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

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Monovisc injection in both knees. Evidence from systematic reviews and randomized controlled trials indicate that although viscosupplementation may relieve knee pain in some patients with osteoarthritis, data has not established which patients will benefit. Guidelines from the American Academy of Orthopedic Surgeons (AAOS) indicate that the data on safety and efficacy of viscosupplementation remain inconclusive. As such, the AAOS does not currently recommend viscosupplementation as routine treatment for osteoarthritis of the knees. Viscosupplementation is reserved for patients with a history of lasting benefit from prior injections and in cases where the remaining options are limited. In this case, the patient has a history of lasting benefit from viscosupplementation with Orthovisc injections of both knees in February 2019 that has been well documented. Physical therapy and home exercises have not reportedly been effective. The patients remaining treatment options are limited, and she has obtained relief from prior viscosupplementation injections in the past. For these reasons, the requested Monovisc injection in both knees is 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 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

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for physical therapy. The Health Plan denied the request and reported the requested services are not medically necessary for the treatment of this patient. At issue in this case is whether physical therapy is medically necessary for the treatment of this patient. The American Physical Therapy Association reports that the initial patient evaluation should support the need for physical therapy. The physical therapist should reexamine the patient as necessary to evaluate progress or change in patients status, and the provider may modify the plan of care accordingly or conclude the episode of care. The physical therapist should conclude an episode of care when the anticipated goals or expected outcomes for the patient have been achieved, when the patient is unable to continue to progress toward goals, or when the physical therapist determines that the patient will no longer benefit from physical therapy. In this case, the medical records do not reveal the patient has deficits that require continued skilled physical therapy. The medical records also do not show that prior skilled physical therapy has led to significant objective functional improvement. The patient was noted to be independent in a home exercise program, and the patient did not require further physical therapy sessions. The medical evidence does not support the requested services in this clinical setting. Therefore, physical therapy is not medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested services 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 physical medicine and rehabilitation 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 authorization and coverage for Synvisc injections in both knees. Per the medical literature, although viscosupplementation may relieve knee pain in some individuals with osteoarthritis, it is not known as to which individuals will benefit. 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 tried and failed other conservative treatments, including corticosteroid injections, with the alternative being bilateral total knee arthroplasties in the presence of moderate osteoarthritis at a relatively young age. Given the patients limited options and based on the current medical literature, the requested services are medically indicated. Therefore, Synvisc injections in both knees 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

