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

A 43-year-old male enrollee has requested acute inpatient or skilled nursing facility admission for treatment of his back pain.  Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested services.  Surgical decompression is the mainstay of treatment for cauda equina syndrome.  Per standards for admission to rehabilitation units or hospitals, a lower level of care should be selected when it is anticipated that a lower level of care can meet a patients functional goals as effectively as inpatient rehabilitation.  In this patients case, there are no documented rehabilitation goals requiring inpatient care at a skilled nursing facility at the present time.  Strength in the upper and lower limbs has been normal.  He has been ambulating with a walker.  The current medical evidence does not support the requested services in this patients case.  All told, neither acute inpatient nor skilled nursing facility admission is medically necessary for the treatment of this patient.
Appeal type: Experimental/Investigational
Decision: Upheld

A 42-year-old female enrollee has requested for meniscal allograft transplantation for treatment of her internal derangement of medial and lateral meniscus. Findings:  Two physician reviewers found that the use of meniscal transplants has increased with the realization of the beneficial relationship between the meniscus and the articular cartilage. However, many of the studies reported focus on the survival of the graft, with less emphasis on the fate of the articular cartilage than on the survival of the transplant. There remains the need to examine the results over a longer time period. At present, transplantation is a reasonable option for the younger patient in need of salvage in cases of meniscal deficiency, but prospective studies comparing similar patients with and without grafts, and which follow patients for longer periods are needed.
Appeal type: Experimental/Investigational
Decision: Upheld

A 47-year-old male enrollee has requested for osteochondral allograft of the left ankle with arthroplasty, bone graft, application uniplane and application multiplane for treatment of her left ankle post-traumatic arthritis. Findings:  Two physician reviewers found that remains the standard treatment option for ankle arthritis, there has been interest in other modalities. As noted by Lalonde and Conti, allograft transplantation has been explored.  Although some reports have been encouraging, others have reported a high rate of failure with evidence of radiographic failure and need for revisions. As noted by Berti and colleagues, there is a need for longer follow-up of osteochondral allograft of the ankle in patients with post-traumatic ankle arthritis.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for radiofrequency neurolysis. The Health Plan has denied this request indicating that the services at issue were considered investigational for treatment of the enrollees back pain. Findings:  In the documentation available for review, the provider does not document an examination consistent with facet arthropathy prior to the requested procedure. The literature recommends that a diagnostic medial branch block is to be performed prior to radiofrequency ablation, specifically using a pain diary for the day to verify when the local anesthetic wore off and not using anything other than a local anesthetic for the test. The records indicate that at least two years later, the procedures were repeated. However, the medical records during the time of the prior ablation and the prior medial branch blocks, the corresponding pain dairies were not submitted to corroborate any improvement. There was no mention of a baseline functional status with an actual number value and no perceived pain baseline with an actual number value. In addition, these procedures are not recommended when a patient has radicular problems. The literature indicates that a steroid injection alone may provide relief without having the increased risk from a radiofrequency ablation procedure. From the submitted records, there is no mention of prior failure from facet injections or epidural injections. Finally, there is no mention of a home exercise program. These treatment modalities are standard of care and may have provided benefits to this patient with less risk. Therefore, the records provided have not demonstrated that radiofrequency neurolysis was a superior treatment modality when compared to standard methods of treating this patients medical condition.  Final Result: All three reviewers have determined that the services at issue were 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 reviewers are board certified anesthesiology with sub-specialty certification in pain medicine 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: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for balloon ostial dilation. Findings:  Three physician reviewers found that the records noted a history of posterior nasal discharge and an episode of presumed rhinosinusitis 2.5 months previously which had been medically managed with appropriate therapy. The patient had no clinical evidence of chronic sinusitis.  The single report of the objective finding of the computed tomography (CT) scan from 2018 did not show evidence of chronic sinus problems, as there was no clinical evidence of opacification of any of the paranasal sinuses, and the ostiomeatal units were open, not obstructed. The nasal endoscopy suggested no evidence of any acute sinus problems. The only physical finding was that of a moderate deviated nasal septum, which is not treated with balloon sinus ostial dilation. Balloon sinus ostial dilation is a technique to improve symptoms of recurrent acute rhinosinusitis to help widen and dilate the sinus pathways. However, at this time, functional endoscopic sinus surgical techniques are considered the surgical treatment of choice for the management of chronic rhinosinusitis refractory to medical management. In this case, the patient does not meet medical criteria for surgical treatment of the paranasal sinuses based on the medical records. Therefore, the requested balloon ostial dilation is not likely to be of greater benefit than other treatment options. 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: Physician reviewers 1, 2 and 3 are board certified in otolaryngology 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

