Persius/imr-appeals huggingface dataset:
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for advanced lipoprotein testing performed for evaluation of his coronary heart disease (CAD). Findings:  Three physician reviewers found that in this circumstance, prevention guidelines for the management of cardiac risk and dyslipidemia have been established. These guidelines are periodically updated by expert committees and are endorsed by several national organizations. These guidelines currently do not recommend routine performance of specialized tests in the context of assessing coronary risk including lipoprotein-associated phospholipase A2 (Lp-PLA2), sub-classifications of low density lipoprotein (LDL), high density lipoprotein (HDL) subclasses, lipoprotein(a), C-reactive protein (CRP), high sensitivity CRP, insulin, fibrinogen, genetic testing and homocysteine. Treatment change or addition based on the results of screening with these specialized tests has not been shown to improve cardiac outcome incremental to that achievable by treatment based on standard risk factor profiling and basic lipid analysis. Even though results of some of these specialized tests may be abnormal and considered independent risk markers for coronary disease, there are a lack of controlled trials that demonstrate outcome benefits by treating routinely obtained abnormal results. Credentials/Qualifications: Reviewers 1, 2, and 3 was board certified in internal medicine with sub-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: Overturned

Nature of Statutory Criteria/Case Summary: A patient has requested authorization and coverage for Orthovisc injection series in the right knee.Findings: An exhaustive review of the current medical literature pertaining to viscosupplementation reveals mixed results. Evidence from eight systematic reviews and six randomized controlled trials indicates that although viscosupplementation may relieve knee pain in some individuals with osteoarthritis, it is not known as to which individuals will benefit. Different studies have tried mixing hyaluronic acid with corticosteroids, platelet rich plasma, and other agents to make it more effective. The current evidence is limited, and guidelines from organizations such as the American Academy of Orthopedic Surgeons indicate that the evidence is not conclusive. In light of the foregoing, viscosupplementation can only be recommended in individuals with a history of lasting benefit from prior injections, and in carefully selected cases where everything else has been tried, and the options are limited. In this case, the patient has a history of lasting benefit from prior viscosupplementation. Furthermore, the patients options are limited. The patient has tried and failed other conservative treatments, with the alternative being a total knee arthroplasty. Therefore, the requested Orthovisc injection series in the right knee is medically necessary for treatment of the patients medical condition.Final Result: The reviewer determined that the requested service is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.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: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for HP Acthar Gel. Findings:  Two out of three physician reviewers found that HP Acthar Gel is not likely to be more beneficial than any other available standard treatments for the patients medical condition. There are several studies reviewing the use of Acthar or repository corticotropin injection (RCI) for the treatment of rheumatological disease. One study performed a retrospective review and concluded that RCI may improve disease control and warrants further evaluation. Another study, involving four patients, found that their results were encouraging and suggested that randomized, controlled clinical trials applying RCI to dermatomyositis and polymyositis were warranted. Another recent retrospective case series showed improvement with Acthar in five patients with refractory dermatomyositis (DM) or polymyositis (PM). This study is small, however, and larger studies are needed. Although there is literature to show possible efficacy of Acthar in refractory myositis, these studies are small. There is no randomized controlled trial (RCT) demonstrating the efficacy of Acthar in the treatment of refractory myositis. The current literature supports the use of rituximab in cases of resistant myositis. In this case, the patient was diagnosed with statin induced myopathy mimicking PM. His statin was stopped with initial improvement in symptoms. There is no history of other more first line immunosuppressive agents reflected in the submitted documentation. The submitted records fail to demonstrate that the patient is resistant to more standard first line therapy. Under these circumstances, HP Acthar Gel is not likely to be more beneficial than any other available standard treatments for the patients medical condition.Final Result: The reviewers determined that the requested medication is not likely to be more beneficial than any other available standard treatments for this patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: Physician reviewer 1 is board certified in internal medicine and allergy and immunology, with subspecialty certification in rheumatology, and is actively practicing. Physician reviewer 2 is board certified in internal medicine and allergy and immunology, and is actively practicing. Physician reviewer 3 is board certified in internal medicine, with subspecialty certification in rheumatology, and is actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the gene test (BRCA testing) Findings:  The physician reviewer found that this patient is a candidate for risk assessment and genetic testing. The patient is of Ashkenazi ancestry and has a first degree relative with cancer. BRCA1 mutation can increase risk for breast, ovarian, cervical, uterine, pancreatic, gastric, and prostate cancers. BRCA2 mutations can increase risk for breast, ovarian, pancreatic and gastric cancers (Tai, et al; Ferrone, et al). In the event the BRCA tests were negative, there is still a possibility of hereditary predisposition from another gene defect. Given this patients indication for testing, the gene test (BRCA testing) was likely to have been more beneficial for evaluation of this patients medical condition than standard available testing. Findings:  Three physician reviewers found the gene test (BRCA testing) was likely to have been more beneficial for evaluation of this patients medical condition than standard available testing.Final Result: The reviewers determined that the gene test (BRCA testing) was likely to have been more beneficial for evaluation of this patients medical condition than standard available testing.Credentials/Qualifications: Physician reviewers 1 and 2 are board certified in internal medicine with subspecialty certifications in medical oncology and hematology and are actively practicing. Physician reviewer 3 is board certified in internal medicine with subspecialty certification in medical oncology 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 patient has requested authorization and coverage for EBI Electric Bone Growth Stimulator (HCPCS Code E0748). This patient has a history of cervical myelopathy. She underwent C4-7 anterior cervical discectomy and fusion. Operative findings documented severe central stenosis due to disc osteophyte complex, as well as cervical kyphosis and degenerative disc disease. The patients provider recommended an EBI electric bone growth stimulator. Researchers concluded that there was moderate quality evidence supporting the use of post-operative electrical stimulation as an adjunct to spinal fusion surgery. The authors found that patients treated with electrical stimulation have significantly greater rates of successful fusion. Overall, the evidence based medical literature supports the use of bone growth stimulator as safe and effective for patients undergoing multiple cervical or spinal fusion procedures. Given the operative findings and multilevel fusion, the requested EBI Electric Bone Growth Stimulator (HCPCS Code E0748) is medically necessary for treatment of this patient.   Final Result: The reviewer determined that the requested device 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: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested for immunoglobulin G (IgG) 1, 2, 3 or 4 testing performed for evaluation of the enrollee, who had an elevated immunoglobulin A (IgA).Findings: The three physician reviewers found that patients are often referred to immunologists for the evaluation of reduced serum IgG levels. The presence of low IgG level may indicate early signs of humoral deficiencies, which are the most common of the primary immune defects. Early detection of humoral immunity defects in these patients is valuable. In this patients case, she presented with a reduced level of total IgG. The provider evaluated the patient for the presence of impaired immunologic function based on this laboratory finding by conducting a repeated IgG total level as well as IgG subclasses.  Per the medical evidence, the services at issue were an important step to evaluate or rule out primary or secondary immunodeficiency.  Therefore, IgG 1, 2, 3 or 4 testing performed was likely to have been more beneficial than other methods of evaluating this patient. Final Result: The reviewers determined that the services at issue were likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: All three physician reviewers are board certified in allergy and immunology and are actively practicing. The reviewer 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

