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

A 64-year-old female enrollee has requested for a low intensity pulsed ultrasound device (LIPU) bone growth stimulator for treatment of her left foot fifth metatarsal fracture.   Findings:  The physician reviewer found that the literature in the past has recommended, in very athletic individuals who truly have a defined Jones fracture (fracture of the diaphysis of the fifth metatarsal), that these fractures should be treated surgically. Other fractures of the fifth metatarsal should heal in due time. The definition of a delayed/non-union is: no progression of clinical signs of healing or radiographic signs of healing. For these signs to occur, one has to wait at least 6-8 weeks or even longer. Thus, a fracture of the metaphyseal/diaphyseal juncture of the fifth metatarsal should heal in due time. It may take 2-3 months indeed to heal, but closed treatment, without bone growth stimulation and/or surgery, is appropriate and most often sufficient.
Appeal type: Medical Necessity
Decision: Overturned

An enrollee has requested authorization and coverage for Orthovisc injection to the left knee. Current medical literature pertaining to viscosupplementation reveals mixed results. Evidence from eight systematic reviews and six randomized controlled trials indicates that although viscosupplementation may relieve knee pain in some individuals with osteoarthritis, it is not known which individuals will benefit. The current evidence is limited and guidelines from organizations such as the American Academy of Orthopedic Surgeons indicate that the evidence is not conclusive. As such, the Academy does not currently support viscosupplementation as standard treatment for osteoarthritis of the knees. In light of the foregoing, viscosupplementation can only be recommended in individuals with a history of lasting benefit from prior injections and in carefully selected cases when everything else has been tried and the options are limited. In this case, the patient has a known history of excellent relief from viscosupplementation over at least three years with at least six to nine months of relief from each series of injections. Furthermore, the patients options are limited, with the alternative being a total knee arthroplasty. Under these circumstances, Orthovisc injection to the left knee is 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 Technivie and ribavirin for treatment of her hepatitis C.  Findings:  The physician reviewer found that according to the most recent joint guidelines issued by the American Association for the Study of Liver Diseases and the Infectious Diseases Society of America, all patients with chronic hepatitis C should be treated except those with limited life expectancy due to non-liver-related conditions.  This applies regardless of fibrosis stage or viral load.  The guidelines recommend that treatment-naive genotype 4 patients should be treated with Technivie and ribavirin for 12 weeks.  All told, the requested treatment with Technivie and ribavirin is medically necessary for the treatment of this patients hepatitis C infection.  Final Result: The reviewer determined that the requested medications are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.  Credentials/Qualifications: The reviewer is board certified in internal medicine with sub-specialty certification in gastroenterology 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 laser therapy (CPT code 17106). Rosacea is a common chronic disorder characterized by periods of exacerbation, remission and possible progression. In rosacea, the non-pharmacologic approach to therapy is adequate skin care, trigger avoidance, and photoprotection. In addition, there are several topical, herbal, systemic and light based therapies available. Further, the US Food and Drug Administration (FDA) has approved treatments include topical metronidazole and azelaic acid. Laser treatment can be used in combination with medical and topical treatments. Since this patient has failed many standard treatments, a multifaceted approach to therapy that includes laser treatment was an appropriate treatment option. Accordingly, the laser therapy was likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.One reviewer found that the laser therapy was not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: Two of the three 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:  One reviewer is board certified in dermatology and is actively practicing. One Reviewer is board certified in dermatology and is actively practicing.  One Reviewer is board certified in dermatology and is 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: Overturned

An 18-year-old female enrollee has requested for breast reduction surgery for treatment of her bilateral macromastia.  Findings:  The physician reviewer found that the American Society of Plastic Surgeons (ASPS) guidelines state that, Based on the results of Level I and II Evidence, reduction mammaplasty has been proven effective at reducing macromastia related symptoms and improving postoperative quality of life. The ASPS also note that, documentation of at least two symptoms is supported by a Level II, prospective study examining the medical necessity of reduction mammaplasty. Further, an evaluation of managed care policy with respect to macromastia is provided by Nguyen and colleagues. Based on this patients complaints, photographs, and physical examination, she satisfies these guidelines. Her breast hypertrophy has impacted her quality of life and she has chronic breast pain, upper back and neck pain, shoulder grooving and headache. Her photographs support these findings as well. Consistent with the ASPS treatment recommendations, this patients condition of macromastia is causing functional problems and is likely to significantly benefit from bilateral breast reduction surgery. As such the requested surgery is medically necessary for management of her medical condition.
Appeal type: Medical Necessity
Decision: Upheld

