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

Patient has tried and failed conservative treatment, including corticosteroid injections that only provided short-term relief and was able to decrease her use of antiinflammatories. She has benefitted from viscosupplementation with Euflexxa in the past and the provider has recommended repeat Euflexxa injections into both knees. At issue is whether Euflexxa knee injections are medically necessary for treatment of this patient.According to Maheu and colleagues, intra-articular hyaluronic acid provides a moderate symptomatic benefit to knee osteoarthritis patients without major safety concerns. Viscosupplementation may offer one of the best benefit-to-risk ratios among pharmacologic options, as measured by improvements in knee osteoarthritis symptoms, overall gain in quality of life, and substantial delay in time to total knee replacement. The clinical benefits of intra-articular hyaluronic acid on knee osteoarthritis may include lubrication and shock absorption of the joint, and the re-establishment of joint homeostasis. In this case, the patient has a history of significant benefit from prior Euflexxa injections. Given this support, the requested Euflexxa injections for both knees are medically necessary for treatment of this patients osteoarthritis of the knees.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

A 51-year-old female enrollee has requested Synvisc (Euflexxa) injections for treatment of her right knee osteoarthritis and degenerative joint disease.  Findings:  The physician reviewer found that the medical records provided for review evidence long-term care for multiple orthopedic conditions in the upper and lower extremities. At the knee, there is subjective documentation of medial compartment narrowing and patellar facet chondromalacia changes. X-rays demonstrated prior tibial tubercle transposition or Houser procedure. The records document a previous positive response to prior hyaluronan injections. However, there is limited or no benefit demonstrated in well-designed, double-blinded studies, but there is the possibility of acute local reactions. All told, the requested Synvisc (Euflexxa) injections are not supported as medically necessary for treatment of this patients medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for advanced lipoprotein testing for evaluation of the enrollees hyperlipidemia. Findings:  The physician reviewer found that based on the records provided the patient presented with increased cardiovascular risk.  In this circumstance guidelines for the management of cardiac risk and dyslipidemia have been established, are periodically updated by expert committees and are endorsed by several national organizations. These guidelines currently do not recommend routine performance of specialized tests in the context of assessing coronary risk including lipoprotein-associated phospholipase A2, sub-classifications of low-density lipoprotein (LDL), high-density lipoprotein (HDL) subclasses, lipoprotein(a), CRP, high sensitivity CRP, insulin, fibrinogen, genetic testing and homocysteine. Treatment change or addition based on the results of screening with these specialized tests has not been shown to improve cardiac outcome incremental to that achievable by treatment based on standard risk factor profiling and basic lipid analysis. Even though results of some of these specialized tests may be abnormal and considered independent risk markers for coronary disease, there is a lack of controlled trials that demonstrate outcome benefits by treating routinely obtained abnormal results. Therefore, the advanced lipoprotein testing provided was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Final Result: The reviewers determined that the testing at issue was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: Reviewers 1, 2 and 3 are board certified in internal medicine with sub-specialty certification in cardiovascular disease and are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for Afirma gene expression classifier for evaluation of her indeterminate thyroid nodule. Findings:  All three physician reviewers found that while Fine Needle Aspiration biopsy of a suspicious thyroid nodule is typically an accurate means of assessing whether the nodule is benign or malignant, approximately 15% of Fine Needle Aspiration biopsy results are considered indeterminate (Alexander, et al). Until recently, studies have shown that the only way to establish whether the nodule was in fact thyroid cancer was via surgical excision even though the majority of the cases turn out to be benign. The Afirma Thyroid Fine Needle Aspiration Analysis utilizes a gene expression classifier in order to help determine the likelihood of malignancy of nodules with indeterminate cytology on Fine Needle Aspiration biopsy, thereby decreasing unnecessary surgeries. Because it is very sensitive and has a high negative predictive value, a negative Afirma result is rather suggestive of a benign nodule and can therefore preclude such surgical procedures. For the reasons stated above, the Afirma gene expression classifier provided was likely to have been more beneficial for the evaluation of this patient than any available standard therapy. Final Result: The reviewers determined that the services at issue were likely to be more beneficial for the 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, diabetes and metabolism and is actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

The parent of an eight-month-old male enrollee has requested a cranial remolding orthosis (DOC band) for treatment of the enrollees plagiocephaly and brachycephaly.  Findings:  The physician reviewer found that the records do not indicate that the patient has cervical motion restriction. In addition, there is no documentation of skin complications other than dermatitis noted that pre-dates the cranial orthotic device application. Moreover, no documentation was provided of a skin complication that impacted the utilization of the cranial orthotic device. Further, the patient does not have cephalic index that is more than two standard deviations from the mean. Given the documentation provided for the review, the cranial orthotic device is not medically necessary for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld

A 59-year-old male has requested a third penile implant for treatment of his Peyronies disease.  Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested third penile implant in this patients case.  Per the medical records, he underwent placement of an inflatable penile prosthesis eight years ago.  The documentation noted that the patient was not satisfied with the length of the device and desired to undergo placement of a larger device.  Subsequently, replacement of the penile prosthesis was performed the following year.  This patient is now requesting coverage for a third penile implant.  The current medical evidence does not support the services at issue in this clinical setting.  The requested third penile implant will involve a high risk for complications and infection.  All told, the requested services are not medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Overturned

The enrollee is requesting authorization and coverage for the medication, Tecfidera for multiple sclerosis. The enrollee wants to change to an oral medication. The neurologist prescribed Tecfidera as the enrollee has already used Copaxone and Glatopa. The enrollee is unable to self-administer the injections because of the large number of painful nodules that have developed in his suitable injection sites. The physician has indicated the appropriate therapy is to discontinue Copaxone and start Tecfidera, an oral agent, to treat his multiple sclerosis. Gilenya is not an appropriate therapy for this enrollee because he also has diabetes mellitus and Gilenya carries a cardiac and infection risk. The enrollee has multiple sclerosis and is currently on an injectable medication, but can no longer tolerate the injections. The other injectable formulary medication, interferon, would have similar problems. As such, an oral agent is medically necessary. Dimethyl fumarate (Tecfidera) is a well-studied oral agent with a good safety profile that is used to treat multiple sclerosis. It is a good alternative for those who do not want or cannot tolerate injectable medications. Literature notes dimethyl fumarate is an oral disease-modifying therapy approved for the management of relapsing-remitting multiple sclerosis individuals. Results from phase three clinical trials and follow-up studies provide good evidence of its efficacy and safety profile. Reported outcomes showed a stabilization or boost in health-related quality of life for those treated with dimethyl fumarate compared to placebo, reflecting higher enrollee satisfaction with therapy. General neurology standards of care for the treatment of multiple sclerosis allow for the use of any disease-modifying therapy that the provider feels is appropriate for the patient. Tecfidera is indicated for the treatment of patients with relapsing forms of multiple sclerosis. Given the patient has been utilizing Copaxone, but is having difficulty with his injections, it would be considered standard of care to change the patient to an oral medication.  Final Result: The reviewer determined that the requested service is medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The physician 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 similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

A 40-year-old female enrollee has requested  for a panniculectomy for treatment of her redundant skin condition.  Findings:  The physician reviewer found that the patient has generalized skin laxity consistent with her history of massive weight loss. Correction of skin laxity following massive weight loss is generally considered cosmetic in the absence of clear and compelling documentation of specific signs and symptoms that (1) are plainly related to the excess skin (2) are health threatening or cause significant functional disability and (3) have failed to improve despite reasonable attempts at conservative therapy. A reasonable standard for evaluating the medical necessity of potentially cosmetic surgery is whether the submitted records include confirmatory evidence of a chronic functional problem that has failed reasonable attempts at conservative therapy. The proposed procedure does not meet this standard as there is no documentation over time of skin infections in the abdominal folds (e.g., series of office notes, dermatology consultations, or prescription records) and no photographs documenting cellulitis, ulcerations or rashes were submitted. Additionally, the American Society of Plastic Surgeons criteria for third party coverage of skin resection following massive weight loss has not been satisfied as  the records do not document panniculitis or the failure of medically supervised conservative therapy to control intertrigo. A panniculectomy may be desirable for aesthetic reasons, but it is not medically indicated.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a 15-year-old female enrollee requested authorization and coverage of continued residential treatment for treatment of bipolar disorder.  The health plan denied the enrollees request indicating that continued residential treatment is not medically necessary.One physician reviewer performed a medical necessity Independent Medical Review.  The physician reviewer overturned the health plans denial on the basis that the requested services are medically necessary.
Appeal type: Experimental/Investigational
Decision: Upheld

A 37-year-old female enrollee requested the Acessa procedure that uses radiofrequency ablation for medical treatment of her uterine fibroids.  Findings:  Three physician reviewers found that the requested services are not likely to be more effective than other treatment options.  A CT scan is not a reliable or preferred method to address the size and location of uterine fibroids.  The current medical evidence supports a laparoscopic or open myomectomy in this clinical setting.  The Acessa procedure has not been recommended in women wishing to retain reproduction capabilities.  Myoma coagulation or myolysis has been associated with adhesion formation and may increase the risk of uterine rupture in pregnancy.  All told, the superior efficacy of the requested Acessa procedure that uses radiofrequency ablation has not been established.
Appeal type: Medical Necessity
Decision: Overturned

