Persius/imr-appeals huggingface dataset:
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Euflexxa injections. Findings:  Two of the three physician reviewers found that there is sufficient support for the requested services in this clinical setting. Hyaluronic acid injections in the knee are recommended as a possible option for patients with osteoarthritis who have not responded adequately to recommended conservative treatments for at least three months. The current medical evidence supports hyaluronic acid injections to potentially delay total knee replacement for patients with pain that interferes with functional activities. There is no maximum amount of injections established by high-quality scientific evidence. This patient presented with progressive worsening of bilateral knee pain. The patient has failed to adequately improve with recent conservative treatment, including a home exercise program. The patient has previously undergone three series of Euflexxa injections, with excellent pain relief and functional improvement. The medical evidence 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 delay of knee replacement surgery. Therefore, the requested Euflexxa injections are likely to be more efficacious than other treatment options.Final Result: The reviewers determined that the requested services are likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: Physician reviewers 1, 2 and 3 are board certified in orthopedic surgery 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: Upheld

A female enrollee requested Orthovisc injections to the right knee for medical treatment of her right knee arthritis.  Findings:  The physician reviewer found that carefully conducted double-blinded studies published in the medical literature do not demonstrate clinical effect from hyaluronan injections. In addition, there is a recognized incidence of aseptic inflammatory reactions due to allergic response and risk of iatrogenic infection within the joint. Further, the risk of sensitization is expected to increase after repeated exposure to an antigenic substance. All told, the requested Orthovisc injections to the right knee are not supported as medically necessary for treatment of this patients right knee pain.
Appeal type: Medical Necessity
Decision: Upheld

A 62-year-old male enrollee requested the brand name medication Diovan 160mg for medical treatment of his hypertension.  Findings:  The physician reviewer found thatthe documentation provided in the medical records does not support that there has been intolerance to or inefficacy of the specific formulary medications referenced by the Health Plan.  Generally, generic alternatives to the brand name medication Diovan have been demonstrated to be of equal effectiveness in treatment of hypertension.  Generic alternatives contain the same active ingredients as their brand name counterparts and are within an acceptable bioequivalent range to the brand name medication with respect to pharmacokinetic and pharmacodynamic properties.  Moreover, side effect profiles of the formulary medications would not typically include symptoms of chest discomfort or dyspnea that the patient has reported.  Therefore, the requested brand name medication Diovan 160mg is not medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld

A 24-year-old male has requested methadone and Dilaudid for treatment of his osteosarcoma pain.  Findings:  The physician reviewer found that based on review of the available medical records, the patients request for Methadone and Dilaudid is not supported as medically necessary. These narcotics at the doses the patient is presently taking, are indicated for severe cancer pain in patients who are opioid tolerant and with a limited life expectancy. This patient was assessed and described as completely disease-free three years ago. The current standard of care for chronic pain is treatment in a multidisciplinary practice to include physical therapy, massage therapy, cognitive behavioral therapy, and injections to help reduce pain. Opiates are considered adjunctive to this therapy under close monitoring by a certified physician. Short release/acting medication with a high risk of dependence and tolerance such as Dilaudid with an accumulating highly addictive medication like Methadone is not recommended (Fishman). In the medical literature, Baron and McDonald reported that high dose opiates might contribute to pain sensitization via opioid-induced hyperalgesia, decreasing patient pain threshold and potentially masking resolution of a preexisting pain condition. In this retrospective study, the majority of patients undergoing detoxification of high dose opiates for chronic pain reported a significant decrease in pain at the end of the study, further supporting the theory of opioid-induced hyperalgesia. It is in the patients best interest to wean off opioids and participate in adjunctive therapy including non-narcotic medications, physical therapy, massage therapy, with cognitive behavioral therapy, in order to address his chronic pain issues. In addition, high dose opiates may also cause adverse outcomes. Ballantyne and Mao reported that prolonged use of high dose opiates might induce tolerance, abnormal pain sensitivity, and hormonal effects. The aim of current guidelines is to protect patients from the adverse effects of opioid therapy. Methadone and Dilaudid without an integrated pain management program is not supported as within the standard of care.
Appeal type: Medical Necessity
Decision: Upheld

