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

The enrollee is requesting authorization and coverage for an injection, Synvisc One, for the left knee. The enrollee has moderate left knee osteoarthritis. A magnetic resonance imaging (MRI) scan was ordered due to acute pain. The enrollee was status-post arthroscopic surgery and the documentation noted there was concern for another tear. The MRI results showed osteoarthritis with no new tears. His range of motion is restricted and painful. There is no effusion. There is medial femoral condyle tenderness. His patellar grind test is positive. There is no instability. The enrollee has received cortisone injections multiple times with good benefit in the beginning. However, they are no longer effective. The enrollee reported receiving less than one week of benefit from the last cortisone injection. He has received Synvisc One injections twice; one year ago and six months ago. The enrollee reported it had been beneficial. Now the pain has returned and the enrollees orthopedic surgeon is requesting approval of Synvisc One injections. According to the literature, viscosupplementation therapy is indicated for enrollees who suffer from symptomatic osteoarthritis and have not adequately responded to conservative, non-pharmacologic therapy and simple analgesics (e.g. acetaminophen). Some specialty societies do not recommend the use of hyaluronic acid injections in those with symptomatic osteoarthritis of the knee unless a clear and compelling rationale for an alternative approach is present. The documentation noted this enrollee had previously undergone multiple cortisone injections, as well as Synvisc injections.  This enrollee no longer receives benefit from corticosteroids. However, he has received approximately six months of pain relief with each hyaluronic acid injection.  He is an appropriate  candidate for Synvisc One injection as there is no documentation of end stage disease. Given the return of symptoms, the requested Synvisc One injection is medically necessary.Final Result: The reviewer determined that the requested service is medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The physician 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 similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Saxenda. A study describes liraglutide as a glucagon-like peptide 1 (GLP-1) receptor agonist that has emerged as an effective therapy for type 2 diabetes and obesity. The study further notes that as an adjunct to a reduced-calorie diet and increased physical activity, treatment with liraglutide 3.0 mg may provide statistically significant and clinically meaningful weight loss. The study notes that obesity treatment guidelines recommend the use of pharmacologic therapy in adults who have a BMI of 30 or higher. Given this patients history of obesity and that the patient has responded well to Saxenda, the requested medication is medically indicated. Therefore, Saxenda 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 internal medicine with sub-specialty certification in endocrinology, diabetes, and metabolism 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 55-year-old female enrollee has requested for percutaneous tibial nerve stimulation (PTNS) for treatment of her bladder dysfunction.   Findings:  Three physician reviewers found that the efficacy of PTNS remains unproven at this time. A review of the literature does not reveal validated studies showing this technique to be better than other standard treatments. While PTNS appears promising (a validated sham technique was recently published by Peters, et al.), the evidence currently available is not sufficient to demonstrate the superiority of PTNS over standard therapy, which does not appear to have been exhausted in this case. At this time, there is inadequate medical literature supporting the use of PTNS to treat this patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a 10-year-old female has requested 4 sessions per month of individual therapy and 2 sessions per month of family therapy for treatment of her mood disorder, not otherwise specified, and anxiety disorder, not otherwise specified.  Findings:  The physician reviewer found that current psychiatric practice is focused on the aggressive treatment of anxiety and depression, particularly in the acute phase of the illness, followed by less frequent services, and greater community involvement, in the maintenance phase to foster patient autonomy and recovery.  The current evidence suggests that a short-term increase in services can be effective at decompressing morbidity and improving functionality.  The modalities of both cognitive behavioral therapy and family therapy are trusted interventions in the treatment of mood disorders and anxiety in children and adolescents, and are well-supported by scientific evidence. In this patients case, considering that treatment gains have not been consolidated with the current plan of care, a 3-month course of 4 sessions of individual therapy per month (12 total sessions) and a 3-month course of 2 family therapy sessions per month (6 total sessions) are medically necessary. The patient should be evaluated at the end of the three-month period to determine if additional therapy beyond the three-month period is indicated. As such, a portion of the requested therapy is medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary:  The parent of an enrollee has requested occupational therapy (sensory integration therapy) for treatment of the enrollees medical condition.  Findings:  The physician reviewer found that the research around sensory integration therapy or sensory processing disorder is mixed.  There are methodologic flaws in some studies.  However, these methods have been used in schools with good effect for a long time. Parents have particularly reported the benefits of occupational therapy for sensory processing leading to improvements in behavioral regulation and social interactions.  The review done by May-Benson and Koomar showed many benefits to sensory integration approach for children with delays.  There is evidence that occupational therapy with sensory processing intervention is helpful to improve family functioning, improve self-regulation and decrease maladaptive behaviors.  These interventions are better than any other available intervention, including medications or standard occupational therapy.  All told, the requested occupational therapy (sensory integration therapy) 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 pediatrics with sub-specialty certification in developmental-behavioral pediatrics 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 64-year-old male enrollee has requested a positron emission tomography (PET) scan for evaluation of his confusion and disorientation.  Findings:  Two physician reviewers found that the requested diagnostic procedure is not likely to be of greater benefit than other modalities for evaluating this patient.  A PET scan is not standard of care for a patient with documented cognitive symptoms.  A brain magnetic resonance imaging (MRI) and selected laboratory studies are the typical first-line of evaluation in this setting.  Although a PET scan may have utility in differentiating between Alzheimers dementia and frontotemporal dementia, the records do not demonstrate that the requested PET scan will be performed for this purpose.  Therefore, the requested PET scan is not likely to be more efficacious than other methods of evaluating this patient.
Appeal type: Medical Necessity
Decision: Upheld