An 18-year-old female enrollee has requested reimbursement for chemical dependency inpatient detoxification treatment provided over four days for treatment of the enrollees opioid dependence. Findings:  The physician reviewer found that the submitted documentation demonstrates the medical necessity of the services at issue in this patients case.  This patient was experiencing opiate withdrawal following chronic use of heroin for at least six months.  Her symptoms were consistent with opiate withdrawal.  She reported significant withdrawal symptoms when she was not using heroin.  Additionally, the medical records noted a history of anxiety, depression, and post-traumatic stress disorder.  The current medical literature supports the services at issue in this clinical setting.  Given this patients condition, multiple medications were required for managing her opiate withdrawal.  All told, chemical dependency inpatient detoxification provided over the dates in questions was medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Euflexxa injections. The Health Plan has denied this request indicating that the requested medication is not medically necessary for treatment of the enrollees osteoarthritis.The submitted documentation supports the medical necessity of the requested medication. A study conducted a systematic review on the efficacy and safety of repeat courses of hyaluronan therapy in patients with osteoarthritis of the knee and concluded that repeat courses of the hyaluronans were safe and effective in the treatment of pain associated with osteoarthritis of the knee. Current medical guidelines state that hyaluronic acid injections in the knee are recommended as a possible option for patients with severe osteoarthritis who have not responded adequately to recommended conservative treatments for at least three months, including failure to adequately respond to aspiration and injection of intra-articular steroids. There is no maximum amount of injections established by high-quality scientific evidence. This patient presents with significant left knee pain that is limiting her activities of daily living. Clinical examination findings are consistent with reported bone-on-bone right knee osteoarthritis. Reasonable conservative treatment, including medications and activity modification, have failed to provide adequate symptom relief. Prior viscosupplementation has been performed on at least two prior occasions, with good benefit and 50% pain reduction for at least six months. The medical literature supports the use of viscosupplementation injections for the treatment of pain in patients with osteoarthritis of the knee. Repeat viscosupplementation injections have been found to be safe and effective and allow for delay of knee replacement surgery. Given the previous response, repeat viscosupplementation injections are indicated. Therefore, the requested Euflexxa injections are 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 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 requested a one-on-one visit with a nutrition specialist for medical treatment of her diabetes. Findings:  The physician reviewer found that the submitted documentation supports the requested services in this clinical setting.  This patient has a high BMI and has type 2 diabetes mellitus.  Lifestyle interventions and medical nutritional therapy are essential cornerstones of diabetes management.  It is standard of care that obese patients with diabetes be referred to individualized medical nutritional therapy as part of diabetes self-management education, especially if they have been unsuccessful in losing weight.  A patient with morbid obesity requires individualized medical nutritional therapy.  A weight loss of 5% or greater may have significant effect in the outcomes and improvement of diabetes and blood pressure control.  All told, the requested one-on-one visit with a nutrition specialist is medically indicated 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 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: Upheld

The enrollee is requesting authorization and coverage for Monovisc injection in the right knee. The enrollee has a history of right meniscus surgery. He described a sudden onset of pain in his right knee after rising from the couch. He was seen by a sports medicine provider for right lateral knee pain. He received a corticosteroid injection and right knee x-ray showed no evidence of fracture or acute bony abnormalities, but it demonstrated tricompartmental osteoarthritis, most severe in the lateral compartment, with near bone-on-bone apposition on the posteroanterior view. The physician also submitted a request for authorization of Monovisc injection for the right knee. Review of the record indicates physical examination showed trace effusion to the right knee with no tenderness.  There was 3-120 degrees range of motion to the right and crepitus with range of motion to the right.  X-rays were obtained showing tricompartmental osteoarthritis most severe in the lateral compartment with near bone-on-bone apposition. According to the medical literature, hyaluronic acid injection is indicated for enrollees with symptomatic osteoarthritis who have not responded adequately to conservative non-pharmacologic therapy and simple analgesics, such as acetaminophen. The medical literature does not recommend the use of hyaluronic acid injections in enrollees with symptomatic osteoarthritis of the knee unless a clear and compelling rationale for an alternative approach is present. The records indicate the enrollee was evaluated for knee pain. The treatment plan included physical therapy and an unloader brace. A corticosteroid injection was administered and a request for Monovisc was submitted. However, there is insufficient evidence of follow-up in the record indicating a clear, compelling rationale for the requested Monovisc injection.  Records do not substantiate the enrollee continues to have symptoms, despite the recommended treatment nor trials of other treatment modalities.Final Result: The reviewer determined that the requested service is not medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The physician 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 similar medical condition.