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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Euflexxa (Hyaluronan) injections for both knees. The submitted documentation supports the medical necessity of the requested services. Researchers concluded that hyaluronic acid was the best pharmacologic intervention for knee osteoarthritis in their meta-analysis of various studies. Hyaluronic acid was found to be better than injected placebo or injected corticosteroids. Researchers concluded that repeated cycles of intra-articular sodium hyaluronate treatment to delay time to total knee replacement in patients with knee osteoarthritis, which failed conservative treatment, was found efficacious. In this case, this patient presented with chronic bilateral knee pain. Clinical examination findings are consistent with x-ray evidence of severe osteoarthritis in the lateral and patellofemoral compartments. Reasonable conservative treatment, including activity modification and NSAIDs, has failed to provide adequate symptom relief to this patient. Prior Euflexxa injections to both of the patients knees provided pain relief and good functional improvement in activities of daily living, allowing him to reduce NSAID use. Evidence-based medical peer-reviewed literature supports the use of viscosupplementation injections for the treatment of pain in patients with osteoarthritis of the knee. Repeat viscosupplementation injections have been found to be safe and effective and allow for the delay of knee replacement surgery. Given the patients previous significant long-term response, repeat Euflexxa injections are supported. Therefore, the requested bilateral Euflexxa injections (Hyaluronan) for the knees are medically necessary for treatment of the patients medical condition.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: Overturned

Nature of Statutory Criteria/Case Summary:  An enrollee has requested a hospital stay for treatment of his medical condition.  Findings:  The physician reviewer found that according to the documentation submitted for review, initial inpatient level of care was not medically necessary as the patient was being treated in the emergency department during this time. The patient presented with headache and neurologic deficits on exam.  The concern was for an infectious etiology given the abnormal lumbar puncture and cerebral spinal fluid results.  According to medical literature cited above, empiric treatment for herpes simplex virus (HSV-1) infection with acyclovir IV should always be initiated as soon as possible if the patient has encephalitis without apparent explanation. Early therapy is vital because it is associated with a significant decrease in mortality and morbidity. The recommendation is for treatment with IV acyclovir, and oral treatment should not be used. The IV acyclovir should continue until the results of the testing confirm that the patient does not have HSV encephalitis. In this case the patient presentation was concerning for a viral encephalitis.  Empiric treatment with IV acyclovir was medically necessary until laboratory tests confirmed that the patient did not have HSV infection.  Thus, a subsequent hospital stay was medically necessary. All told, a portion of the services at issue were medically necessary for treatment of the patients medical condition. Final Result: The reviewer determined that a portion of the services at issue were medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be partially overturned.  Credentials/Qualifications: The reviewer is board certified in internal 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 male enrollee requested quarterly magnetic resonance imaging (MRI) for medical evaluation of his medical condition.  Findings:  The physician reviewer found that this patient was found to have an arachnoid cyst, which may have been present preoperatively, and which has been stable on postoperative imaging for greater than one year.  This patients cyst is not likely to be causing his ongoing pain syndrome, and has been stable. Serial imaging on a quarterly or other set interval basis is not medically needed. Should there be significant clinical change, such as new focal posterior fossa neurologic findings, repeat imaging may be needed at that time.  All told, the requested quarterly MRI is not medically indicated for the evaluation of this patient.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for C-naltrexone 4.5 mg capsules.Findings:  Three physician reviewers found that the submitted documentation does not establish that the requested medication is likely to be more beneficial than standard therapy. Of note, there is no documentation of percent relief, duration of relief or improvement in function with the use of the requested medication. Further, there is a lack of controlled studies documenting the efficacy of compounded naltrexone capsules in the management of complex regional pain syndrome. The limited studies that are available regarding naltrexone therapy are not relevant to this clinical setting. Thus, C-naltrexone 4.5 mg capsules are not likely to be of greater benefit than other treatment options. Final Result: The reviewers determined that the requested medication is 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: Physician reviewers 1, 2 and 3 are board certified in anesthesiology with sub-specialty certification in pain medicine and are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Dupixent 300 mg/2 mL pen injector. The records provided for review document that this patient has significant itching, redness, bleeding, and pain due to his severe atopic dermatitis, which affects their ability to perform activities of daily living. The patients provider noted that the patient has failed treatment with clobetasol and hydrocortisone. The provider has recommended treatment with Dupixent. The U.S. Food and Drug Administration (FDA) has approved Dupixent for the treatment of patients with moderate-to-severe atopic dermatitis whose disease is not adequately controlled with topical therapies. A recent consensus article of atopic dermatitis by Boguniewicz and colleagues defined moderate-to-severe atopic dermatitis as more than 10% BSA involvement and/or involvement of highly visible areas or those important for function and significantly impaired quality of life. The severity of this patients symptoms meet the criteria for moderate-to-severe disease with more than 30% BSA involvement and symptoms in areas important for function. In addition, Dupixent has the highest-quality trial evidence for safety and efficacy in atopic dermatitis (Siegels, et al.). Systemic cyclosporine is not recommended for long-term use to due to toxicities. Methotrexate is an immunosuppressant that has been associated with increased hospitalizations when a patient is infected with COVID-19. For these reasons, the requested Dupixent 300 mg/2 mL pen injector is medically necessary for 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: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for Botox injection provided for treatment of the enrollee, who was diagnosed with vocal process granuloma. Findings:  2/3 of the physician reviewers found that there is a lack of support for the services at issue in this clinical setting.  