The mother of a 17-year-old male enrollee has requested Penlac for treatment of onychomycosis.  Findings:  The physician reviewer found that Penlac nail lacquer is the only FDA-approved topical medication for the treatment of onychomycosis. Various studies demonstrate an efficacy range of 10% to 20% for this medication, however the side effects are minimal. Despite the warning in regard to hepatic complications, Lamisil is a very safe and effective treatment for onychomycosis and studies demonstrate a 70% to 90% efficacy range. Therapeutic side effects may occur in 1% to 2% of those treated with Lamisil and are reversible. There are no contraindications mentioned in the available documentation that would preclude this patient from taking Lamisil.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for phase 2 orthodontic treatment with extraction of upper bicuspids (ADA code D8080 comprehensive orthodontic treatment of the adolescent dentition) for treatment of the enrollees severe Class II protrusion. Findings:  The physician reviewer found that review of the HLD, line 11, shows that the mandible and the maxilla show obvious anterior crowding, which add five more points to the HLD score. Using standard orthodontic practice, the overbite measured it be at least 5 mm from lower anterior incisal edge to upper anterior incisal edge when in full posterior occlusal contact and line 6B, overjet, should be about 10 mm. The HLD score would then be 25 and this would also change line 6A. In addition, the occlusal relationship between the upper and lower arches when in full intercuspation is cusp tip to cusp tip, making the patient a Class II division I malocclusion. The potential exists that the occlusion can worsen as the patient ages and temporomandibular joint issues may emerge as the upper anterior teeth continue to move forward. The request for removal of the upper left and right first bicuspids is also dentally necessary to create space for tooth movement forcing the upper anterior teeth back to correct the Class II malocclusion. Taking these factors into consideration, the requested phase 2 orthodontic treatment with extraction of upper bicuspids (ADA code D8080 comprehensive orthodontic treatment of the adolescent dentition) is supported as dentally necessary for treatment of this patients Class II protrusion. Final Result: The reviewer determined that the requested services are dentally necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in oral and maxillofacial 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

A 53-year-old male enrollee has requested Cymbalta 30mg capsule (duloxetine HCL) twice per day for treatment of his neuropathy and radiculopathy.  Findings:  The physician reviewer found that based on review of the available records, duloxetine (Cymbalta) is medically necessary for the patients medical condition. The patient has tried and failed to benefit from standard therapies. Additionally, the patients medical condition is both chronic and seriously debilitating. Cymbalta is supported in the peer-reviewed medical literature as a safe and effective treatment for combined disorders of chronic joint pain, neuropathy and depression. Raskin and colleagues performed a multi-center double blind randomized controlled trial to assess the efficacy and safety of Cymbalta on the reduction of pain severity in patients with diabetic peripheral neuropathy. The study demonstrated that Cymbalta was superior to placebo. The authors concluded that Cymbalta 60mg once per day and twice per day were safe and effective in the management of diabetic peripheral neuropathy. Skljareviski and colleagues performed a randomized double blind placebo controlled study to assess the efficacy and safety of Cymbalta in patients with chronic low back pain. The authors reported that patients treated with Cymbalta reported greater reduction in pain than the placebo-controlled group. All told, the requested Cymbalta 30mg capsule (duloxetine HCL) twice per day, is supported as medically necessary for treatment of the patients medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: A patient requested reimbursement for gene testing services (Oncotype DX) that were performed. The Health Plan has denied the services at issue as investigational for evaluation of the enrollees colon cancer. Findings:  Two physician reviewers found that it has not been established if molecular markers are useful in treatment determination and prognosis in patients with colon cancer. In addition, the 12-gene recurrence score Oncotype DX does not have specific U.S. Food and Drug Administration (FDA) approval for use in stage II colon cancer. Furthermore, none of the assays have been able to predict which patients with stage II disease could benefit from adjuvant therapy. It is important to note that the 12-gene recurrence score was created as a prognostic marker. While it may have the ability to better estimate a patient's risk of recurrence, whether such increased risk can be overcome by adjuvant chemotherapy is not clear. A technical brief on gene expression profiling for predicting outcomes in stage II colon cancer concluded that the clinical utility of all of the gene expression assays, including the 12-gene recurrence score, was uncertain. Therefore, the gene testing services (Oncotype DX) that were performed were not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. One physician reviewer found that the gene testing services (Oncotype DX) that were performed were likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the services at issue were 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 reviewers 1, 2 and 3 are 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: Urgent Care
Decision: Overturned

