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 custom foot orthotic inserts. The current medical evidence supports the requested equipment in this clinical setting. Researchers concluded that the use of custom-made foot orthoses improved the level of forefoot pain in rheumatoid arthritis, hallux valgus and secondary metatarsalgia. This patient presents with severe foot pain and functional mobility limitations. Clinical examination findings and radiographic evidence are consistent with a pes planus deformity and hallux valgus. He has failed to improve with activity modification. The literature supports the use of custom orthotics in this clinical setting. Therefore, custom foot orthotic inserts are medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested equipment 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

Nature of Statutory Criteria/Case Summary:   An enrollee has requested Subsys spray for treatment of his malignant neoplasm of larynx and chronic pain syndrome.  The physician review found that according to the National Comprehensive Cancer Network (NCCN), rapidly acting transmucosal fentanyl may be considered in patients who are opioid-dependent and have brief episodes of pain that is not effectively controlled or attributed to inadequate dosing of around-the-clock opioids medications. The NCCN guidelines also indicate that transmucosal fentanyl is often the choice for patients who are unable to swallow. Additionally, the U.S. Food and Drug Administration (FDA) states that Subsys is indicated for the management of breakthrough pain in adults with cancer, who are already routinely taking other opioid pain medicines around-the-clock for cancer pain. The documentation provided for review indicates that the patient has been diagnosed with metastatic nasopharyngeal carcinoma of the neck that is associated with severe neck pain and swallowing difficulties. The patient is currently prescribed oxycodone and Vicodin for management of the cancer pain which was noted to adequate control the pain. However, the documentation also indicates that the patient has continued complaints of unpredictable episodes of breakthrough pain. Overall, the medical literature supports the use of Subsys in this clinical setting for this patients breakthrough cancer pain despite treatment with 24-hour opioid medications. Therefore, based on the referenced medical literature, the requested Subsys spray is medically necessary. 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 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

A 48-year-old female enrollee has requested a panniculectomy for treatment of her excess skin.  Findings:  The physician reviewer found that this patient has an abdominal pannus with photographic evidence of intertrigo and PCP notes that confirm treatment for chronic infections since 2004.  Her rashes have persisted despite the use of antifungal powders. This patient has a large pannus with recurrent infections.  Her history is confirmed by photographs and PCP notes. Because the patient has persistent infections despite conservative care, the requested panniculectomy is medically necessary.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for the bilateral Orthovisc injection series into the knees. Per the medical literature, although viscosupplementation may relieve knee pain in some individuals with osteoarthritis, it is not known as to 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. 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 patient has a history of relief from prior injections and reported only short-term relief from other conservative treatments. Given the patients limited options and based on the current medical literature, the requested services are medically indicated. Therefore, Orthovisc injection series into the knees were medically necessary for the 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: Medical Necessity
Decision: Overturned