The parents of a six-year-old male enrollee requested authorization and coverage of ongoing treatment with EEG biofeedback therapy. The Health Plan denied the request indicating that the requested therapy is considered experimental for treatment of the enrollees behavioral health problems.Three physician reviewers performed an experimental/investigational Independent Medical Review. All three physician reviewers concluded that the requested therapy is not likely to be more beneficial for treatment of the enrollees medical condition than any available standard therapy. Because all three physician reviewers concluded that the requested therapy is not likely to be more beneficial for treatment of the enrollees medical condition than any available standard therapy, the Health Plans denial has been upheld.
Appeal type: Medical Necessity
Decision: Upheld

A male enrollee requested scleral contact lens for the left eye for medical treatment of his irregular astigmatism.  Findings:  The physician reviewer found that the fitting of a scleral contact lens for the left eye is not indicated for this patients medical condition. From the clinical notes provided for review, the patient is already wearing a gas permeable contact lens with vision correction to 20/20 in the left eye. The current medical literature describes the fitting of scleral contact lenses in cases in which a pathologic diagnosis is noted such as the corneal ectasia that this patient has in the right eye. Given the absence of evidence supporting a diagnosis of corneal ectasia in the left eye, the requested scleral contact lens for the left eye is not medically necessary.
Appeal type: Medical Necessity
Decision: Upheld

A 37-year-old female enrollee has requested surgery to remove excess skin on her bilateral medial and anterior thighs for the treatment of her bilateral leg pain. Findings:  The physician reviewer found that this patient has redundant thigh tissue, but has already had thigh lift surgery.  Her primary complaint is thigh pain, and the surgeon notes that he has not previously performed thighplasties for pain reduction.  The medical literature provides no evidence that thigh lift surgery is an appropriate treatment for thigh pain, and even if this were the case, the patient has already had thigh lift surgery.  The physicians exam shows well-healed, non-painful thigh scars and no focal areas of tenderness along the thigh muscles.  Thigh lift surgery is cosmetic.  Her redundant thigh skin is not an abnormal structure of the body, and the requested surgery will not improve function. The surgery will primarily improve appearance and is cosmetic.  She has extra thigh skin, but the extra skin is not abnormal in any way.
Appeal type: Medical Necessity
Decision: Upheld