Some authors have found positive results, but numbers are small.  The 2012 study done at Massachusetts Eye and Ear Infirmary resulted in the conclusion that there was significant recurrence of vocal granuloma after injection of the thyroarytenoid muscle with botulinum toxin, but that better results were obtained with injection into the inter-arytenoid musculature. This evaluation was done with small population study and as a retrospective review.  There is currently an efficacy study underway to further evaluate this method of injection and compare recurrence rates with those found to occur with the use of anti-reflux therapy alone.  At this time, the superior efficacy of Botox injection provided has not been established.  Final Result: 2/3 of the 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: Physician reviewer number one is board certified in otolaryngology 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.Physician reviewer number two is board certified in otolaryngology 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.Physician reviewer number three is board certified in otolaryngology 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 48-year-old female enrollee requested authorization and coverage of a referral to an orthopedist for the treatment of back pain.  The Health Plan denied the enrollees request indicating that the requested treatment is not medically necessary.One physician reviewer performed a medical necessity Independent Medical Review.  The physician reviewer overturned the health plans denial on the basis that the requested services are  medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned

A 43-year-old female has requested  removal of a mole (skin tag) under her eye.  Findings:  The physician reviewer found that based on review of the available records, the patient has a mole that is symptomatic and possibly enlarging. The diagnosis that needs to be considered is one of malignancy.  The American Society of Plastic Surgeons recommendations state that, Removal of a skin lesion(s) is considered reconstructive surgery and medically necessary when one of the following diagnoses or conditions are present. Two of those conditions include symptoms of pain or itching, which is present for this patient. In addition, McGuire and colleagues, the differential diagnosis of lentigo maligna includes some benign lesions. This patient is documented to have a nevus. Thus, based on these considerations, removal is medically necessary. Further, a mole or skin lesion that is symptomatic or changing should be considered abnormal. The diagnosis is in question based on the symptoms and examination. Thus, a tumor/malignancy has to be considered. To this end, the goal of the surgery would be to affect overall function. Diagnosing a possible malignancy would be reconstructive and medically indicated as well. Overall, the surgery would help to correct the symptoms of pruritus and tenderness that the mole has created. Moreover, the requested services are likely to result in a more than minimal improvement considering the estimated size of the lesion. Therefore, the requested removal of moles (skin tag) under the eye is supported as medically necessary for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for magnetic resonance imaging (MRI) of the left knee. Current medical literature does not support an MRI in the absence of a prior radiographic evaluation. In this case, the patient has chronic left knee and ankle pain. A radiographic evaluation of the bilateral knees on previously was unremarkable. The documents do not reflect extenuating circumstances to support the need for an MRI without completion of the x-rays and the ultrasound ordered most recently. Given that the provider has recommended radiographic evaluation, and that a more recent study would be appropriate prior to MRI evaluation, the requested service is not medically indicated. Therefore, MRI of the left knee is not medically necessary for the evaluation of this patient.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 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 an Omnipod insulin pump. Per colleagues, [i]nsulin pumps can provide a greater flexibility in insulin administration and meal planning, as compared with multiple insulin injections, and they may be particularly suitable for the pediatric age group. Per colleagues, [p]atients using insulin pump therapy had a better longterm glycemic control relative to the matched injection therapy cohort. Continuous subcutaneous insulin infusion improves glycemic control, limits excessive weight gain, reduces the frequency of hypoglycemic events, and results in overall improved satisfaction in patients and their parents. Here, this patients caregivers have demonstrated that they possess the necessary tools to carry out an effective treatment and follow-up plan on insulin pump therapy. The patient and his family have adhered to frequent blood glucose monitoring, have kept appointments with the childs various health care providers, and have adhered to dietary recommendations. The patients current insulin pump is malfunctioning and is in need of replacement. A new insulin pump is medically necessary and appropriate for this patient.Final Result: The reviewer determined that the requested service is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in pediatrics with a subspecialty certificate in pediatric endocrinology, 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 50-year-old male enrollee has requested speech therapy for treatment