Nature of Statutory Criteria/Case Summary: The patients parent has requested authorization and coverage for Dupixent. Findings: The records document that this patient has atopic dermatitis with involvement of over 10% of her body surface area (BSA). The provider charted that since starting treatment with Dupixent in August 2021, the patient has experienced improvement. The provider has recommended continued treatment with Dupixent. The U.S. Food and Drug Administration (FDA) has approved Dupixent for the treatment of children and adults with moderate-to-severe atopic dermatitis whose disease is not adequately controlled with topical prescription therapies. The data supporting the use of Dupixent in the treatment of patients with moderate-to-severe atopic dermatitis is substantial and studies have reported a favorable side effect profile in comparison to other systemic agents for use in this clinical setting. A study concluded that, In two phase 3 trials of identical design involving patients with atopic dermatitis, dupilumab improved the signs and symptoms of atopic dermatitis, including pruritus, symptoms of anxiety and depression, and quality of life, as compared with placebo. Based on all of the information provided, this patient is a good candidate for treatment with Dupixent. Therefore, the requested Dupixent is 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 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: Medical Necessity
Decision: Upheld

A 30-year-old female requested authorization and coverage of a bunionectomy. The Health Plan denied the request indicating that the requested procedure is not medically necessary for treatment of the enrollees bunion.One podiatry reviewer performed a medical necessity Independent Medical Review. The podiatry reviewer upheld the Health Plans denial on the basis that the requested procedure is not medically necessary.
Appeal type: Experimental/Investigational
Decision: Upheld

A 45-year-old male enrollee has requested Velcade for treatment of his primary effusion lymphoma.  Findings:  Two physician reviewers found that Primary effusion lymphoma is a very rare form of lymphoma ocurring predominantly in HIV positive patients.  The data regarding Velcade for the treatment of primary effusion lymphoma is very minimal.  This medication has demonstrated some in vitro activity against primary effusion lymphoma, usually when combined with other agents.  Siddiqi and colleagues reported a favorable response in one HIV positive patient who was treated with a combination of bortezomib, liposomal doxorubicin and Rituxan.  However, the contribution of bortezomib in that case is unknown.  At this time, there is a lack of data demonstrating the efficacy of Velcade in this clinical scenario.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Repatha 140 mg/mL SureClick.The patient has established coronary artery disease and is status post coronary angioplasty. He has a strong family history of coronary artery disease and should be managed with intensive risk factor modification per American College of Cardiology/American Heart Association (ACC/AHA) guidelines. He had attempted combination therapy with atorvastatin/ezetimibe at highest doses, but his LDL level did not reach goal. Although rosuvastatin did get him to goal, it was not tolerated due to severe side effects. A reattempt at atorvastatin/ezetimibe, which would be the only other option to get him to goal along with lifestyle modifications, was unsuccessful. He was appropriately prescribed Repatha, which lowered his LDL level to goal without side effects. The patient meets published ACC/AHA guidelines for Repatha use. Therefore, Repatha 140 mg/mL SureClick is medically necessary for the treatment of the patients medical condition.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 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