A 52-year-old female enrollee has requested 5 Supartz injections for treatment of her suspected meniscal tear in the left knee.  Findings:  The physician reviewer found that viscosupplementation for the treatment of osteoarthritis of the knee is an accepted procedure in mild to moderate cases (Brzusek and Petron). To date, no superiority has been shown among the various products (Dagenais). Viscosupplementation is not considered a treatment for a torn meniscus, although it is being studied as a potential technique for reducing pain after meniscectomy in current clinical trials. In the case of this patient, the diagnosis of symptomatic osteoarthritis of the knee is not documented; the provider only commented that the degenerative process was starting at the time Supartz was initiated. In addition, there is no documentation of any other treatment for osteoarthritis, such as anti-inflammatory medications, having been attempted. Further, there is no documentation of the use of the Plans preferred medications prior to the use of Supartz. For these reasons, the Health Plans denial was appropriate.
Appeal type: Medical Necessity
Decision: Upheld

A 58-year-old male enrollee has requested a discogram (both physician fee and hospital charge) for an evaluation of his chronic low back pain. Findings:  The physician reviewer found that the patient had a previous discography which demonstrated concordant pain at all levels.  It is not clear through these medical records, the benefit which would be gained by repeating a discogram, which previously was inconclusive in substantiating a specific level of involvement.  An MRI also demonstrates multilevel degenerative disc disease.  One would question the need for discography in light of this MRI finding and in light of the fact that this is a postsurgical spine.  Based on the medical records, discography is not medically indicated and necessary. It should be noted that conservative measures have not been clearly documented in the medical records, but those should be exhausted before undergoing diagnostic intervention such as an MRI.  It is not clear that these have been done recently.
Appeal type: Medical Necessity
Decision: Overturned

A female enrollee requested a wearable cardioverter defibrillator for medical treatment of her medical condition. Findings:  The physician reviewer found that the patient sustained a cardiac arrest due to ventricular fibrillation in the setting of infection.  The patients active infection precluded immediate defibrillator device implantation.  Therefore, the use of a wearable cardioverter/defibrillator was indicated until the patients infection was completely cured and an implantable defibrillator could be scheduled.  All told, the wearable cardioverter defibrillator was medically indicated for the treatment of this patient.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested prospective authorization and coverage for ablation and Atria without bypass for treatment of his history of atrial fibrillation.Findings: Three physician reviewers found that the Society of Thoracic Surgeons 2017 guidelines summary states the following, In the treatment of atrial fibrillation (AF), multidisciplinary heart team assessment, treatment planning, and long term follow up can be useful and beneficial to optimize outcomes (class 1, Level C expert opinion). Surgical ablation for symptomatic AF in the absence of heart disease that is refractory to class I/3 antiarrhythmic drugs or catheter based therapy is reasonable as a primary stand-alone procedure (class 2A, Level B randomized). Surgical ablation for symptomatic persistent AF is reasonable stand-alone using full lesion set compared to pulmonary vein isolation alone (class 2A, level 3 nonrandomized). As such, it is the consensus of the 2017 international experts in cardiology and thoracic surgery that stand alone AF surgery should be considered for the symptomatic AF patients who prefer a surgical approach or have failed one or more attempts at catheter ablation, such as in this patients case. This patient has had a longstanding history of AF and failed therapies. Therefore, this patient is a good candidate for the requested procedure. In sum, ablation and Atria without bypass is likely to be more effective than the other standard modalities for treatment of this patient. Final Result: The three reviewers determined that the services at issue were likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: All three physician reviewers are board certified in thoracic surgery and are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

The father of a 14-year-old female enrollee has requested for Humatrope growth hormone for treatment of the enrollees short stature.    Findings:  The physician reviewer found that the patient does not meet the clinical definition for pathologic short stature.  Her height is in the 7th percentile, which is not the -2.25 standard deviations indicated for growth hormone use.  In addition, given her normal bone age, she is likely to have familial short stature. Furthermore, there are no lab abnormalities.  Also, there is no note of her Tanner stage, but with menarche at age 11, she is very likely Tanner V with closed epiphyses.  Closed epiphyses are a contraindication for use of growth hormone.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for residential treatment center (RTC) services.  Applying ASAM guidelines, this patient was at significant risk for relapse and withdrawal without medication-assisted treatment. This patient was at an increased risk given his preference to use fentanyl. The records noted that he continued to receive supportive medications for post-acute withdrawal such as Imodium and Robaxin. The patient has biomedical conditions including obesity, poorly controlled diabetes mellitus, and obstructive sleep apnea (OSA). He was at increased risk of overdose if he resumed opioid use after discontinuation. The patients mental status was sufficient to permit participation and he was unable to control his substance use without 24-hour support. Prior treatment has included at least two treatment admissions with supervised withdrawal and RTC level of care treatment. The patient demonstrated limited insight and awareness into his need for continued care. He remained at high risk for relapse as he was in imminent danger of relapse due to a crisis. The patient endorsed high cravings and multiple psychosocial stressors including the sudden death of his father and his close friend. The patients cravings, prior treatment failures, and acute stressors of losing his father and close friend support that he was in imminent danger of relapse. The patients recovery environment was too chaotic to support the patients treatment goals. The records establish that the patient required structured therapy and 24-hour milieu during the period under review. All told, the RTC 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.