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

Nature of Statutory Criteria/Case Summary: An enrollee has requested magnetic resonance imaging (MRI) and second opinion consultation for evaluation of the enrollees right knee pain. Findings: The physician reviewer found that this patients records document careful and thorough medical care referencing a condition of polyarthralgia, right knee chronic pain and swelling, exogenous obesity with an elevated BMI, history of anxiety, development of ventricular premature beats and cardiac work-up. The medical history documents an anterior cruciate ligament tear of the right knee in 1978 followed in 1980 and 1990 with arthroscopic debridements of the right knee and finally followed by a hamstring anterior cruciate ligament reconstruction in 2000. Current examinations specifically state no malalignment varus or valgus and no instability at the knee. He has undergone evaluation with a full series of x-ray examinations including standing films. He has had conservative management including recommendations for physical therapies, patellar orthotics and steroid local injections into the right knee. Given these evaluations and interventions, the requested MRI of the right knee is not medically necessary. There is nothing to be gained through the added information obtained through MRI examination. Further, the American Academy of Orthopaedic Surgeons (AAOS) does not recommend arthroscopic debridement for degenerative changes within the knee joint and these changes have been documented with the x-rays obtained. There are no symptoms to suggest an isolated meniscal remnant tear and the history suggests that there would be little benefit from further arthroscopic surgery. Thus, the requested MRI and second opinion consultation as part of evaluation of the patients right knee pain is not medically necessary.Final Result: The reviewer determined that the requested services are not medically necessary for evaluation of the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is board certified in 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