The patient is a 45-year-old male with at least a 3.5-year history of intermittent chest pain. The patient was evaluated by a cardiologist in July 2001. He was seen in March 2004 for left chest pain and the clinical impression at that time was costochondritis. A left rib series was reported to be negative. On 9/3/04, the patient returned with low back pain and a painful lump in the lower left ribs. The plan for the rib abnormality was observation. The patient was again seen on 9/13/04 for left-sided chest pain. Follow-up stress test and CT scan of the chest were ordered. There is a past history of gastroesophageal reflux with a fundoplasty in 2000. At issue is whether a CT scan of the chest is medically necessary. Based upon the clinical evidence provided, a CT scan of the chest is not clinically indicated at this time. The plan for the mass in the area of the left lower ribs was observational with a CT to be obtained if there was an increase in the size of the mass. The report from the clinical exam dated 9/13/04 did not mention a mass. The patients recurrent chest pain requires further evaluation. A chest x-ray and cardiology consult are more medically appropriate and likely to be of greater value than a CT scan. Therefore, I have determined that the requested CT scan is not medically necessary for evaluation of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for transcranial magnetic stimulation. Findings:  Two of the three physician reviewers found that the submitted documentation supports the requested services in this patients case. One study reported in a multicenter prospective trial that the use of single pulse transcranial magnetic stimulation has a beneficial effect in reducing the number of headache days and headache intensity for patients with migraine headaches. Other medical literature stated that transcranial magnetic stimulation was an effective treatment for migraine. The study noted that this treatment modality had the added advantages of being safe and well-tolerated by patients. The use of single pulse transcranial magnetic stimulation is likely to be beneficial in this clinical setting. This patient has experienced reduced frequency and intensity of migraine headaches with transcranial magnetic stimulation. Thus, transcranial magnetic stimulation is likely to be of greater benefit than other treatment options.Final Result: The two of the three physician 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 neurology 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: An enrollee has requested authorization and coverage for Harvoni 90-400mg medication, one tablet daily, for 12 weeks. Findings:  The physician reviewer found that according to the recent joint guidelines issued by the American Association for the Study of Liver Diseases and the Infectious Diseases Society of America (AASLD/IDSA), all patients with chronic hepatitis C should be treated except those with limited life expectancy due to non-liver-related conditions. The guidelines recommend that all patients should be treated, regardless of fibrosis stage. The guidelines recommend that non-cirrhotic, treatment naive, genotype 1 patients should be treated with Harvoni for 12 weeks. These recommendations are based on multiple randomized clinical trials, and the medication is U.S. Food and Drug Administration approved for all patients with chronic hepatitis C genotype 1 regardless of fibrosis stage. AASLD/IDSA guidelines cite data showing reduced survival with delayed treatment. For these reasons, Harvoni 90-400mg medication, one tablet daily, for 12 weeks is supported as medically necessary for the treatment of this patients hepatitis C infection. 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 internal medicine with sub-specialty certification in gastroenterology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for transcatheter implantation of a permanent leadless pacemaker into the right ventricle. On review of the current peer-reviewed medical literature, there is a lack of support for the requested leadless pacemaker for treatment of this patients high-grade atrioventricular (AV) block in the presence of atrial fibrillation. Leadless cardiac pacing holds promise as a permanent cardiac pacing option for patients requiring single ventricle pacing and appears both safe and efficacious in the short-term. However long-term comparative trials are not available and remain to be determined. One study reported successful implantation on 96% of patients, which was less than conventional lead device placement, as well as significant side effects in 6.7% of patients at six-month follow-up. In addition, this patients tricuspid regurgitation is described as severe and is not likely to worsen with placement of a leaded system. All told, the requested transcatheter implantation of a permanent leadless pacemaker into the right ventricle is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Findings: Two of the three physician reviewers found the requested services are not 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 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: Physician reviewer 1 is board certified in internal medicine with subspecialty certification in cardiology and is actively practicing. Physician reviewer 2 is board certified in internal medicine with subspecialty certifications in cardiovascular disease and adult congenital heart disease and is actively practicing. Physician reviewer 3 is board certified in internal medicine with subspecialty certifications in cardiovascular disease and clinical cardiac electrophysiology 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

A 50-year-old female enrollee has requested substance abuse sub-acute residential services for treatment of her substance abuse.  Findings:  The physician reviewer found that applying the American Society of Addiction Medicine (ASAM) and American Psychiatric Association (APA) treatment guidelines, in order for a patient to require the RTC level of care with the 24-hour monitoring and supervision, a patient must exhibit psychiatric symptoms, dangerous, or self-destructive behaviors, that could not likely be safely and adequately managed at a less restrictive level of care. In addition, there must be evidence of major functional impairment in at least two domains such as work, school, activities of daily living (ADLs), family, interpersonal, or physical health. Further, the records should document the risks of the patient maintaining abstinence outside of a 24-hour structured setting. This patient does not meet the severity of illness criteria for the RTC level of care during the period under review. Specifically, she was not described as exhibiting any acute withdrawal or psychiatric symptoms which may have warranted treatment at the RTC level of care. Overall, the records demonstrate that her alcohol dependence issues could have been treated in a less restrictive setting. Beginning on the said date, the patient was appropriate for step-down to intensive outpatient program (IOP) services. For these reasons, this patient does not meet the intensity of service criteria for RTC services and the medical necessity of the services at issue has not been established in this case. As of the date in question, the medically necessary level of care for this patient was IOP.
Appeal type: Medical Necessity
Decision: Upheld

