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 injections in the left knee.An exhaustive review of the 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 as to which individuals will benefit. Different studies have tried mixing hyaluronic acid with corticosteroids, platelet rich plasma, and other agents to make it more effective. The current evidence is limited, and guidelines from organizations such as the American Academy of Orthopedic Surgeons indicate that the evidence is not conclusive. 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 where everything else has been tried, and the options are limited. In this case, the patients options are limited. The patient has tried and failed other conservative treatments, with the alternative being a total knee arthroplasty in the presence of mild osteoarthritis of the left knee. Therefore, Euflexxa injections for the left knee are medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested services are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in orthopedic surgery and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for robotic unroofing surgery to repair the myocardial bridge.The medical literature does not support that the requested robotic unroofing surgery to repair the myocardial bridge is medically necessary. While surgical unroofing of a myocardial bridge is generally accepted as appropriate treatment in selected patients with refractory myocardial ischemic symptoms, there have been no outcomes data comparing standard open heart surgical approaches to robotically assisted off-pump procedures. In this case, the patient has sufficient symptoms and objective findings to justify surgery. However, there is insufficient data to recommend the robotic procedure, and she does not represent a prohibitive surgical risk for a standard surgical approach. Under these circumstances, robotic unroofing surgery to repair the myocardial bridge is not medically necessary for treatment of the patients medical condition.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 certification in cardiovascular disease, 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 Euflexxa injection series in the left knee.An exhaustive review of the 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 as to which individuals will benefit. Different studies have tried mixing hyaluronic acid with corticosteroids, platelet rich plasma, and other agents to make it more effective. The current evidence is limited, and guidelines from organizations such as the American Academy of Orthopedic Surgeons indicate that the evidence is not conclusive. 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 where everything else has been tried, and the options are limited. In this case, there is a history of lasting benefit from prior viscosupplementation. Furthermore, the options are limited. The patient has tried and failed other conservative treatments, with the alternative being a total knee arthroplasty. Thus, the requested Euflexxa injection series for the left knee is medically necessary for the treatment of the patients medical condition.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.
Appeal type: Medical Necessity
Decision: Overturned

A 64-year-old female enrollee has requested the Flector patch for the treatment of her sacroiliitis. Findings:  The physician reviewer found that the literature demonstrates that plasma concentrations of diclofenac in subjects treated with a Flector patch were significantly lower (less than 1%) than those treated with a single dose of oral diclofenac (50 mg). Therefore, the use of the diclofenac (Flector) patch does have an impact in the treatment of this patient who has a history of thrombocytopenia and therefore is at risk of bleeding complications with the use of systemic NSAIDs. Further, when this patient was exposed to oral ibuprofen, it caused ecchymosis resulting in discontinuation of the medication. The use of the Flector patch for management of this patients pain is therefore a reasonable medical option and should be authorized.
Appeal type: Medical Necessity
Decision: Overturned

The parent of an eight-year-old male enrollee has requested speech therapy for treatment of the enrollees dysfluency (stuttering). Findings:  The physician reviewer found that in the medical literature, Ward noted that stuttering, or speech dysfluency, may be divided into developmental stuttering, neurogenic stuttering that results from neurological problems, and psychogenic stuttering that occurs following psychological trauma. Although it is believed that up to 80% of all patients who experience developmental dysfluency or mild pathologic dysfluency recover spontaneously, a certain number of children deteriorate, developing severe dysfluency. Those with non-developmental stuttering also fall within this latter category and require therapy in order to recover from the disorder. Lawrence and Barclay concluded that, In general, referral is indicated if the child is over 4 years old, has been stuttering for more than 3 months, showed consistent stuttering and demonstrates tension or struggle behavior when stuttering. Overall, the scientific data suggest that therapy is considered to be most effective when started early. This patient has a stuttering disorder rather than normal childhood dysfluency. Some experts consider stuttering to be the result of subtle neurophysical dysfunctions resulting in disruption of the precision needed to produce speech. Given the severity of his symptoms and his age, the patients chances of spontaneous recovery are negligible. For this reason, aggressive speech therapy offers the patient the best chance for full recovery. Thus, speech therapy has been demonstrated to be appropriate and medically necessary for management of this patients condition.
Appeal type: Medical Necessity
Decision: Upheld

A 60-year-old male enrollee has requested removal of benign lesions for treatment of his skin lesions. Findings:  The physician reviewer found that this patient is requesting coverage for treatment of seborrheic keratoses.  Seborrheic keratoses are benign skin lesions that do not have malignant potential.  Hafner and Vogt noted that this is a benign condition, and treatment of these lesions is not medically necessary, but may be done for cosmetic reasons.  Based upon the submitted medical records, there is a lack of documentation regarding the symptomatic nature of these lesions. There is no medical indication for removal of the skin lesions in this patients case.  All told, the medical necessity of the requested removal of benign skin lesions has not been established by the submitted clinical documentation.
Appeal type: Medical Necessity
Decision: Overturned

