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

The patient has requested authorization and coverage for Orthovisc injections (hyaluronic acid) 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 standard 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 osteoarthritis of both knees, which interferes with her ability to perform activities of daily living. She had tried and failed conservative treatments. There is a history of excellent relief from viscosupplementation in the past with over one year of pain relief. Furthermore, the patients remaining treatment options are limited to a total knee arthroplasty. For these reasons, Orthovisc injections (hyaluronic acid) in both knees are 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 parent of an enrollee has requested reimbursement for services rendered at a residential treatment center for treatment of the enrollees behavioral health conditions. Findings: The physician reviewer found that Per the submitted documentation, the patient does not meet the criteria for treatment in a residential 24-hour facility. Prior to admission, the patient was reportedly suicidal with a plan. At that point, she would have met criteria for an acute psychiatric hospital admission. There is no evidence that this was considered.  The letter from the residential treatment facility does not describe her as being suicidal upon her admission. The letter describes her as having some suicidal thoughts only in week four of treatment and not recurring. The patient does not have any comorbid medical problems or substance abuse. She does not live in an environment that would prevent her from progressing in treatment. The records do not indicate that she has tried and failed less restrictive treatment other than individual therapy and medication. She has not been treated and failed at the intensive outpatient program or partial hospitalization program level of care. Final Result: The reviewer determined that the services at issue were 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 psychiatry with sub-specialty certification in child and adolescent psychiatry 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 parent of a 10-year-old male enrollee has requested authorization and coverage for a computed tomography (CT) scan for treatment of the enrollees costochondritis and mild persistent asthma. Findings:  The physician reviewer found that Hussain and colleagues note that chest pain is a reasonably common complaint in the pediatric population. In terms of referral to pediatric cardiology, it ranks second only to heart murmurs. The most common cause is idiopathic, occurring in up to half of cases. Other causes include pulmonary, musculoskeletal, gastrointestinal, and psychological. Actual cardiac causes are present in less than five percent of cases. Most children have normal physical exam findings. Interventions depend upon etiology: bronchodilators for reactive airways disease, anti-reflux medications for gastroesophageal reflux, and non-steroidal anti-inflammatory medications for musculoskeletal pain. When cardiac cause is suspected, a reasonable evaluation would include comprehensive history and complete physical examination, selective laboratory studies including metabolic studies and indicators of cardiac stress, electrocardiogram, chest x-ray, and echocardiogram. In some cases, a period of cardiac monitoring may be indicated. Other patients may benefit from a Holter 24-hour monitor or an event monitor. In this childs case, he initially presented with chest pain that began during physical education, and with subsequent onset of dry cough. He was evaluated multiple times by all pertinent specialists, with normal testing throughout and examination consistent with costochondritis. Ultimately he was also diagnosed with habit cough after completing a course of prednisone and azithromycin. There is nothing in his history or the submitted documentation that would indicate that a chest CT would add any additional useful information. In weighing risk and benefit, the risk of radiation exposure from CT far outweighs any potential benefit given his symptomatology and low yield for diagnosis. Therefore the computed tomography scan is not medically necessary. 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 pediatrics with subspecialty certification in pediatric critical care 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: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Cosentyx 300 mg solution auto injection 150 mg/mL. Systemic treatment of psoriasis is indicated when topical treatments fail or do not achieve sufficient control of the disease. While the U.S. Food and Drug Administration (FDA) has approved several systemic options for the treatment of psoriasis including non-biologics such as methotrexate, cyclosporine, acitretin, cyclosporine, and apremilast, and biologics such as tumor necrosis factor (TNF)-alpha inhibitors, interleukin (IL)-17 pathway inhibitors like Cosentyx, IL-12/23 inhibitors, and IL-23 inhibitors, some of these medications carry severe potential side effects. For example, cyclosporine is contraindicated in those with hypertension and kidney impairment, is immunosuppressive and associated with increased infection risk, and often results in psoriasis flares after being discontinued as it may not be used in the long-term due to toxicities. Kridin and colleagues report that the use of oral methotrexate was associated with increased odds of COVID-associated hospitalization, whereas the use of biologic drugs was not associated with worse outcomes of COVID-19 among patients with psoriasis. Menter and colleagues note that topical therapies alone or combined with phototherapy may be insufficient for patients with moderate-to-severe psoriasis, and that biologic agents, as monotherapy or combined with other topical or systemic medications, have a high benefit-to-risk ratio. In this case, given that the patient has tried and failed treatment with narrowband ultraviolet B (UVB) and topical steroids including triamcinolone and clobetasol, treatment with a systemic biologic agent, such as Cosentyx. is medically indicated. Therefore, Cosentyx 300 mg solution auto injection 150 mg/mL 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 64-year-old female enrollee has requested a panniculectomy for treatment of her hernia repair.   Findings:  The physician reviewer found that the condition of a recurrent hernia would be an abnormal occurrence associated with previous surgery. The abdominal pannus can be considered a collection of skin and subcutaneous tissue beyond that normally expected in that region. The umbilical hernia could be considered caused by a developmental abnormality, while the incisional hernia would be directly related to previous surgery for a possible infection. The surgery at issue, specifically the panniculectomy, may have been expected to improve function by reducing the incidence of recurrent hernia or by allowing improved exposure of the hernia repair. However, the documentation does not support this conclusion in this case. The photographs provided do not demonstrate that functional improvement was reasonably expected by removal. There is some indication from the plastic surgeon that removing the abdominal pannus is necessary, but there is no documentation from the general surgeon to support this as the goal of the procedure. There is no preoperative assessment, medical history, physical examination, current weight status, or history of weight loss provided for review. Also absent are relevant factors including the patients weight over this course, previous attempts to reduce her weight and pannus, and detail of the cause and chronological occurrence of the hernias. Further, there is insufficient data indicating the surgery was being performed in an attempt to create as normal an appearance as possible. The photographs do not allow for this consideration and there is no history and physical examination available to clarify the providers rationale for the procedure. Overall, there is minimal evidence to support a finding of the abdominoplasty as reconstructive nature in this instance. In the medical literature, Shermak concluded that there can be a functional and aesthetic improvement from the combination of abdominoplasty and hernia repair. Also, Reid and Dumanian indicate a functional reasoning behind panniculectomy and hernia repair being combined. In this case, however without sufficient evidence to support the functional need for the surgery at issue, it cannot be determined to be reconstructive or medically necessary.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Ambien for treatment of the enrollees sleep disorder. Findings:  The physician reviewer found that Current American Academy of Sleep Medicine guidelines and the medical literature regarding the treatment of circadian rhythm sleep disorders do not recommend the use of any sedative hypnotic agents.  The guidelines did not recommend the use of sedative hypnotic agents, particularly Ambien, noting that the research conducted showed no clinical benefit to next day functioning.  Furthermore, a higher rate of adverse events were noted with Ambien when compared to other therapies. In regards to the management of insomnia in general, particularly chronic insomnia, current evidence based research and practice guidelines recommend the use of non-pharmacological interventions. Moreover, non-pharmacological approaches have been shown to have equivalent benefit over time when compared to the use of pharmacological agents.  Final Result: The reviewer determined that the requested medication is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.  Credentials/Qualifications: Physician reviewer number one is board certified in neurology with sub-specialty certification in sleep 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: Medical Necessity
Decision: Upheld

