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

The parent of a 10-year-old male enrollee has requested for continued acute inpatient psychiatric treatment for treatment of the enrollees major depressive disorder.  Findings:  The physician reviewer found that the patients ability to engage in treatment has also been limited by his tendency to withdraw and express conflict with his providers. Given these dimensions, transition to treatment in a residential setting with 24-hour monitoring is indicated following discharge from his current acute level of care. This finding is consistent with Child and Adolescent Level of Care Utilization System (CALOCUS) guidelines. Treatment at a level of care that does not include 24-monitoring has been attempted without success, and at this juncture, is likely lead to further deterioration. Therefore, the requested discharge to residential level of care is also clinically reasonable.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for Gelsyn-3 injections to the left knee. 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. 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 patients options were limited. She was unable to take cortisone injections due to cardiac complications and had tried and failed physical therapy, restriction of activities, and NSAIDs. Therefore, Gelsyn-3 injections to the left knee were medically necessary for the 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 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:  An enrollee has requested sofosbuvir and simeprevir for treatment of his hepatitis C virus.  Two physician reviewers found that according to the American Association for the Study of Liver Diseases (AASLD) and Infectious Diseases Society of America (IDSA) guidelines, all patients with chronic active hepatitis C should be treated, except those with limited life expectancy less than 12 months due to non-liver-related comorbid conditions. The AASLD/IDSA guidelines recommend treatment with sofosbuvir and simeprevir for 12 weeks in genotype 1b hepatitis C patients without cirrhosis, as a Class I, Level A recommendation. This is based on the U.S. Food and Drug Administration (FDA) approval and multiple studies, which have confirmed its safety and efficacy. Additionally, treatment of patients before they progress to cirrhosis is advantageous. Based on evidence of safety and efficacy in the published literature, and clinical guidelines, sofosbuvir and simeprevir are medically necessary in this patients case. Final Result: Two reviewers determined that the requested medications are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.  Credentials/Qualifications:  One reviewer is board certified in gastroenterology and is actively practicing.  Two reviewers are board certified in internal medicine with sub-specialty certification in gastroenterology 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: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for IVIG for a course of five days. Per researchers, MFS is an extraordinarily rare condition, and recurrence of MFS is rarer still. There are no established guidelines or protocols for treatment of recurrent MFS, but additional IVIG therapy would seem reasonable if presentation of symptoms were to persist or recur. In this case, however, the ophthalmologists report indicates that the patient is improving. There is also no documentation of a recent neurological exam that would confirm recurrence/persistence of symptoms. Therefore, additional IVIG therapy is not medically necessary for this patient at this time.Final Result: The reviewer determined that the requested service 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 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: Experimental/Investigational
Decision: Upheld

A 47-year-old female enrollee has requested a wireless capsule endoscopy for evaluation of her gastrointestinal symptoms. Findings:  Three physician reviewers found that there is no documentation included for review that supports the use of a wireless capsule endoscopy in this case. The records provided do not support a diagnosis of gastroparesis and would not alone provide a basis for the diagnostic procedure at issue. The patients upper GI studies identified only reactive gastropathy, which is likely reflective of her use of prednisone. In general, wireless capsule endoscopy is reserved for use only in patients with obscure GI bleeding, inflammatory bowel disease, small bowel tumors, and refractory malabsorption. None of these factors are present in the instant case based on the medical records provided. The clinical value of wireless capsule endoscopy has not been established in this particular setting.
Appeal type: Medical Necessity
Decision: Upheld

A male enrollee requested vasectomy reversal surgery for medical treatment  of his condition. Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested services.  The medical records noted orchialgia and physical examination revealed diffuse scrotal tenderness.  Post vasectomy orchialgia is a possible complication following bilateral vasectomy.  However, it is rare for this pain to be bilateral and is usually secondary to a sperm granuloma at the excision site.  Per the current medical evidence, vasectomy reversal does not consistently resolve the pain.  All told, the requested vasectomy reversal surgery is not medically indicated for the treatment of this patient.
Appeal type: Urgent Care
Decision: Upheld

A male enrollee requested emergency room medical services on an emergent basis.  Findings:  The physician reviewer found that review of the submitted clinical documentation demonstrates that a prudent layperson would not have sought immediate medical attention. According to the documentation submitted for review, there was no wheezing and no apparent threat to normal bodily function. There was no significant pain and no sign of systemic allergic reaction.  All told, the patients symptoms would not lead a prudent layperson to believe their health to be in imminent danger. In sum, the patients symptoms did not meet prudent layperson criteria for emergency care.
Appeal type: Experimental/Investigational
Decision: Overturned