The parent of a two-year-old male enrollee has requested physical therapy and occupational therapy for treatment of the enrollees autism.  Findings:  The physician reviewer found that this patient has significant documentation of signs and symptoms consistent with ASD since of 18 months of age. Repeated evaluations by both physical and occupational therapists have revealed significant developmental delays in fine motor skills, sensory modulation defects, and activities of daily living. In the medical literature, the article from Myers and colleagues recommended OT based on community practice, although the authors noted there were limited literature studies of this modality. However, subsequent to their report, Case-Smith and Arbesman compiled a meta-analysis of the literature, documenting the value of OT in the young autistic population. Similarly, Dawson and Watling reported on the value of OT in the motor treatment of autistic children discussing positive studies facilitating improvement in motor skills utilizing OT therapies. In addition, Turner and colleagues conducted a long-term, controlled study of both OT and PT services in children with ASD and found that the treated group had far greater improvement in motor, adaptive, and social skills than the untreated group. Thus, PT is also an accepted modality in this setting and is often included as part of a coordinated, multi-disciplinary approach. All told, it is medically necessary for this patient to receive both OT and PT services for treatment of his medical condition.
Appeal type: Medical Necessity
Decision: Upheld

The parent of a 17-year-old female enrollee has requested transcranial magnetic stimulation (TMS) therapy for treatment of the enrollees major depressive disorder. Findings:  The physician reviewer found that the submitted documentation does not demonstrate the medical necessity of TMS therapy in this patients case.  TMS therapy has been endorsed by the American Psychiatric Association, and there is a growing base of evidence-based studies supporting its utility and efficacy for adults with depression.  However, at this time, there is a lack of well-designed clinical studies in the peer-reviewed medical literature with significant statistical power demonstrating similar outcomes in the adolescent population.  Per the current medical evidence, TMS is not routinely prescribed in this clinical setting.  In the adolescent population, TMS does not align with generally accepted standards of medical practice, and its clinical appropriateness for those with anxiety and eating disorder has not been demonstrated in the scientific literature.  All told, the requested TMS therapy is not medically indicated for the treatment of this patient.
Appeal type: Experimental/Investigational
Decision: Overturned

A 47-year-old male enrollee has requested knee surgery (osteochondral allograft(s)) for treatment of his knee pain. Findings:  Two physician reviewers found that the patient leads an active lifestyle and has multi-focal full-thickness lesions involving the medial femoral condyle, lateral femoral condyle, and lateral tibial plateau of his left knee. He has chronic knee pain that interferes with his activities of daily living. In spite of multiple medical and surgical interventions, the patient continues to be persistently symptomatic with a diminished quality of life. At his relatively young age, total knee arthroplasty would ultimately commit him to multiple revisions in the future. Biological restoration would maximize his function and potentially be more durable than total knee arthroplasty. The use of osteochondral allografts is well-documented in the orthopedic literature with good success. Although microfracture is contraindicated in large lesions with multiple lesions in the same compartment of the knee, this is the exact circumstance for which osteochondral allograft may be the most beneficial. Osteochondral allografting is indicated as the preferred treatment for cartilage defects greater than 2 cm2 or lesions involving both sides of the joint.
Appeal type: Experimental/Investigational
Decision: Upheld

A 50-year-old female enrollee has requested a PET scan for an evaluation of her Parkinsons disease. Findings:  Three physician reviewers found that this patient has been diagnosed with idiopathic Parkinsons disease. The records indicate that she does not respond to L-Dopa and ropinirole. The use of an F-DOPA PET to evaluate this patient is unlikely to alter the usual therapy of a patient with a Parkinsonian syndrome as there is no difference in the treatments, just a difference in the patients response to those treatments. Since the result of such a test would not change treatment, and as the technology remains unproven in this setting, the requested F-DOPA PET is not likely to be superior to other diagnostic modalities in this setting.
Appeal type: Experimental/Investigational
Decision: Upheld