A 63-year-old male enrollee requested authorization and coverage of continued treatment with the medication Serostim. The Health Plan denied the request indicating that the requested medication is not medically necessary for treatment of the enrollees lipodystrophy.One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer overturned the Health Plans denial on the basis that the requested medication is medically necessary.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested authorization and coverage for Nutropin AQ Nuspin.Nutropin AQ Nuspin is one of several FDA-approved formulations of somatotropin (growth hormone). FDA-approved indications for somatotropin in youth with open physes include growth hormone deficiency (GHD) evidenced by multiple clinical criteria such as hypoglycemia or length small-for-gestational age (SGA) in the newborn period, pathological GH or IGF-I gene mutation, or growth failure during childhood or adolescence (e.g., height z-score more than 1.5 standard deviations below MPTH z-score after adjusting for bone age; height z-score below -2; growth velocity below 10th percentile; IGF-I z-score below -2; IGFBP-3 z-score below -2; failure of peak circulating GH level to exceed 10 ng/mL either upon insulin-induced hypoglycemia or after two independent provocative agents other than insulin administered to a non-obese child).  Other FDA-approved indications for somatotropin in youth with open physes include SHOX gene haplosufficiency, Noonan syndrome, Turner syndrome, idiopathic short stature with height z-score below -2.25, growth failure due to renal insufficiency prior to renal transplant, and SGA with failure to display catch up growth by age 2 years.In this case, the patient is obese and with normal stature, and he displays a growth velocity that is consistent with his early pubertal development (Tanner stage 2). The failure of GH to rise after modest provocation, despite some priming by puberty, is a well-recognized, spurious phenomenon in obese pediatric patients who have intact GH production. The submitted documentation does not support any FDA-approved indication for somatotropin with respect to the patient. Under these circumstances, Nutropin AQ Nuspin is not medically necessary for the patients medical condition.Final Result: The reviewer determined that the requested medication is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is board certified in pediatrics, with subspecialty certification in pediatric endocrinology, and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Duavee. Menopausal management is a very complex issue. Enrollees have a variety of physiologic and emotional symptoms related to the change in their hormonal milieu that occurs with cessation of ovarian and/or adrenal hormonal production. Management of these symptoms typically needs to be individualized and tailored to help address the specific symptoms the enrollee may be experiencing and kept in context with any other medical issues they may have. Some of these more traditional hormonal and non-hormonal therapies include exercise, weight loss, stress reduction, biofeedback, counseling, and serotonin reuptake drugs, most specifically Paxil. For vaginal symptoms, management can include topical lubricants and moisturizers and topical estrogens. In this enrollees case, the records indicate that the enrollee's menopausal symptoms included occasional hot flashes and vaginal dryness. There are other available options for the treatment of this enrollee. If it is deemed that the enrollee can be given oral estrogens, then it would be reasonable to consider some of the other estrogens with a more traditional progestin. If the risks associated with estrogens and their potential relationship to uterine or other breast/reproductive cancers is driving management, then the use of non-hormonal management, such as Paxil, may be a better option. Duavee has not been found to be safer than other combination options. Therefore, Duavee is not medically necessary for the treatment of this enrollee. Final Result: The reviewer determined that the requested medication is not medically necessary for treatment of the enrollees medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is board certified in obstetrics and gynecology 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 has requested authorization and coverage for Orthovisc weekly injections x 3 in the left knee. Per the medical literature, although viscosupplementation may relieve knee pain in some individuals with osteoarthritis, it is not known as to 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. 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, patient has tried and failed other conservative treatments. Given the patients limited options and based on the current medical literature, the requested services are medically indicated. Therefore, Orthovisc weekly injections x 3 in the left knee is 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 surgery to remove and/or repair hernia mesh for treatment of the enrollees left lower quadrant abdominal pain, bilateral inguinal hernia, and groin pain. Findings:  The physician reviewer found that chronic postoperative pain is common after inguinal hernia repair. According to data from the Swedish Hernia Registry, 218 out of 167,760 patients underwent reoperation for chronic groin pain. Risk factors for reoperation included young age, female gender, direct hernia, a previous Lichtenstein or plug repair, bilateral repair, and postoperative complications. Colleagues developed an international consensus algorithm for management of chronic postoperative inguinal pain. The authors noted that if an expectative phase of a few months has passed without any amelioration of chronic postoperative inguinal pain, a multidisciplinary approach is indicated and a pain management team should be consulted. Pharmacologic, behavioral, and interventional modalities including nerve blocks are essential. If conservative measures fail and surgery is considered, triple neurectomy, correction for recurrence with or without neurectomy, and meshoma removal if indicated should be performed. Colleagues performed a randomized controlled trial of injection therapy versus neurectomy for postherniorraphy inguinal neuralgia and reported that of the 54 patients randomized, tender point infiltration was successful in 22% while neurectomy was successful in 71%.  The authors concluded that a step up treatment strategy starting with tender point infiltration followed by a tailored neurectomy is advised. This patient has multiple risk factors for chronic postoperative groin pain including young age, previous plug repair, and bilateral repair. Given these recommendations, the patient should proceed with pain management consultation including possible nerve blocks or tender point infiltration prior to any consideration for surgery for neurectomy or mesh removal. Accordingly, the requested surgery to remove and/or repair hernia mesh is not medically necessary. Final Result: The reviewer determined that the requested surgery is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in general 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

A 70-year-old female enrollee requested authorization and coverage of continued home health care for the treatment of her medical condition.  The Health Plan denied the enrollees request indicating that the requested treatment is not medically necessary.One physician reviewer performed a medical necessity Independent Medical Review.  The physician reviewer upheld the health plans denial on the basis that the requested services are not medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld

A 45-year-old male enrollee has requested Botox injections for the treatment of his lower back pain. Findings:  The physician reviewer found that there is a lack of evidence of effectiveness of Botox in chronic axial back pain. The clinical practice guidelines for chronic non-malignant pain syndrome do not support the use of Botox in this situation.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary:   An enrollee has requested Orthovisc injections to the knee for treatment of his osteoarthritis.  Findings:  The physician reviewer found that there is a lack of support in evidence based literature for Orthovisc injections for treatment of this patients medical condition. Studies have also shown the possibility of complications such as iatrogenic intraarticular infection and sensitivity reactions to hyaluronan injections. Moreover, the basic science rationale for administering hyaluronan to manage and treat arthritis of the knee has not been confirmed. Long-term tissue reaction to break down products of hyaluronan as well as acute reactions should be considered. Therefore, due to the lack of clinical evidence supporting the use of hyaluronan injections for treatment of osteoarthritis of the knees, the requested Orthovisc injections 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.  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 mother of a five-year-old male enrollee requested authorization and coverage of continued speech therapy. The Health Plan denied the request indicating that the requested therapy is not medically necessary for treatment of the enrollees speech delay.One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer upheld the Health Plans denial on the basis that the requested therapy is not medically necessary.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/ Case Summary:  The enrollees parent requested authorization and coverage for Relizorb. The enrollee has a history of cystic fibrosis, pancreatic insufficiency, gastroparesis and suboptimal weight gain, despite gastrostomy tube feeding.  The pediatric gastroenterologist indicated that an attempt was previously made to increase Peptamen 1.5 overnight to three cans, but the enrollee began vomiting. His Marinol was increased to twice a day and his weight increased by one and a half pounds. His body mass index increased from four to five percent. The provider indicated he is not a sedation candidate, so he needs maximal medical management of gastroparesis. Relizorb, 12 cartridges, is recommended. The medical literature indicates the Relizorb cartridge is safe and well tolerated, and resulted in increased levels of plasma fatty acids, suggesting overall increased fat absorption. Scientific evidence shows Relizorb is superior to the available pancreatic enzyme replacement products in terms of effectiveness and compatibility with tube feeding. There is sufficient scientific evidence supporting the safety and effectiveness of Relizorb in improving fat absorption in enrollees with pancreatic insufficiency and cystic fibrosis. Therefore, Relizorb is more beneficial and more appropriate than the available alternatives. Final Result: Three of the three reviewers determined that the requested service is likely to be more beneficial than any available standard therapy for treatment of the enrollees medical condition. Credentials/Qualifications: Two reviewers are board certified in pediatric gastroenterology, one is board certified 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

A 66-year-old male enrollee has requested anesthesia administered during a colonoscopy for treatment of his history of chronic diarrhea. Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the services at issue in this patients case.  The American Association of Anesthesiologists notes that moderate sedation is generally recommended for both diagnostic and uncomplicated therapeutic endoscopic procedures. Moderate sedation involves the administration of medication with or without analgesia to achieve a state of depressed consciousness while maintaining the patients ability to respond to stimulation. For routine endoscopic procedures and screenings among patients without risk factors or significant medical conditions, moderate sedation, which can be administered by the endoscopist, is considered a sufficient level of sedation.Monitored anesthesia case is directly provided by anesthesia personnel and may include varying levels of sedation, analgesics, and anxiolysis.  The American College of Gastroenterology states that the use of deep sedation is medically necessary when there is documentation by the endoscopist and the anesthesiologist that specific risk factors or significant medical conditions are present. Those risk factors or significant medical conditions include prolonged or therapeutic endoscopic procedures requiring deep sedation, increased risk for complications due to severe comorbidity (ASA class III or greater), and history of anticipated intolerance to standard sedatives.  Additionally, patients who are younger than 12 years of age, patients 70 years of age or older, patients with active medical problems related to drug or alcohol abuse, acutely agitated uncooperative patients, and patients at increased risk for airway obstruction due to anatomic variation may also require monitored anesthesia care.In this patients case, the records do not document a specific medical comorbidity that necessitated the use of deep sedation for the colonoscopy.  The patient was an acceptable and appropriate candidate for moderate sedation to be administered by the endoscopist.  All told, anesthesia administered during the colonoscopy performed on the date in question was not medically indicated in this clinical setting.
Appeal type: Experimental/Investigational
Decision: Upheld

A 39-year-old female enrollee requested authorization and coverage of bariatric surgery by a laparoscopic vertical gastrectomy and duodenal switch procedure. The Health Plan denied the request indicating that the requested procedure is considered experimental for treatment of the enrollees morbid obesity.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 enrollee'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.