A 59-year-old female enrollee requested authorization and coverage of Lap-Band surgery. The Health Plan denied the request indicating that the requested surgery is considered experimental for treatment of the enrollees obesity.Three physician reviewers performed an experimental/investigational Independent Medical Review. Two of the physician reviewers concluded that the requested procedure is likely to be more beneficial for the treatment of the enrollee's medical condition than any available standard therapy. One of the physician reviewers concluded that the requested procedure is not likely to be more beneficial for the treatment of the enrollee's medical condition than any available standard therapy. Because two of the three  physician reviewers concluded that the requested therapy is likely to be more beneficial for the treatment of the enrollee's medical condition than any available standard therapy, the Health Plans denial has been overturned.
Appeal type: Medical Necessity
Decision: Overturned

The patient is a 45-year-old male who underwent an ACL reconstruction. Postoperatively he utilized a CPM device as prescribed by his orthopedic surgeon.  He is requesting reimbursement for the rental cost of the device. The Health Plan denied coverage based upon their determination that the CPM device was not medically necessary following the patients surgery. A CPM device is commonly prescribed by surgeons for postoperative rehabilitation following ACL reconstruction. Patient compliance is generally good and many surgeons find that patients regain their range of motion faster and have better pain control with the device.  Physical therapy cannot usually be started immediately after surgery secondary to postoperative pain. The orthopedic community has recognized the benefit of early range of motion following this type of surgery and the use of the device for 12 to 14 days postoperatively is medically appropriate. Therefore, I have determined the device at issue was medically necessary for treatment of the patients medical condition. The Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Overturned

This case concerns a 12-year-old girl with idiopathic short stature. Her mid parental height was 160 cm (63 inches). Her recent bone age was 10 years giving her an adult height prediction in the range of 5.05 to 51.5. Recent height velocity is 3 cm per year. The patient had a workup for other causes of short stature demonstrating normal TSH, IGFBP-3 and IGF-1 levels and a normal karyotype. She was said to be beginning pubertal development. A request has been made for authorization and coverage for growth hormone therapy. The Health Plan has denied this request on the basis it is not medically necessary for treatment of the patients condition.The literature cited documents the efficacy of growth hormone therapy for children with short stature. These findings led to the FDAs ruling in July of 2003 that growth hormone therapy was indicated when a childs height is 2.23 standard deviations below the mean and that child would be judged unable to achieve a normal adult height.  In this case, the patients height prediction places her in the low-normal adult range for women but shorter than her potential height. The studies cited supersede the Lawson-Wilkins guidelines of 2003 and document that adult height can be safely advanced in idiopathic short stature (ISS). A growth hormone trial is medically reasonable and appropriate in this instance.Based upon the information set forth above, I have determined that the requested therapy is medically necessary for treatment of the patients medical condition. The Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Overturned

The wife of a now deceased male enrollee has requested an extension of the skilled nursing facility (SNF) stay for physical and occupational therapy services for the treatment of the enrollees acute renal failure and multiple myeloma. Findings:  The physician reviewer found that the patient was functionally impaired on admission to the SNF. The skilled care he needed was to restore function. Skilled rehabilitation services are appropriate for patients with the functional capacity to participate and benefit from the services. Dialysis patients certainly can benefit as this patient demonstrated. Functional capacity, not diagnosis, determines benefit. Clearly, the patient progressed in a clinically appropriate and expected manner.  The services were ordered appropriately and provided appropriately. The skilled rehabilitation services were best provided on an inpatient basis.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary:   An enrollee has requested transcatheter closure of patent foramen ovale for treatment of her medical condition.  Findings:  Two physician reviewers found that there is sufficient support for transcatheter closure of patent foramen ovale in this clinical setting.   Per the medical literature, the requested services are beneficial in the prevention of recurrent neurologic events.  The records document that this patient is intolerant to standard medical therapy.  In this patients case, the requested transcatheter closure of patent foramen ovale is likely to be more effective than other treatment alternatives.  Final Result: Two 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:  All three reviewers are board certified in internal medicine with sub-specialty certification in cardiovascular disease 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: Medical Necessity
Decision: Upheld

A 54-year-old female enrollee has requested aquatic-based physical therapy (PT) from a non-contracted provider for the treatment of her knee status post total knee arthroplasty. Findings:  The physician reviewer found that although aquatic therapy is certainly a choice of modality for treatment, there is no proven benefit over land-based PT in the treatment of osteoarthritis of the knee/hip. The study by Wyatt and colleagues found that both aquatic and land-based exercise programs were beneficial for osteoarthritis. Bartels and colleagues review of several studies for aquatic exercise for knee and hip osteoarthritis determined that the available studies were not conclusive to recommend aquatic therapy over land-based therapy. This reviewer did not find any published randomized, controlled trials comparing the effects of land-based versus aquatic PT for patients following TKA. Ulrich and colleagues study regarding focused rehabilitation treatment of poorly functioning TKA recommends various rehabilitation techniques, but they do not include aquatic therapy. Based on the totality of the available evidence, aquatic therapy following TKA has no proven benefit over land-based PT. Here, although this patient had improvement in ROM, aquatic therapy is not proven to be superior to traditional (i.e., land-based) physical therapy. The gains may have been made had the patient continued land-based therapy.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for neurofeedback three times per week, eye movement desensitization and reprocessing (EMDR) twice per week and one on one psychiatric therapy for treatment of the enrollees brain injury. Findings:  The physician reviewer found that The use of neurofeedback and EMDR are beneficial and medically appropriate in patients who have a history of neurological and psychiatric complications. There is notable evidence in the literature which suggests that neurofeedback and EMDR are effective for treatment of patients who are diagnosed with PTSD. Moreover, neurofeedback and EMDR are an appropriate non-invasive alternative for treatment of a wide range of neuropsychiatric disorders.  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 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