of his stuttering. Findings:  The physician reviewer found that a review of the scientific literature reveals a study by Koedoot and colleagues which states, moderate to severe stuttering has a negative impact on overall quality of life. In regards to treatment, a review by Blomgren states, although it is presented that a comprehensive approach to stuttering treatment will provide the best results, no single approach to stuttering treatment can claim universal success with all adults who stutter. In the case of this patient, he reportedly has stuttering however there is no description of the severity, duration, onset or prior treatment, if any. While the scientific data confirms that severe stuttering can be quite disruptive, the submitted medical records do not document the severity and duration of the patients stuttering. Further, it is not known what other modalities have been attempted, if any. In the absence of such evidence, the medical necessity of speech therapy has not been established.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested naltrexone injections for treatment of the enrollees opiate dependence.  Findings: The physician reviewer found that the naltrexone injections provided were medically necessary for treatment of the patients opiate dependence. Naltrexone is a promising pharmacotherapy in the treatment of opioid use disorder. Naltrexone blocks opioid receptors and thus removes the reward of getting high. The medication is available as an oral preparation taken every day or a microsphere formulation delivered monthly via intramuscular injection. Use via injection avoids the first-pass effect, and the bodys monthly exposure to the medication is much less (1500 mg orally versus just 380 mg intramuscularly), resulting in fewer side effects, while the delivery system ensures medication adherence improving outcomes. In this case, the patient has had a three-year intravenous heroin addiction. Further, she had significant psychiatric co-morbid diagnoses. It appears that she was prescribed oral naltrexone but was non-adherent resulting in relapse. The medication was recommended by the patients treating provider who knows the patients illness burden, characterological organization, support system and living environment. Thus, the U.S. Food and Drug Administration (FDA) approved intramuscular naltrexone was and is reasonably expected to improve the patients condition and prevent a worsening of her condition. Further, the use of the particular medication via injection is safe, appropriate and consistent with good medical practice. Therefore, the naltrexone injections provided was medically necessary for treatment of the patients medical condition.Final Result: The reviewer determined that the medication at issue was and 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 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: Overturned

The parent of a 7-month-old female patient has requested a cranial remolding or banding helmet for the treatment of the enrollees head shape. Findings:  The physician reviewer found that plagiocephaly can lead to abnormalities of the orbit, temporal bone, and jaw.  Cranial remodeling/banding helmet therapy is not effective at later ages and is only appropriate when there is no synostosis.  It is a reconstructive process that is part of the appropriate management of plagiocephaly and it is not cosmetic.  The information submitted demonstrates that the patient is an appropriate candidate for cranial remodeling/banding therapy and that such therapy will prevent the occurrence of potential abnormalities related to the patients plagiocephaly.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a 10 year old female enrollee has requested speech therapy for the treatment of the enrollees auditory processing disorder. Findings:  The physician reviewer found that the American Speech-Language-Hearing Association (ASHA) broadly defines auditory as the efficiency and effectiveness by which the central nervous system (CNS) utilizes auditory information. Auditory processing disorder is described as a deficit in neural processing of auditory stimuli that is not due to higher order language, cognitive, or related factors. In order to properly assess young patients, ASHA emphasizes that evaluation must be individualized with testing based on complaints and symptoms. A wide variety of tests can be utilized to provide a thorough assessment, including auditory discrimination, auditory temporal processing, and patterning. Interpretation of these tests should be performed by a specialist trained in the complexities of central auditory processing disorders. It is recommended that intervention should be implemented as soon as possible following the diagnosis, to exploit the plasticity of the CNS, maximize successful therapeutic outcomes, and minimize residual functional deficits. The medical literature also suggests that the 7% of children with auditory processing disorders typically present with difficulties understanding what they hear, listening through background noise, following oral instructions, and understanding rapid or degraded speech. Bamiou and colleagues reported that, Auditory processing disorders may have detrimental consequences on a childs life, if undiagnosed and untreated. As noted in the case under review, this patient has significant deficits in auditory processing that have already and will continue to affect her participation in academic and social interactions if left untreated.
Appeal type: Experimental/Investigational
Decision: Upheld

The representative of a 22-year-old male enrollee requested authorization and coverage of intravenous Cipro and Tobramycin for the treatment of the enrollees medical condition. The Health Plan denied the request indicating that the requested therapy is considered investigational for treatment of the enrollees pulmonary infections.Three physician reviewers performed an experimental/investigational Independent Medical Review. All three physician reviewers concluded that the requested therapy is not likely to be more beneficial for the treatment of the enrollees medical condition than any available standard therapy. Because all three physician reviewers determined that the requested therapy is not likely to be more beneficial for the treatment of the enrollees medical condition than any available standard therapy, the Health Plans denial has been upheld.