A 26-year-old male has requested approval for face-to-face mental health therapy for treatment of his behavioral health condition.   Findings:  The physician reviewer found that the central issue in this case is the patients formidable formal thought disorder, which represents the most debilitating of psychiatric disorders. The patient has chronic, serious mental illness and his resulting impairment presents a significant challenge to any plan of care. As such, the patient requires a comprehensive, multimodal treatment plan that includes, among other interventions, psychotropic medications. The most appropriate way to address the patients ongoing management is for the patient to follow-up with a therapist for assessment and treatment planning. Based upon the documentation provided, the Health Plan has offered this service to the patient in lieu of face-to-face therapy. A treatment planning session such as this invariably includes at least elements of supportive psychotherapy and is the most appropriate next step for this patient who is in need of comprehensive psychiatric services. As such, the medical necessity of face-to-face mental health services has not been established.
Appeal type: Experimental/Investigational
Decision: Overturned

A 21-year-old female enrollee requested authorization and coverage of autologous peripheral blood stem cell transplantation (APBSCT) for the treatment of systemic lupus erythematosus (SLE).  The health plan denied the enrollees request indicating that the requested treatment is experimental.Three physician reviewers performed an experimental/investigational Independent Medical Review.  Each of the three physician reviewers concluded that autologous peripheral blood stem cell transplantation (APBSCT) is likely to be more beneficial for treatment of the enrollees systemic lupus erythematosus (SLE) than any available standard therapy.  Because all three physician reviewers concluded that the requested treatment is likely to be more beneficial for treatment of the enrollees medical condition than any available standard therapy, the review organization overturned the health plans denial.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/ Case Summary:  The enrollee requested coverage for magnetic resonance imaging of the right shoulder received. This patient with a reported history of cervical radiculopathy. On 4/30/20, he had a telemedicine consultation with his neurosurgeon during which he reported right sided neck pain that radiated to the shoulder right arm for several days duration. He had been treated in the past with steroids for his cervical radiculopathy. The patient reported his shoulder hurts when he sleeps on his right side. He denied numbness, tingling, or weakness. Upon examination, he had good range of motion of his neck and shoulder. He had pain when he pushed on the front of his shoulder. The neurosurgeons impression was primary right shoulder pain, possibly due to impingement syndrome or possible cervical radiculopathy. The plan was for magnetic resonance imaging of the right shoulder with re-evaluation after completion of the magnetic resonance imaging. The magnetic resonance imaging was performed on 6/12/20. X-rays of the right shoulder were not performed first and the patient was not referred for treatment with a physical therapist. X-rays are necessary as preliminary screening tools prior to magnetic resonance imaging as most people do not need magnetic resonance imaging and care can be safely provided with use of x-ray data information. If unusual findings are noted on x-ray then magnetic resonance imaging may be obtained if necessary. Therefore, given this and the history provided in the medical record, magnetic resonance imaging was not indicated. Final Result: The reviewer determined that the magnetic resonance imaging of the right shoulder received on 6/12/20 was not medically necessary for the treatment of the enrollees medical condition.Credentials/Qualifications: The physician reviewer is board certified in neurosurgery 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