Nature of Statutory Criteria/Case Summary:  An enrollee has requested right ventriculoperitoneal shunt placement with laparoscopic placement of peritoneal catheter for treatment of her hydrocephalus.   The physician reviewer found that the submitted documentation supports the medical necessity of the requested services.  This patient has Down syndrome and worsening hydrocephalus.  Per the records, a recent computed tomography (CT) scan demonstrated worsening hydrocephalus.  The patient has been declining neurologically at the same time that her hydrocephalus is radiologically worsening.  She has had a trial of lumbar puncture with clinical improvement.  The current medical evidence supports the requested services in this clinical setting.  All told, the requested right ventriculoperitoneal shunt placement with laparoscopic placement of peritoneal catheter is medically indicated 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 neurological 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

A 59-year-old female enrollee has requested hormone replacement therapy with pellet implants for treatment of her transgender hormone therapy.  Findings:  Three physician reviewers found the submitted clinical documentation reveals the patient has received hormone replacement therapy with pellet implants in the past. Her estrogen level while receiving implantable estradiol pellets was excessively high. There are significant potential risks associated with pellet implants. The increased estrogen dose administered via implantable pellet therapy is not likely to provide this patient with an improved health outcome over treatment with a lower dose of estrogen. All told, the requested hormone replacement therapy with pellet implants is not supported as likely to be more beneficial for treatment of this patients medical condition than standard available therapies.
Appeal type: Medical Necessity
Decision: Overturned

The patient is a 21-year-old woman with chronic migraine headaches with a recent worsening in her headache pattern. Her primary care physician, an internist, ordered an MRI and an MRA of the brain, which were both performed.  The studies were normal and there is no information about the current status of the patient.  The Health Plan determined the MRA was not medically necessary and has denied coverage.The patient had a recent change in her headache pattern, with progression to daily headaches. An imaging study is standard of care in these situations, with MRI being the preferred study. MRA is also a reasonable study in patients with new chronic daily headache, specifically to look for aneurysm.  There are no standard published guidelines that address the utility of MRA in the evaluation of chronic headache. However, MRA does have a role in the evaluation of chronic headache as many headache specialists, if not the majority, utilize MRA for diagnostic evaluation for patients with a recent change in their headache pattern. Given the patients clinical condition at the time, an MRA was medically reasonable and appropriate.Based upon the information set forth above, I have determined the diagnostic procedure at issue was medically necessary for evaluation of the patients medical condition. The Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Taltz. Findings:  The physician reviewer found that U.S. Food and Drug Administration (FDA) approves the use of Taltz (ixekizumab), a humanized interleukin-17A antagonist, for the treatment of adults with moderate to severe plaque psoriasis. In a comparison of ixekizumab with etanercept or placebo in the treatment of moderate to severe psoriasis, Griffiths and colleagues noted that in two studies, ixekizumab dose regimens had greater efficacy than placebo and etanercept over 12 weeks. Menter and colleagues noted that the American Academy of Dermatology (AAD) and National Psoriasis Foundation (NPF) guidelines on the management and treatment of psoriasis with biologics recommend ixekizumab as a monotherapy treatment option in adult patients with erythrodermic psoriasis. In this case, the patient has erythrodermic psoriasis and has tried and failed other medications. The documentation reflects that the patient reported significant improvement of his symptoms with Taltz. Given the current medical literature and the providers recommendation that this patient continue treatment with Taltz, the requested medication is medically indicated. Therefore, Taltz is medically necessary for the 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 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 34-year-old female has requested a cold therapy unit for her postoperative rehabilitation. Findings:  The physician reviewer found that postoperative cold therapy is utilized by some orthopedists for managing pain and inflammation. However, use of cold therapy units has not been shown in long-term peer-reviewed literature to offer superiority over the traditional use of ice. The units studied have not been proven to significantly lower the intra-articular temperature of the knee. There is no study literature indicating that use of this device itself would decrease a patients hospital stay or shorten the rehabilitation period.  Appropriate monitoring of the application of ice packs eliminates the concern for skin or tissue break down.