A 66-year-old female enrollee requested authorization and coverage for an increase in dosage of the prescription medication Vioxx.  The health plan has denied this request indicating that the requested increase in dosage is not medically necessary for treatment of the enrollees osteoarthritis.One physician reviewer performed a medical necessity Independent Medical Review.  The physician reviewer upheld the health plans denial on the basis that the requested increase in prescription dosage is not medically necessary.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for multiple trigger point injections every two weeks. The European League Against Rheumatism (EULAR) guidelines on the management of fibromyalgia include the strongest recommendations for aerobic and resistance training exercise along with cognitive behavior therapy. These non-pharmacological interventions have the best evidence to support their use in a multi-modal treatment plan. The EULAR guidelines do not recommend or mention regular trigger point injections as part of balanced treatment plan. The records provided for review document that this patients fibromyalgia symptoms have responded well to trigger point injections. However, ongoing repeated injections are not supported in the medical literature for use in this clinical setting. Trigger point injections typically consist of local anesthetic and sometimes corticosteroids, which can cause long-term harm in patients exposed to them repeatedly. Local anesthetics are toxic to the muscles that are injected, and prolonged exposure can degrade the tissue and predispose to further injuries. Treatment with corticosteroids can lead to variety of problems, including osteoporosis, weight gain, and endocrine problems. Based on the information available for review and the most recent evidence based reviews of trigger points and guidelines, the requested multiple trigger point injections every two weeks are not medically necessary for treatment of this patient. Final Result: The reviewer determined that the requested services are not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in anesthesiology with subspecialty certification in pain management 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 50-year-old female enrollee has requested ProDisc-C artificial disc replacement surgery (C5-6 anterior cervical discectomy and artificial disc replacement using ProDisc-C and C6-7 anterior cervical discectomy and fusion using plate fixation and allograft) for treatment of her cervical spondylosis and degenerative disc disease.  Findings:  Three physician reviewers found that artificial disc replacement surgery in the cervical spine in the attempt to limit adjacent segment disc disease has been employed with some early encouraging results. However, the maintenance of these results over the long-term has not yet been determined (Murrey and colleagues). The effectiveness of these implants is still uncertain, and the progression of degenerative change at the adjacent levels of standard fusion surgery may represent physiological progression of the natural history of the process, rather than being related to the surgery (Denaro and colleagues). In addition, heterotopic ossification has been reported after artificial disc replacement (Mehren and colleagues) and a significant frequency of spontaneous fusion in replacement surgery should be anticipated during long-term follow-up (Suchomel and colleagues). The need for long-term evaluation of artificial disc replacement surgery was recognized in the original approval of the ProDisc-C by the Food and Drug Administration for single-level replacement. Thus, an additional period of surveillance was required, a period which has not yet been completed. Finally, the utilization of an artificial disc implant at more than one level has been attempted (Ozturk and colleagues), as has the insertion of an implant at one level with fusion at another (as is the case with this patient, Lee and colleagues), but the reported studies have limited numbers and lack long-term outcomes.Because there are many unanswered questions regarding the efficacy of total artificial disc replacement surgery in the cervical spine, particularly when combined with fusion, it remains an unproven procedure at this time.
Appeal type: Urgent Care
Decision: Upheld

A 33-year-old female has requested coverage for past emergency services.  Findings:  The physician reviewer found that the patient presented to the emergency department for evaluation of a rash. She complained of the gradual onset of an itchy rash beginning two days prior to her arrival in the emergency department.  The medical records indicate her vital signs were normal, and she was not in any pain (0/10 on the pain scale). The physical examination revealed hives (urticaria) on her arms, legs and chest. She did not have evidence of upper airway edema, and she was not wheezing or in any respiratory distress. Her blood sugar level was unremarkable at 107, and her urine was negative for evidence of infection although it did show trace blood of uncertain significance. Her pregnancy status was unknown. There is no documentation in the medical records that a urine or serum pregnancy test was performed. She was diagnosed with urticaria and given Benadryl 50 mg orally while still in the emergency department.  She was discharged from the emergency department with prescriptions for Benadryl and Prednisone and instructed to follow-up with her primary care physician within two days.  At issue in this case is whether a prudent layperson in the patients circumstances would have sought immediate medical attention on the date at issue. 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.A review of the submitted evidence demonstrates that the patient had an itchy rash but had no fever, was not in any respiratory distress, and was not in any pain. Although it was later determined the patient was pregnant, the patient stated that at the time of her visit to the hospital, she was unaware she was pregnant. There was no documentation in the medical records that a urine or serum pregnancy test was ordered. All told, a prudent layperson would not have thought this to be an emergency medical condition and would not have sought immediate medical attention on the date at issue.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: an enrollee has requested reimbursement for Botox injections performed. Findings:  The physician reviewer found that hyperhidrosis is excessive sweating beyond that required to return body temperature to normal. It can be localized or generalized, commonly affecting the axillae, palms, soles or face, and can have a substantial negative effect on a patients quality of life. Santana-Rodriguez and colleagues reported that Botox treatment is a useful alternative to surgical treatment and is safe and effective for focal hyperhidrosis. In sum, there is evidence dating back many years which supports Botox injections as an efficient and appropriate treatment for facial and head hyperhidrosis. Final Result: The reviewers 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: Physician 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: Overturned