A 40-year-old female enrollee requested authorization and coverage of chiropractic treatment.  The Health Plan denied the request indicating that the chiropractic care is not medically necessary for treatment of the enrollees back pain.One chiropractic reviewer performed a medical necessity Independent Medical Review. The chiropractic reviewer overturned the Health Plans denial on the basis that the requested therapy is medically necessary.
Appeal type: Urgent Care
Decision: Upheld

A 46-year-old male enrollee requested ambulance services provided on an emergent, or urgent in nature, basis.  Findings:  The physician reviewer found that there was no indication that this patients health was in serious jeopardy. His 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; serious impairment to bodily functions; or serious dysfunction of any bodily organ or part. All told, based on the documentation provided for review, the patients symptoms did not meet prudent layperson criteria for emergency care and the patient did not meet the above-stated criteria for urgently needed services.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for radiofrequency ablation. In the documentation available for review, the recent examination is not consistent with facet arthropathy. In addition, the literature states that a diagnostic medial branch block should be performed prior to radiofrequency ablation. A pain diary should be kept for the day of the medial branch block to help determine when the local anesthetic wore off. Further, only a local anesthetic should be used for the medial branch block. This patient received monitored anesthesia care with a medial branch block. All told, the requested authorization and coverage for radiofrequency ablation is not medically necessary for treatment of this patients back pain and lumbar radiculopathy. 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 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: Medical Necessity
Decision: Overturned

The parent of a 19-year-old female enrollee has requested the medication Provigil for the treatment of the enrollees excessive daytime sleepiness. Findings:  The physician reviewer found that provigil is known to be effective in reversing excessive daytime sedation caused by various psychoactive medications. This agent is often used off-label for this purpose. Excessive daytime sleepiness is an iatrogenic effect of many psychoactive and antipsychotic medications, and can be a disabling part of a patients illness. In this particular case, the patient has a complex variety of clinical symptoms and medications. Provigil is clinically indicated to counteract her daytime sedation and optimize her therapeutic regimen. It has clearly been effective for this patient and the treatment should be maintained.
Appeal type: Medical Necessity
Decision: Upheld

A 59-year-old female enrollee has requested for anesthesia services for treatment of the her colonoscopy.  Findings:  The physician reviewer found that conscious sedation provided by the gastroenterologist is routinely utilized in uncomplicated colonoscopies. Review of the submitted records reveals no factors in this patients history that would place her at high risk for conscious sedation. Nor has any clinical evidence been provided which documents the reasons MAC was utilized for this patient.
Appeal type: Medical Necessity
Decision: Upheld

A male enrollee requested Celebrex 200 mg for medical treatment of his back pain status post lumbar discectomy.   Findings:  The physician reviewer found that  Celebrex is a cox-2 inhibitor (coxib) nonsteroidal anti-inflammatory drug (NSAID). The medical literature states that NSAIDs are recommended for osteoarthritis at the lowest dose for the shortest period in patients with moderate to severe pain to reduce the risk of complications associated with cardiovascular disease and gastrointestinal distress.  In this patients case, there is lack of documentation of gastrointestinal risk requiring a cox-2 inhibitor NSAID. Thus, the requested Celebrex 200 mg is not supported as medically necessary.
Appeal type: Medical Necessity
Decision: Upheld

A female enrollee requested acupuncture for medical treatment of her upper back and shoulder pain.  Findings:  The physician reviewer found that neither the number of prior acupuncture sessions nor the benefits obtained with such care were documented.  The request for additional acupuncture did not include current examination findings, orthopedic tests performed, or functional-motor-sensory deficits to be addressed by the acupuncture requested.  Although there is peer-reviewed literature that supports acupuncture as appropriate for the shoulder, there is a lack of documentation of examination findings, significant orthopedic tests results and functional deficits in order to demonstrate the necessity of the requested services.  All told, the requested acupuncture is not medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld

A 47-year-old female enrollee has requested  for the medication Forteo for treatment of her cervical non-fusion. Findings:  The physician reviewer found that the clinical significance of this finding is not clear in this instance. Markers of bone turnover are generally used for diagnosing and treating metabolic bone disease. A study of  patients with non-fusion would be needed to determine if bone alkaline phosphatase has any clinical relevance for a patient such as this one. She has neck pain, but also has foraminal stenosis at C3-4 and C4-5 and her pain may not be related to bone fusion. There is no evidence that Forteo will improve the healing of the patients cervical fusion. In addition, she does not have osteoporosis on DEXA scan or a history of fracture despite treatment with anti-resorptive agent.
Appeal type: Medical Necessity
Decision: Upheld

