposition. Thus, the requested genetic testing is not supported as medically necessary for evaluation of this patients medical condition. Final Result: The reviewer determined that the requested testing is not medically necessary for evaluation 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 medical oncology 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 has requested authorization and coverage for facial feminization surgeries. Facial feminization surgery is medically necessary for many transgender women to help alleviate the psychological distress they experience related to gender dysphoria. Moreover, the World Professional Association for Transgender Health (WPATH) supports facial feminization surgery in well-selected patients. WPATH noted that non-genital surgical procedures are oftentimes of greater practical significance in the patients daily life than reconstruction of the genitals. The guidelines further report that, these reconstructive procedures are not optional in any meaningful sense, but are understood to be medically necessary for the treatment of the diagnosed condition. This patient meets the WPATH criteria for gender dysphoria and indication for facial feminization surgery based upon clinical documentation of persistent gender dysphoria related to masculine facial features associated with social dysfunction. Her provider has recommended additional procedures including facial feminization surgeries with forehead, brow and eye orbital, upper lip, and rhinoplasty. Given the support from WPATH, the requested facial feminization surgeries are medically necessary for 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 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: Upheld

The patient is a 56-year-old male who was treated with Provigil, Paxil, and amphetamine, apparently for depression. The patient stopped his medications and reports that he feels better. He has requested reimbursement from the Health Plan for the cost of the Provigil. The Health Plan has denied his request on the basis that there is insufficient evidence Provigil was medically necessary. Although Provigil is sometimes used for augmentation of antidepressant medications, in the case of this patient he also received treatment with amphetamine, which alone would serve to augment the antidepressant. There is no literature support for the use of Provigil combined with amphetamines. The inclusion of Provigil in the patients medication regimen was not within the standard of care or clinically indicated. As such, I have determined that the medication at issue was not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a two-year-old male enrollee has requested a circumcision for treatment of the enrollees medical condition.  Findings:  The physician reviewer found that there has been significant debate about the necessity of neonatal circumcision.  Most recently, the American Academy of Pediatrics published a policy statement which noted that the health benefits of newborn male circumcision outweigh the risks.  Per the current medical evidence, these benefits include prevention of urinary tract infections, penile cancer, and transmission of some sexually transmitted infections.  There is sufficient medical evidence supporting the requested services in this setting.  All told, the requested circumcision is medically indicated in this patients case.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a 1-year, 3-month-old female enrollee has requested physical therapy (PT) for 2 hours per week for treatment of the enrollees Down syndrome.  Findings:  The physician reviewer found that children with Down syndrome may have medical vulnerabilities and congenital abnormalities occurring in greater frequency (Parker, et al). As a result, the prevention of secondary disability is important. The central hypotonia slows the acquisition of gross motor skills while the ligamentous laxity complicates the ability to acquire appropriate gross motor skills (Baum, et al). As recommended by the American Academy of Pediatrics (AAP), PT with early intervention services is needed for continued improvement in gross-motor skills in this patient population. The long-term benefit of PT includes prevention of compensatory movement patterns that patients with Down syndrome are prone to developing. Should these issues go untreated, this can lead to orthopedic and other functional problems (Rasmussen, et al). This patient has identified gross motor delays in all domains as documented by her provider during the most recent PT evaluation. As such, she will benefit from ongoing PT for two hours per week as it is medically necessary and within the standard of care for treatment of her Down syndrome.
Appeal type: Medical Necessity
Decision: Overturned

A forty-eight year-old female with dural cranial fistula is requesting authorization of a craniotomy.Reviewers Findings:  The reviewing physician found that the requested services are medically necessary for the patients condition.  The Health Plan denial was overturned.