The patient is a 54-year-old male who has requested reimbursement for EECP, hyperbaric oxygen, and chelation therapy for treatment of coronary artery disease. The records indicate the patient was treated for hypertension, diabetes type II, dyslipidemia, and hypogonadism. The submitted records do not include detailed information regarding the patients coronary artery disease. Reference is made to an abnormal stress test and coronary angiogram prior to December 2002. A stress test in January 2003 indicates the patient exercised 10 minutes to a heart rate of 148. The test was terminated because of fatigue. No chest pain was reported. ST depression was detected in the post exercise period. EECP therapy commenced three days later in January 2003. The subsequent medical records indicate the patient did not complain of chest pain. He was not treated with anti-angina medication. The Health Plan has denied reimbursement for EECP, hyperbaric oxygen therapy and chelation therapy on the basis the services were not medically necessary for treatment of the patients condition.The Health Plans denial should be upheld. With regard to EECP, in 2002 the American College of Cardiology and the American Medical Association issued a joint statement indicating the procedure was investigational.  In 1999, HCFA approved EECP as a reasonable and necessary treatment for patients suffering from stable angina pectoris refractory to medical and/or surgical therapy. HCFA states coverage of this therapy is provided for patients who have been diagnosed with disabling angina (Class II or Class IV, CCSF score or equivalent of classification), who in the opinion of a cardiologist or cardiothoracic surgeon are not readily amenable to surgical intervention. In the case of this patient there is no documentation of angina pectoris. The patient has not submitted documentation of medical or surgical management for angina pectoris. Objective testing indicates he did not meet medical necessity criteria for treatment.Regarding hyperbaric oxygen therapy, there is no body of medical literature supporting the use of hyperbaric oxygen therapy for the treatment of symptomatic or asymptomatic coronary artery disease. The American College of Cardiology and the American Heart Association have not published guidelines for the use of hyperbaric oxygen therapy in coronary artery disease. This treatment has not been established as effective and therefore, was not medically indicated in this patients management.Furthermore, regarding chelation therapy, position statements by the American College of Cardiology and the American Medical Association conclude there is insufficient scientific evidence to justify the application of chelation therapy for atherosclerosis on a clinical basis. At the present time, there is insufficient evidence chelation therapy is effective for atherosclerosis. As such, use of chelation therapy for treatment of this patient was not medically necessary.As set forth above, I have determined the services at issue were not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested authorization and coverage for chiropractic care twice per month for treatment of the enrollees scoliosis. Findings: The physician reviewer found that according to reviews of current literature, there is a paucity of data demonstrating the efficacy of manual therapy, chiropractic and osteopathy in the treatment of idiopathic scoliosis. The majority of studies have poor methodology or are observational case studies. At present, non-specific manual therapy has not been shown to be beneficial for patients with idiopathic scoliosis. Further prospective, randomized, controlled studies are needed in order to reliably assess the usefulness of non-specific manual therapy in the treatment of idiopathic scoliosis. 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 a board certified chiropractor 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 52-year-old female enrollee has requested for a 2-level lumbar disc replacement arthroplasty for treatment of her low back pain. Findings:  The physician reviewer found that lumbar artificial disc replacement is still an unproven procedure for the treatment of lumbar degenerative disc condition. Though early studies remain encouraging, there are no long-term outcomes studies to establish the safety and efficacy of the procedure and complications are not well-defined. More quality outcomes data is needed to establish the effectiveness of this procedure in the long-term. Fusion remains the gold standard treatment. Furthermore, outcomes with respect to two-level artificial disc replacement in the long-term are not known.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Octagam intravenous immune globulin (IVIG) 120 gm, divided over three to five days as the loading dose, then 60 gm divided over one to two days every three to four weeks. Oaklander and colleagues describe chronic inflammatory demyelinating polyradiculoneuropathy (CIDP) as a chronic progressive or relapsing and remitting disease that usually causes weakness and sensory loss, with symptoms due to autoimmune inflammation of peripheral nerves. The authors further note that CIDP usually responds to treatments that reduce inflammation. IVIG and corticosteroids remain first line treatments for CIDP. Doneddu and colleague report that there are several CIDP variants, including purely sensory CIDP, or chronic inflammatory sensory neuropathy (CISP), a condition that presents with sensory neuropathy, ataxia, and normal nerve conduction from selective sensory nerve root inflammatory demyelination. The American Academy of Neurology guidelines on IVIG in the treatment of neuromuscular disorders lists IVIG as an effective, long-term treatment for CIDP. In this case, the patient has a diagnosis of CISP, a sensory variant of CIDP, that is progressive and affects activities of daily living. Given that current medical literature supports the efficacy of IVIG therapy in patients with sensory CIDP, the requested medication is medically indicated. Therefore, Octagam IVIG 120 gm, divided over three to five days as the loading dose, then 60 gm divided over one to two days every three to four weeks, is medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested medication is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in neurology 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 56-year-old female enrollee has requested early repeat course of Orthovisc (hyaluronan) injections for treatment of her right knee pain. Findings:  The physician reviewer found that the submitted documentation and relevant literature fails to demonstrate the medical necessity of the requested services. Rutjes and colleagues assessed the efficacy of viscosupplementation for adults with symptomatic knee osteoarthritis. This study concluded after review of a total of 89 trials involving 12,667 adults that in patients with knee osteoarthritis, viscosupplementation is associated with a small and clinically irrelevant benefit and that there is an increased risk of serious adverse effects (Rutjes et al). In addition, the American Academy of Orthopaedic Surgeons guidelines for the treatment of osteoarthritis of the knee states, We cannot recommend using hyaluronic acid for patients with symptomatic osteoarthritis of the knee. Furthermore, several studies evaluating repeated treatment protocols document adverse events including inflammatory changes within the knee joint and in some cases requiring arthrocentesis after multiple injections. Based on the medical literature cited above, the request for an early repeat course of hyaluronan injections in the form of Orthovisc for treatment of the patients right knee pain is not medically necessary.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Epclusa 400/100 mg tablets for 12 weeks. Findings:  The physician reviewer found that according to joint guidelines issued by the American Association for the Study of Liver Diseases (AASLD) and the Infectious Diseases Society of America (IDSA), all patients with chronic hepatitis C should be treated except those with life expectancy less than 12 months due to non-liver-related conditions. This applies regardless of fibrosis stage, and advanced fibrosis is not required for treatment. Per the guidelines, Epclusa is recommended as first-line therapy for treatment naive genotype 2 patients, based on clinical trials including ASTRAL-1 and ASTRAL-2, which showed a 99% cure rate and superiority to Sovaldi with ribavirin . Delay in treatment may result in decreased survival. For these reasons, Epclusa 400/100 mg tablets for 12 weeks is supported as medically necessary for the treatment of this patients hepatitis C infection. 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 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: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested breast tomosynthesis for evaluation of her medical condition.  Findings: Two physician reviewers found that the services at issue were likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. There is sufficient support in the peer-reviewed literature for the services at issue in this clinical setting. According to the study by Ciatto and colleagues, the addition of breast tomosynthesis reduces false positives and increases cancer detection when compared to two-dimensional mammography alone. In addition, Detection rates, including those for invasive and in situ cancers, were 6.1 per 1000 examinations for mammography alone and 8.0 per 1000 examinations for mammography plus tomosynthesis (Skaane, et al). Given the support above, breast tomosynthesis was likely to be more beneficial for evaluation 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 evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned.  Credentials/Qualifications: All three physician reviewers are board certified in diagnostic radiology 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: Overturned