A 20-year-old female enrollee has requested reimbursement for emergency services. The Health Plan has denied this request indicating the services at issue were not required on an emergent basis. Findings:  The physician reviewer found that The patient presented to the emergency department with chief complaint of sore throat of four days duration associated with cough, headache, runny nose, joint pain and muscle aches. The patient reported experiencing a fever of 105 degrees at home. Upon presentation to the emergency department, the patient reported the severity of her symptoms as a 9 on a scale of 1 to 10. Vital signs included temperature 100.2 degrees, pulse 122, respirations 22, and oxygen saturation 99% on room air. The patient was diagnosed with influenza A and fever and Tylenol and Norco were administered in the emergency department. At issue in this case is whether a prudent layperson in the patients circumstances would have sought immediate medical attention on the date in question. California law defines an emergency medical condition as a medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain) such that the absence of immediate medical attention could reasonably be expected to result in any of the following: (1) Placing the patients health in serious jeopardy; (2) Serious impairment to bodily functions; (3) Serious dysfunction of any bodily organ or part. Review of the submitted documentation demonstrates that on the date in question the patient was experiencing symptoms of sufficient severity to cause a prudent layperson to seek immediate medical attention. Specifically, the patient had acute symptoms of high fever prior to presenting to the emergency room, headache, muscle aches, and sore throat. Given these symptoms, the patient was at risk for significant morbidity and mortality related to possible infectious complications including sepsis, meningitis and others. All told, a prudent layperson in these circumstances would have reasonably believed they were experiencing an emergency medical condition and would have sought immediate medical attention.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary:  An enrollee has requested kyphoplasty (CPT 22513 and 22514) for treatment of her thoracic pain.  Two physician reviewers found that kyphoplasty (CPT 22513 and 22514) is not likely to be more beneficial for treatment of the patients medical condition than other modalities. The medical records do not demonstrate an adequate trial and failure of conservative measures to include bracing. Also, the medical literature indicates that kyphoplasty is not more effective than conservative or sham treatment for osteoporotic vertebral compression fractures. In sum, kyphoplasty is not indicated for this patient with thoracic spine pain and evidence of compression fracture. For the reasons provided, the requested services are not likely to be superior to conservative measures to relieve this patients thoracic spine pain. Final Result: Two 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: 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 authorization and coverage for lower back injection (lumbar/sacral facet joint block). Findings:  The physician reviewer found that there is sufficient support for the requested services in this patients case. The records document a history of chronic low back pain with some radiation down the left lower extremity. She is status post lumbar laminectomy. The documentation noted excellent results from prior facet blocks. The medical literature noted that lumbar facet joints are a common source of low back pain. The authors evaluated the diagnostic validity and therapeutic value of lumbar facet joint interventions for patients with chronic low back pain. The authors indicated that there was significant evidence for the diagnostic validity of facet joint nerve blocks, and moderate evidence for therapeutic radiofrequency neurotomy and therapeutic facet joint nerve blocks in managing chronic low back pain. In this patients case, the requested services are medically appropriate. Therefore, lower back injection (lumbar/sacral facet joint block) is 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: Experimental/Investigational
Decision: Overturned

A 33-year-old female enrollee has requested chemical treatment of varicose veins for treatment of her chronic venous disease, class 2.  Findings:  Three physician reviewers found that in this patients case, the requested services are likely to be more efficacious than other treatment options.  The peer-reviewed medical literature supports the use of sclerotherapy in conjunction with endovenous ablation for the treatment of symptomatic tributaries.  Per the current medical evidence, the requested services are likely to be of benefit in this clinical setting.  All told, the requested chemical treatment of varicose veins is likely to be more effective than other treatment alternatives.
Appeal type: Medical Necessity
Decision: Overturned

A 63-year-old male enrollee has requested for the medication Valium for treatment of his anxiety disorder. Findings:  The physician reviewer found that the patient does not have an `imminent risk` for switching or not switching from Valium at this point. Since the psychological referral was discussed with the patient, a reasonable period of time for the patient to seek transfer of care and/or for psychiatric referral and evaluation to be performed would be six months from the date that this option was discussed. As such, the continued use of Valium is medically necessary.