A 40-year-old female enrollee has requested reimbursement for the bilateral ophthalmic dx image anterior tomography (anterior segment optical coherence tomography) for evaluation of the enrollees keratoconus.  Findings:  Three physician reviewers found that the patient was diagnosed with keratoconus by her in-network ophthalmologist. She was subsequently seen by an out-of-network ophthalmologist for additional consultation. Anterior optical coherence topography was provided as one of the services by the consultant.  The patients best corrected visual acuity was 20/30+ in the right eye and 20/20 in the left eye. There is no indication in the medical record of spectacle correction or contact lens use. There is no mention of intolerance to contact lenses, corneal edema, or scarring. The patient has requested reimbursement for the bilateral anterior optical coherence tomography (OCT) performed during a consultation. The patient was seen by an out-of-network consultant without prior authorization for the visit. Anterior segment OCT has not been demonstrated to provide any additional critical information that is not already available with standard clinical testing for keratoconus (Am Acad of Ophthal, 2007; and Li, et al.).  As anterior segment OCT does not provide additional information, the testing at issue was not likely to be more beneficial for evaluation of the patients medical condition than standard testing.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a 17-year-old female enrollee requested authorization and coverage of accutane for the treatment of acne.  The health plan denied the enrollees request indicating that the requested medication is not medically necessary.One physician reviewer performed a medical necessity Independent Medical Review.  The physician reviewer overturned the health plans denial on the basis that the requested medication is medically necessary.
Appeal type: Medical Necessity
Decision: Overturned

A 34-year-old female enrollee has requested for Gilenya 0.5mg capsules for treatment of her multiple sclerosis. Findings:  The physician reviewer found that this patient has multiple sclerosis, and she has been on disease-modifying therapy with Betaseron or Rebif.  When she has discontinued disease-modifying treatment, she has had exacerbations. In general, patients prefer oral treatments and are more likely to be compliant with oral treatments when compared to injectable therapies.  Gilenya has been studied and found to be as effective as oral therapy. All told, Gilenya 0.5mg capsules are medically indicated for the treatment of this patient.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for left occipital radiofrequency ablation (RFA). Findings:  The physician reviewer found that the peer-reviewed medical literature, Urits and colleagues compared treatment options for occipital neuralgia. The authors found that RFA, peripheral nerve stimulation and surgical management have proven to have varying degrees of efficacy; however, they do demonstrate the potential benefits of decreased recurrence, increased functionality and overall improvement compared with conservative treatments. Hoffman and colleagues analyzed pain reduction in 39 patients treated for occipital neuralgia with radiofrequency ablation using the visual analog scale (VAS). The authors reported findings supporting that radiofrequency is effective at reducing pain scores for six months in patients with occipital neuralgia. In this case, the patient has chronic left-sided occipital neuralgia that has failed to respond to conservative care including medication management using non-steroidal anti-inflammatory drugs (NSAIDs), baclofen, gabapentin, and tricyclic medications. The records show that the patient has responded well to occipital nerve blocks and pulsed RFA treatments with improvement of symptoms for a meaningful duration up to three months. Given these findings, the requested left occipital RFA 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 left occipital RFA 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 reviewers 1, 2, and 3 are board certified in anesthesiology with subspecialty certification in pain management 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: Experimental/Investigational
Decision: Overturned

A 50-year-old male enrollee has requested right hip resurfacing arthroplasty utilizing the Conserve Plus device for the treatment of his osteoarthritis of the right hip. Findings:  Two physician reviewers found that the enrollee is relatively young with a previously active lifestyle. The record documents that the patient has a low head/neck ratio and the Conserve Plus is the only device available in 2mm increments. The Conserve Plus hip resurfacing device is in clinical trial under FDA supervision and is classified as a category B1 device. Considering all of the clinical aspects, the Conserve Plus appears to be the most appropriate device for this patient.