Nature of Statutory Criteria/Case Summary:   The parent of an enrollee has requested applied behavioral analysis (ABA) therapy at the frequency of 10 hours per week for treatment of the enrollees medical condition.  Findings:  Two physician reviewers found that the submitted documentation establishes the medical necessity of the requested therapy. ABA therapy is the standard of care in the therapeutic intervention of autistic children and the documentation submitted for review has confirmed a diagnosis of autism. In sum, this patient has a diagnosis consistent with autism spectrum disorder, for which ABA therapies are medically necessary.  Final Result: Two reviewers 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: One reviewer is board certified in pediatrics and pediatric critical care medicine and is actively practicing. Two reviewers are board certified in pediatric neurology 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: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for residential treatment center (RTC) services.  Per the American Society of Addiction Medicine (ASAM) criteria, this patient meets Level 3.5 criteria for Clinically Managed High-Intensity Residential Services. ASAM criteria focuses on six dimensions to determine the appropriate level of care including: (1) intoxication and withdrawal potential; (2) biomedical conditions; (3) emotional, behavioral and cognitive conditions; (4) readiness to change; (5) relapse, continued use, or continued problem potential; and (6) recovery environment. For dimension 1, the patient was in withdrawal and his disease had worsened as evidenced by increased frequency of relapses. The patient met dimension 2 as his continued substance use placed himself and others at serious risk of injury due to his driving while intoxicated. For dimension 3, the patient reported feelings of hopelessness and suicidal ideation. The patient met dimension 4 since he was admitted voluntarily, but this was the first time he attended treatment willingly, so his readiness to change was new and vulnerable. For dimension 5, the patient met this criterion given his pattern of multiple relapses within recent weeks while trying to maintain sobriety on his own. Without any major changes, he was likely to relapse again. The patient met dimension 6 as he was homeless. The patient required safe and stable living environment in order to develop his recovery skills. Thus, the patient met the ASAM criteria for Level III treatment, which was similar to what patient received at the facility. Given these findings, the RTC services 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 psychiatry with expertise in addiction 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: An enrollee has requested authorization and coverage for an echocardiogram. The Health Plan has denied this request indicating that the requested test is not medically necessary for treatment of the enrollee's condition. A review of the record indicates that the enrollee has been diagnosed with a small anterior muscular ventricular septal defect (VSD) and patent foramen ovale (PFO). An echocardiogram indicated no PFO was seen and the PFO appeared smaller in comparision to the echocardiogram.At issue in this case is whether the requested echocardiogram is medically necessary for treatment of the patients medical condition. Colleagues note that VSDs are the most common congenital heart defects in newborns. Muscular defects are the most frequent ones with most of them being small. The probability of a VSD spontaneuous closure is high, even after the first year of life. This is a healthy with a trivial heart defect. Initially she had a small PFO which was normal at that age and which subsequently closed on follow up. The VSD was described as small on the initial exam. At her most recent echocardiogram, the VSD had gotten smaller. The VSD was now described as trivial. She never had any symptoms of congestive heart failure and never required treatment. This is the natural history of a muscular VSD, which is very likely to close completely without intervention. A repeat echocardiogram so soon following the 6-month study is not medically necessary and would not alter her treatment. She was never symptomatic and no decisions had to be made regarding her treatment. Therefore, the echocardiogram is not medically necessary.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 pediatric cardiology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

The parent of a 13-year-old male enrollee has requested growth hormone (GH) Saizen 8.8 mg for treatment of the enrollees idiopathic growth hormone deficiency.  Findings:  The physician reviewer found that although the patients current height is more than 2.25 standard deviations below normal for age and gender, from a review of the available records, there is no evidence of poor linear growth velocity as measured longitudinally over time. The patients IGF-1 level was normal for bone age and pubertal stage. In addition, the results of provocative GH testing were normal. The patients adult height prediction, based on the bone age and height measurements is over 65 inches which is considered normal for a US adult male (Cohen, et al). For these reasons, the most likely cause of the patients short stature and delayed bone age is constitutional delay rather than true GH deficiency and as such he is expected to catch up to the normal curve in height when puberty arrives (Gharib, et al). Therefore, GH therapy is not medically necessary for this patient because he does not meet standard criteria for GH deficiency, nor is his predicted adult height short enough to qualify for a trial of GH therapy for treatment of idiopathic short stature, based on FDA guidelines.
Appeal type: Experimental/Investigational
Decision: Upheld

A 33-year-old male enrollee has requested for artificial disc replacement for treatment of his low back pain.   Findings:  Two physician reviewers found that spinal fusion has been the standard for surgical management of low back instability and pain, but the theoretic advantages of removal of the painful disc while preserving motion has led to increasing interest in total disc arthroplasty. Early results have been encouraging, but the long-term benefit of arthroplasty over fusion remains to be determined (see Lin and Wang). A high rate of re-operations has been reported, and potential problems over the long-term have not been addressed (see de Kleuver and colleagues). Nor has the effect of these implants on adjacent segment degeneration been clarified (see German and Foley). No statistical difference between fusion and disc arthroplasty has been demonstrated in clinical outcomes or adjacent level motion (see Guyer and colleagues). The role of total disc arthroplasty is not yet defined. Long-term studies may clarify whether it is appropriate in selected patients (see Madigan and colleagues). However, at this time, total disc arthroplasty has not been shown to be better than fusion. There is uncertainty as to the preservation of motion or modification of adjacent segment disease, and the long-term efficacy and safety of the procedure needs further study (see Resnick and Watters).