A 50-year-old female enrollee requested authorization and coverage of breast surgery. The health plan denied the request indicating that the requested surgery is considered cosmetic in nature and not medically necessary as post-mastectomy reconstructive surgery.One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer upheld the health plans denial on the basis that the requested procedure is not medically necessary.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for a continuous glucose monitoring (CGM) device for treatment of the enrollees diabetes.  Findings:  The physician reviewer found that the American Association of Clinical Endocrinologists and American College of Endocrinology advocate expanding the use of CGM in the management of diabetes, stating that CGM use is shown to improve glucose control and reduce hypoglycemic events, and therefore has the potential to reduce the risk of acute and chronic complications of diabetes.  In this case, the patient is using multiple injections of insulin, and self titrates his meal boluses. However, he has had significant hypoglycemia with unawareness which puts him at risk for vision changes, energy drop, mental status changes and possible coma. Therefore, without the benefit of CGM, the patient protects himself by keeping glucose levels high, which in turns puts him at risk of long-term diabetes related complications. Even though he has a diagnosis of type 2 diabetes, he is likely insulin deficient and must be managed in the same way that a patient with type 1 diabetes should be managed. The records show his fasting glucose levels have been consistently high, which makes the patients normal C-peptide inappropriate for the level of hyperglycemia and insulin resistance consistent with insulin deficiency. The patient is compliant with therapy, and is willing to be under better control with CGM. Thus, CGM will allow the patient to make adjustments to therapy with avoidance of hypoglycemia. Final Result: The reviewer determined that the requested device is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The physician reviewer is board certified in internal medicine with sub-specialty certification in endocrinology, diabetes and metabolism and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

The parent of an enrollee has requested authorization and coverage for a coordinated evaluation with a team of specialists who specialize in Shwachman-Diamond Syndrome (SDS), including a SDS specialist, allergist, gastroenterologist, endocrinologist, and pulmonologist in order to obtain a current treatment plan to best manage the enrollees condition. The submitted documentation supports the medical necessity of the requested services. SDS is a rare autosomal recessive disorder that affects multiple organ systems, and is characterized by exocrine pancreatic insufficiency, impaired hematopoiesis, and leukemia predisposition. There may also be skeletal, immunologic, hepatic, and cardiac abnormalities. SDS is classified as a bone marrow failure syndrome, and patients with this syndrome are at increased risk of developing myelodysplasia. Malignant transformation may result in acute myelogenous leukemia. These patients are susceptible to recurrent infections, particularly of the respiratory system, bones, and skin. Exocrine pancreatic insufficiency results in malabsorption, failure to thrive, steatorrhea, and decreased levels of fat soluble vitamins. Respiratory failure is not uncommon in the neonatal period as a result of rib cage abnormalities. There are a number of other abnormalities associated as well. Definitive therapy for bone marrow failure is hematopoietic cell transplantation. Even with hematopoietic cell transplantation, patients may experience graft failure/rejection, transplant-related toxicities, or relapsed leukemia. Due to the rarity of this disorder with its significant morbidity, multidisciplinary management is medically necessary. The current medical evidence supports the requested services in this clinical setting. Therefore, the requested coordinated evaluation with a team of specialists who specialize in SDS, including an SDS specialist, allergist, gastroenterologist, endocrinologist, and pulmonologist, is medically necessary in order to obtain a current treatment plan to best manage this patients 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 pediatrics with sub-specialty 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: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for durable medical equipment utilized between two dates of service. Findings:  Three physician reviewers found that there is a lack of support for the superior efficacy of the equipment at issue in this clinical setting. There is a lack of evidence-based literature to support the use of superficial cold for pain management. Studies found no additional benefit of consistent cryotherapy using the icing device over intermittent ice bags on postoperative pain, passive range of motion, nausea or vomiting, opioid use, blood loss, lower limb function, or length of stay, after knee surgery despite significant differences in patient-reported compliance and satisfaction. According to another study, there does not appear to be a significant benefit using cold compression over standard ice wraps in patients undergoing shoulder arthroscopy for rotator cuff repair or subacromial decompression. Instead, the studies indicate that cold application, in the form of ice packs, is widely accepted as an effective nonpharmacological intervention for pain management.  Ice packs increase the pain threshold, decrease the inflammatory reaction, swelling, and spasm.  Cold is commonly used in the treatment of acute soft tissue injuries and has been shown to reduce pain effectively in the postoperative period after orthopedic surgery procedures.  However, there is very limited data and research on the effects of continuous flow cryotherapy, as used in this patients case.  As such, greater sample sizes are required to fully determine significant differences between the two techniques for these study parameters. Therefore, the literature does not support the superior benefits of continuous flow cryotherapy over the standard cold packs after a spinal fusion. In light of the foregoing, the durable medical equipment utilized between the two dates of services was not likely to have been more beneficial for the treatment of this patients medical condition than any available standard therapy. Final Result: 3 of 3 reviewers determined that the equipment at issue was 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: All three physician reviewers 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.