The parent of a 12-year-old male enrollee has requested for growth hormone therapy for treatment of the enrollees stated condition of growth hormone deficiency. Findings:  The physician reviewer found that there is no documented evidence of poor growth velocity. Thus, he does not meet criteria for growth hormone deficiency.
Appeal type: Medical Necessity
Decision: Overturned

A 33-year-old female enrollee has requested for duodenal switch procedure for treatment of her morbid obesity. Findings:  The physician reviewer found that the procedure is especially useful in the super obese with significant hepatomegaly which makes conventional Roux-en-Y gastric bypass less tenable. The morbidity of the requested procedure is equal or better than Roux-en-Y gastric bypass nationwide.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for Orthovisc injections. This patient presents with a history of bilateral knee pain due to osteoarthritis. The patient underwent treatment with a series of Orthovisc injections for 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 routine 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, there is no history of prior viscosupplementation. However, the patient has been treated for severe osteoarthritis of the hip in addition to bilateral knee pain. Furthermore, the degree of osteoarthritis of the knees is mild per the available records and the patient is not a candidate for total knee arthroplasties. Given these findings, the Orthovisc injections were medically necessary for treatment of this patient. Final Result: The reviewer determined that the services at issue were medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in orthopedic surgery and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Urgent Care
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested ambulance transport services on an emergent basis.  Findings: The physician reviewer found that review of the submitted documentation demonstrates that a prudent layperson would not have sought immediate medical attention and would not have reasonably believed that the condition required ambulance transport services on the date in question. In this case, the patient called 911 due to an abdominal pain which was getting worse. The patient was not in severe distress and her presenting signs and symptoms were not acute symptoms of sufficient severity. Thus, her symptoms were not of sufficient severity that a prudent layperson would reasonably believe the absence of immediate medical attention would place his health in serious jeopardy or result in serious impairment to bodily functions or serious dysfunction of any bodily organ or part. All told, based upon the documentation provided for review, the patients symptoms did not meet prudent layperson criteria for immediate medical attention or ambulance transport. Final Result: The reviewer determined that the patients symptoms did not meet prudent layperson criteria for emergency care. Therefore, the Health Plans denial should be upheld.  Credentials/Qualifications: The reviewer is board certified in emergency 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

Nature of Statutory Criteria/Case Summary:  The parent of an enrollee has requested residential treatment center services for the treatment of the enrollees behavioral health conditions.  Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the services at issue.  The patient is described as being intelligent, having both internal and external motivation to do well in the program.  He was described as being ready for treatment.  The records do not document prior substance abuse treatment other than outpatient dialectical behavior therapy.  He was not suicidal or homicidal.  The current medical evidence does not support the services at issue in this clinical setting.  All told, residential treatment center services were not medically indicated for the treatment of this patient. 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: Overturned

A 28-year-old female enrollee requested residential treatment center for medical treatment of her behavioral health conditions.  Findings:  The physician reviewer found that the submitted documentation supports the medical necessity of the services.  In this patients case, treatment at the residential level of care was medically appropriate.  The services were for active treatment and were reasonably expected to improve her condition and prevent a more serious episode of illness.  Based on the documentation provided and current treatment guidelines, residential treatment was medically necessary for the treatment of this patient.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary:  An enrollee has requested the Afirma gene test for evaluation of her medical condition.    Findings:  Three physician reviewers found that per the American Thyroid Association (ATA) Guidelines Taskforce on Thyroid Nodules and Differentiated Thyroid Cancer, molecular testing has been proposed as an adjuvant in medical decision making of whether to refer a patient for thyroidectomy. The current ATA guidelines indicate For nodules with AUS/[follicular lesion of undetermined significance] FLUS cytology, after consideration of worrisome clinical and sonographic features, investigations such as repeat [fine needle aspiration] FNA or molecular testing may be used to supplement malignancy risk assessment in lieu of proceeding directly with a strategy of either surveillance or diagnostic surgery. Informed patient preference and feasibility should be considered in clinical decision-making In this case, the patient had a cytopathology result consistent with FLUS. Without this test, the patient would have required a second biopsy or surgery to clarify the diagnosis. Therefore the submission of the specimen to Afirma gene expression classifier was appropriate. It was in benefit of this patient to have this test done more than other available standard therapy. All told, the testing at issue was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.    Final Result: Three reviewers determined that the testing at issue was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned.  Credentials/Qualifications: All three reviewers are board certified in internal medicine with sub-specialty certification in endocrinology and metabolism 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: Experimental/Investigational
Decision: Upheld