This patient is a 50-year-old male who had a colonoscopy at age 49 because of his family history (his father had colon cancer at age 72). The patient was not symptomatic and had no complaints. The Health Plan has denied reimbursement for the colonoscopy on the basis it was not medically necessary.As set forth in the 2003 American Gastroenterological Association (AGA) guidelines for colorectal cancer screening, a colonoscopy was medically indicated in this case. The patients father was diagnosed with colorectal cancer at age 72. The AGA guidelines recommend colonoscopy screening at age 40 for patients with a first-degree relative affected with colorectal cancer at or above the age of 60. Therefore, I have determined the colonoscopy at issue was medically necessary for evaluation of the patients medical condition. The Health Plans denial should be overturned.
Appeal type: Urgent Care
Decision: Upheld

A 64-year-old male enrollee has requested for emergency room services for treatment of his hand injuries. Findings:  The physician reviewer found that a prudent layperson would not have left the emergency department without evaluation and treatment if he believed his health to be in danger. The submitted documentation does not support the argument that an emergency existed in this case.
Appeal type: Medical Necessity
Decision: Upheld

A 57-year-old female enrollee has requested for 24 additional sessions of physical therapy (PT) for treatment of her thoracic outlet syndrome.  Findings:  The physician reviewer found that there is limited documentation of one-to-one skilled therapy. Details of the pool program including specific exercises or the number of repetitions completed is lacking. There is no objective documentation of functional progress in terms of activities of daily living. The patient could have reasonably transitioned to a home exercise program.
Appeal type: Experimental/Investigational
Decision: Upheld

The parent of a 14-year-old male enrollee has requested for biofeedback therapy for treatment of his attention deficit hyperactivity disorder.   Findings:  Three physician reviewers found that the peer-reviewed literature does not support the efficacy of biofeedback for ADHD. A study by Drechsler, et al. found that there is skepticism due to the methodological issues in studies published so far. According to the authors, Two major methodological challenges are to prove convincingly that specific aspects of neurofeedback therapy mediate positive effects and that these effects are comparable or superior to appropriate control treatments. According to certain critics it is questionable whether positive effects after neurofeedback training can be related to the improved cortical regulation or rather to unspecific treatment effects. As principles of behavio[u]ral therapy, such as systematic reinforcement and a positive relationship to a therapist, are integrated parts of the neurofeedback training especially with children, selective effects of the EEG feedback are difficult to isolate. The authors also note that there are concerns that other feedback mechanisms such as respiratory or muscular feedback may be involuntarily involved and may contribute to improved behavior control or serve as relaxation training.
Appeal type: Medical Necessity
Decision: Upheld

The patient has requested authorization and coverage for a 24-hour video electroencephalography (EEG) of the brain. In this case, the patient has a history of a significant traumatic brain injury with subsequent episodes that are potentially suggestive of a seizure disorder. Current practice guidelines and literature readily recommend the performance of a routine EEG to evaluate for possible epilepsy. However, prior to consideration of any extended EEG monitoring, a routine EEG should be performed. A routine EEG can be effective in establishing a diagnosis of a seizure disorder and would preclude the need for further testing. The current standards of practice generally involve completion of a routine EEG study prior to consideration and performance of an extended EEG recording (ambulatory or attended, with or without video). Based on the records that were provided for review, there is no documentation that the patient has undergone evaluation with a routine EEG. For these reasons, the requested 24-hour video EEG of the brain is not medically necessary for evaluation of this patients medical condition. Final Result: The reviewer determined that the requested services are not medically necessary for evaluation of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in neurology with subspecialty certification in sleep 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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for spine surgery on the neck (insertion of artificial intervertebral disc). The Health Plan has denied this request indicating that the requested surgery is considered investigational for treatment of the enrollees neck pain. Findings:  Cervical disc replacement is an accepted alternative to a one level anterior cervical discectomy and fusion for single level cervical disease. The literature has adequate support for the use of cervical disc replacement in the cervical spine at one level. However, in this patients case, the recommended procedure involves the use of a hybrid or multilevel cervical disc procedure. Currently, a review of the peer-reviewed medical literature demonstrates the use of hybrid cervical fusion/arthroplasty remains unproven. There is insufficient evidence to permit conclusions on the net health outcomes of this procedure, in the absence of well-designed and executed randomized controlled trials with adequate follow-up. All told, the requested spine surgery on the neck (insertion of artificial intervertebral disc) is not likely to be more efficacious than the available standard modalities of treating this patients medical condition.Final Result: Two of the three reviewers determined that 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.