A 61-year-old female enrollee has requested for a right total ankle replacement for treatment of her polyarticular arthritis.   Findings:  Three physician reviewers found that the results of a total ankle arthroplasty, as stated in the literature, do appear to be similar to those of an ankle fusion.  One must realize that this individual has had an attempted failed fusion already. The right total ankle arthroplasty, at this juncture, would be more beneficial than an attempted repeat fusion. An arthroplasty would allow some remaining motion and would be a reasonable option for this patient.
Appeal type: Medical Necessity
Decision: Upheld

The patient has requested authorization and coverage for in-home intravenous immunoglobulin (IVIG) infusions given the concerns regarding the Covid-19 pandemic. The American Academy of Neurology (AAN) guidelines support the use of IVIG for refractory dermatomyositis noting that IVIG has been demonstrated to be effective and may be considered for treating nonresponsive dermatomyositis in adults. The records indicate that this patient with dermatomyositis has failed several standard medications. Treatment with IVIG has reportedly improved the patients symptoms. She has expressed concern over possible exposure to Covid-19 with a five-day infusion schedule at the treatment facility. The American College of Rheumatology (ACR) addressed the treatment of active rheumatic diseases, in the absence of infection or Covid-19 exposure. The ACR support continuation of IVIG at the infusion center in this patients clinical scenario. The records fail to demonstrate the presence of life-threatening organ disease or other serious condition that prevents treatment with IVIG in the clinic setting, given the concern for Covid-19. She is receiving IVIG at an immunomodulatory dose and not for a primary immunodeficiency. Her infusion clinic is open and receiving patients with appropriate Covid-19 screening. The records do not demonstrate that she would be at increased risk for infections due to her indication for treatment at home versus an infusion center. All told, the requested in-home IVIG infusions given the concerns regarding the Covid-19 pandemic are not medically necessary for treatment of this patient. Final Result: The reviewer determined that the requested services are not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in internal medicine with subspecialty certifications in allergy and immunology and rheumatology 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 Harvoni for treatment of her chronic hepatitis C virus genotype 1b.  Two physician reviewers found that the patient has chronic hepatitis C virus and has an advanced stage disease as she has progressed to cirrhosis. The American Association for the Study of Liver Diseases (AASLD) and Infectious Diseases Society of America (IDSA) guidelines that set the standard of care in managing and treating patients with hepatitis C virus recommend treatment for all patients except those with a limited life expectancy due to non-liver-related conditions. Based on the available resources, immediate treatment should be prioritized as necessary so that patients at high risk for liver-related complications and severe extrahepatic hepatitis C complications are given high priority. This patient has hepatitis C virus genotype 1b and is treatment naive. Hence, per the current guidelines, the requested Harvoni is medically necessary for treatment of this patients medical condition. Final Result: Two reviewers 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: All three 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 residential treatment center services for treatment of his medical condition.  Findings:  The physician reviewer found that the submitted documentation fails to establish the medical necessity of the services at issue. At the time of admission to residential treatment center services the patient did not have severe symptoms. He had the potential for relapse, but this potential in this population in and of itself is not a reason for 24-hour monitoring in the absence of other factors such as psychiatric comorbidity rendering him unstable in his recovery. He did not require 24-hour medical and nursing supervision, and could have safely and effectively been treated at a lower level of care, such as outpatient services with community resources. Thus, the services at issue were not medically necessary for treatment of the patients medical condition. 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 physician 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

Nature of Statutory Criteria/Case Summary: The patient is a 48-year-old female diagnosed with primary osteoarthritis (OA) of both knees. She reported chronic pain in both knees that was not controlled with corticosteroid injections. Prior treatment with viscosupplementation was reported to be effective. Physical examination findings included bilateral knee joint line tenderness, no effusion, full quadriceps and hamstring strength, and the absence of instability in both knees. The patient has requested coverage for Euflexxa injections. The Health Plan denied the request and reported that the requested treatment is not medically necessary for the treatment of this patient. At issue in this case is whether Euflexxa injections are medically necessary for the treatment of this patients medical condition. Intra-articular hyaluronic acid (IAHA) injections provide a symptomatic benefit for patients with knee OA without major safety concerns. IAHA offers one of the best benefit-to-risk ratios among pharmacologic options, as measured by improvements in knee OA health outcomes, gain in quality-adjusted life years and substantial delays in time to total knee replacement. Viscosupplementation increases functional scores in patients with osteoarthritis of the knee, especially within three months of injection. Viscosupplementation is recommended for patients with a history of lasting benefit from prior injections. The patient has reported benefit with previous viscosupplementation injections to the knees with reduced use of over-the-counter medications and improved pain and activity level. In this case, medical evidence supports the requested treatment in this clinical setting. Therefore, Euflexxa injections are medically necessary for the treatment of 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 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.