The enrollee requested reimbursement for Lynch Syndrome genetic analysis testing. The enrollee has a medical history of Lynch syndrome. The genetic counselor determined the enrollees personal and family history is suggestive of a predisposition hereditary cancer. The report confirmed the enrollee was positive for a mutation, which is consistent with a diagnosis of hereditary non-polyposis colorectal cancer, also known as Lynch syndrome. The genetic cause of the illnesses affecting the enrollee and his family members was already known, based on results of prior testing. The new test only confirmed the results of the prior test. While an enrollee may be an appropriate candidate to undergo this type of genetic testing in certain situations, this testing was not appropriate for this enrollee.Final Result: Three of the three reviewers determined that the requested services were not likely to have been more beneficial than any available standard therapy for treatment of the enrollees medical condition. Credentials/Qualifications: Three reviewers are board certified in clinical cytogenetics 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: Experimental/Investigational
Decision: Upheld

A 44-year-old male enrollee requested authorization and coverage of percutaneous vertebroplasty. The Health Plan denied the request indicating that the requested procedure is considered experimental for treatment of the enrollees medical condition.Three physician reviewers performed an experimental/investigational Independent Medical Review. Two physician reviewers concluded that the requested procedure is not likely to be more beneficial for treatment of the eneollee's medical condition than any available standard therapy. One physician reviewer concluded that the requested procedure is likely to be more beneficial for treatment of the enrollee's medical condition than any available standard therapy. Because two of the three  physician reviewers concluded that the requested surgery is not likely to be more beneficial for treatment of the enrollee's medical condition than any available standard therapy, the Health Plans denial has been upheld.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested Lyrica for treatment of her fibromyalgia. Findings:  The physician reviewer found that there is medical support for the requested medication in this clinical setting. The U.S. Food and Drug Administration has approved Lyrica (pregabalin) for treatment of fibromyalgia.  Pauer and colleagues note that pregabalin demonstrated modest efficacy in pain, global assessment, and function in patients with fibromyalgia, and the study also showed improved sleep across all dose levels. Early onset of pain relief was seen, with separation from placebo detected by week one in all pregabalin groups. All pregabalin doses demonstrated superiority to placebo on the Medical Outcomes Study-Sleep Scale Sleep Disturbance subscale and the Sleep Quality diary.  Pregabalin was generally well tolerated for the treatment of fibromyalgia. A study by Mease and colleagues also notes that patients in all pregabalin groups showed statistically significant improvement in endpoint mean pain score and patient impression of global change (PGIC) patient response when compared with placebo. Compared with placebo, all pregabalin treatment groups showed statistically significant improvement in assessments of sleep and in patients' impressions of their global improvement. In this patient, the submitted medical records support a condition of fibromyalgia. As such, Lyrica is medically necessary for treatment of the patients medical condition. 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 neurology with sub-specialty certification in pain 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: Urgent Care
Decision: Overturned

A 40-year-old female enrollee has requested emergency services for the treatment of her medical condition. Findings:  The physician reviewer found that the patient was suffering from an acute exacerbation of low back pain that was of sufficient severity that a prudent layperson would seek immediate medical attention due to fear of jeopardy to their health and/or bodily function. She required immediate evaluation and treatment of her severe pain in order to continue her normal daily activities.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary:   An enrollee has requested proton beam radiation therapy for treatment of his medical condition.  Findings:  Two physician reviewers found that proton beams have less scatter than other sources of energy such as gamma rays, x-rays, or electrons. Because of this feature, proton beam radiotherapy (PBRT) has been used to escalate radiation dose to diseased tissues while minimizing damage to adjacent normal tissues. Proton beam radiotherapy has been shown to be particularly useful in treating radiosensitive tumors that are located next to vital structures, where complete surgical excision or administration of adequate doses of conventional radiation is difficult or impossible. Because of these physical properties, it has been theorized that PBRT is especially useful for cancers located in areas of the body that are highly sensitive to radiation and/or where damage to healthy tissue would be an unacceptable risk to the patient.  As such, the proton beam radiation therapy at issue was likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.  Final Result: Two reviewers determined that the services at issue were likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned.  Credentials/Qualifications: All three reviewers are board certified in radiation oncology 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.