A 64-year-old female has requested coverage for past monitored anesthesia care during an esophagogastroduodenoscopy with biopsy.  Findings:  The physician reviewer found that moderate sedation is generally recommended and used for both diagnostic and uncomplicated therapeutic endoscopic procedures.  Moderate sedation involves the administration of medication with or without analgesia to achieve a state of depressed consciousness while maintaining the patients ability to respond to stimulation. For routine endoscopic procedures and screenings among patients without risk factors or significant medical conditions, moderate sedation, which can be administered by the endoscopist, is considered a sufficient level of sedation.Monitored anesthesia care is directly provided by anesthesia personnel.  Monitored anesthesia care may include varying levels of sedation, analgesics, and anxiolysis. Per the standards of the American Society of Anesthesiologists, monitored anesthesia care should be provided by qualified anesthesia personnel who must be present continuously to monitor the patient and provide anesthesia care.  The American College of Gastroenterology states that the use of deep sedation is medically necessary when there is documentation by the endoscopist and the anesthesiologist that specific risk factors or significant medical conditions are present.  Those risk factors or significant medical conditions include prolonged or therapeutic endoscopic procedures requiring deep sedation, increased risk for complications due to severe comorbidity, and history of anticipated intolerance to standard sedatives.  Additionally, patients 12 years of age or younger, patients 70 years of age or older, patients who are pregnant, patients with active medical problems related to drug or alcohol abuse, acutely agitated uncooperative patients and patients at increased risk for airway obstruction due to anatomic variation may require monitored anesthesia care.  In this patients case, there was no specific medical comorbidity that necessitated the use of monitored anesthesia care for the elective procedure. The patient was an acceptable and appropriate candidate for moderate sedation to be administered by the endoscopist.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for special portable ramps to be used in the bathroom for treatment of the enrollees stroke with left-sided hemiparesis. Findings:  The physician reviewer found that the request for special portable ramps to be used in the bathroom is not medically necessary for treatment of this patients medical condition. DME is defined as equipment that is used to treat or manage a disease, injury, or disability. This patients documentation does not reveal that a portable ramp will alter this patients disease, injury or disability. The therapy documentation reveals that patient has made significant progress and the caregivers are already independent in assisting the patient to transfer to the shower with use of a Hoyer lift and a new shower chair. A DME evaluation by a therapist deemed that an additional ramp would be a convenience item. The documentation does not reveal that a ramp is needed to enter the bathroom and the patient is currently able to transfer to the shower with caregiver support. The patients current method of entering the shower is described as safe. The provider that evaluated the home noted that the ramp was a convenience item rather than medically necessary. Final Result: The reviewer determined that the requested equipment 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 physical medicine and rehabilitation with sub-specialty certification in neuromuscular 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: Experimental/Investigational
Decision: Upheld

A 35-year-old female enrollee has requested uterine vein embolization for treatment of her pelvic congestion syndrome. Findings:  Two physician reviewers found that chronic pelvic pain is a common and disabling condition often affecting women of childbearing age. The condition may be caused by endometriosis, pelvic inflammatory disease, or referred pain. Pelvic congestion syndrome is a condition of chronic pelvic pain believed to be related to varices of the ovarian veins and can be of variable locations and intensity. Due to the variability of symptoms, diagnosis may be difficult. Treatment with vein embolization includes risks such as vessel injury, allergy, failure, and radiation exposure. Per the medical literature, the procedure is not supported by adequate scientific data as equivalent or superior to standard therapies. Overall, there is a paucity of studies demonstrating the long-term safety and efficacy of the procedure, especially compared to proven interventions. Therefore, the requested procedure is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested plasmapheresis for treatment of her medical condition.  Findings:  Two physician reviewers found that there is a lack of support for the services at issue in this clinical setting.  First-line treatment for this patients condition consists of systemic immunosuppression with systemic glucocorticoids with or without adjuvant immunosuppressive medications.  Per the medical evidence, patients who do not respond to first-line therapies may benefit from additional interventions.  Treatment regimens which include rituximab, cyclophosphamide, intravenous immunoglobulin, or plasmapheresis may lead to clinical improvement in these patients.  In this case, the documentation does not support that the patient has failed treatment with first-line therapies.  There is no documentation of refractory disease that would require alternative treatment with plasmapheresis.  Thus, plasmapheresis performed was not likely to have been more effective than other alternatives. Final Result: Two reviewers 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: One reviewer is board certified in internal medicine and is actively practicing.  Two reviewers are board certified in dermatology 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.