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 Monovisc injections. In the current medical literature, researchers reported that in a multicenter double-blind randomized placebo-controlled trial, the Monovisc group had a significantly greater rate of patient success in 26 weeks compared to saline. Moreover, data has demonstrated that Monovisc is a safe and effective alternative for patients who are not candidates for a total or unicompartmental knee arthroplasty, as in this patients case. With regard to repeated courses of viscosupplementation, the researchers found that repeated courses of intra-articular injections of hyaluronic acid are safe and effective. Furthermore, additional courses of hyaluronic acid were demonstrated to maintain or further improve pain reduction without additional risk. Given these findings, the requested Monovisc injections are medically necessary for treatment of this patients bilateral primary 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: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for an otolaryngology office visit at a tertiary care facility.At issue is whether the requested referral for an otolaryngology office visit at a tertiary care facility is medically necessary to treat the patients condition for any of the following: to prevent disease, disability, and other health conditions or their progression; to prolong life; to promote physical and mental health and efficiency; to correct or ameliorate any physical or behavioral conditions.There is sufficient support for the requested services in this clinical setting. Audiometry follow-up and evaluation of the tympanic membrane after myringotomy and tube placement is part of the standard of care in caring for patients with tubes. In this case, the patient presents with a significant speech delay. He had bilateral tubes placed in 2019. On late 2020, the patient had a vocabulary of 50 words. The plan was for the patient to return in three months. Per the submitted documentation, speech delay is the primary problem in this case. A tertiary care facility is the most appropriate site for follow-up evaluation, which would include speech, audiology, otolaryngology, and pediatric neurology evaluations. Therefore, the requested otolaryngology office visit at a tertiary care facility is medically necessary to prevent disease, disability, and other health conditions or their progression.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 otolaryngology 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

This patient is a four-year-old male with a diagnosis of arthrogryposis, SCAD and history of cerebrovascular accident who is being fed during the night and needs to be maintained in an upright position (it is unclear from the submitted documentation if he is tube fed or fed by mouth).  The parents document that he is somewhat mobile in bed and is thus a fall risk. They also plan to use the bed in order to change his diapers since he is getting larger and is incontinent.  At issue is whether the requested SleepSaferplus is medically necessary.The patient has several needs that should be addressed.  First, routine care necessitates a bed that can be raised and lowered.  The specialty bed requested by the patients parents has a feature that allows for automatic raising and lowering of the bed. This feature is for the purpose of caregiver convenience because this function could be performed with a manual crank.  A second consideration is the possibility that the patient is being tube fed over night.  If so, it is appropriate to have a hospital bed with the ability to raise and lower the head of the bed to prevent aspiration while providing nighttime feedings.  If this is not the case, and the patient is fed orally, then it is not appropriate to feed the child in any form of a reclined position and a hospital bed would not be appropriate.Finally, the safety of the patient is an issue given his documented mobility.  Padded side rails are needed with any style of bed utilized by the patient.  Although the patient does not medically require all of the features of the requested specialty bed, a semi-electric hospital bed with padded side rails would be medically appropriate and indicated if tube feedings occur overnight. It is not recommended that the patient be propped with pillows during feedings if feedings are administered overnight due to the risk of aspiration if the patient rolls off of the pillows.  Based upon the information set forth above, I have determined the requested equipment is not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld

The patient is a 55-year-old male with right hand Dupuytrens contracture involving the middle, ring, and small fingers. The patient reports the right small finger is the most symptomatic. He consulted a hand surgeon who offered surgical release of the Dupuytrens contracture in the right hand. The patient wishes to undergo a needle aponeurotomy instead. The Health Plan has denied authorization and coverage for the requested procedure on the basis it is not medically necessary for treatment of the patients medical condition.Review of the medical evidence reveals no peer-reviewed data demonstrating the efficacy of needle aponeurotomy for treatment of patients such as this patient. Standard treatment for worsening Dupuytrens contracture is not a needle aponeurotomy, but rather, surgical release via an open procedure. The Health Plan has offered the patient care with a hand surgeon. As such, the services offered by the Health Plan are medically reasonable and appropriate. Therefore, I have determined the requested procedure is not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for a custom knee brace. Findings:  The physician reviewer found that the patient presents with extensive injuries that include ACL tear, lateral collateral ligament tear, posterolateral capsular avulsion and avulsion of the biceps tendon from its insertion into the fibular head. The patients recovery has been prolonged and limited by pain and persistent muscle atrophy. He has undergone autologous gracilis tendon grafts and autologous semi-tendinosis grafts. The combination of the original injury and multiple harvesting of hamstring tendon for reconstruction have contributed to a prolonged and limited recovery. His knee with weakened quadriceps and hamstring muscles are vulnerable to re-injury through his activities as a physical education teacher. There is an appropriate need for protective orthotics. The patient is likely to have permanent residual weakness in the limb. He has undergone a physical therapy program and has been discharged with the instruction to continue home based exercises with no further likelihood of strengthening through organized physical therapy. Under these circumstances, a custom fabricated orthotic is medically necessary. Once the initial fitting has taken place then the same design can be utilized over the coming years to provide him the necessary protection in his activities. Final Result: The reviewers 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 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 a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary:   An enrollee has requested Viekira Pak for treatment of his hepatitis C virus. Findings:  The physician reviewer found that according to the 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 limited life expectancy due to non-liver-related conditions. The guidelines report that patients with cirrhosis are highest priority for therapy. Per guidelines, genotype 1b patients with cirrhosis who have failed Sovaldi-based therapy should be treated with a different regimen, such as Harvoni. Ribavirin for 24 weeks and Viekira Pak is not recommended. These guideline recommendations are based on multiple studies showing the effectiveness of Harvoni after Sovaldi failure (Osinusi, et al; Reddy, et al). For cirrhotic patients who have failed Incivek, the AASLD/IDSA guidelines do not recommend Viekira Pak. For this reason, Viekira Pak is not medically necessary for the treatment of this patients hepatitis C infection.  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 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

A 44-year-old female enrollee has requested enhanced external counterpulsation for treatment of her microvascular angina.  Findings:  Two physician reviewers found that enhanced external counterpulsation (EECP) therapy has been shown to have significant effects on chest pain reduction and quality of life scores when used for treatment of un-revascularizable fixed coronary artery disease (CAD). However, there remains a group of patients, a majority of them women, who have persistent and life limiting anginal type symptoms without evidence of fixed obstructive CAD on coronary angiography. It is known that those who continue to have persistent symptoms despite medical therapy have worse long-term outcomes and more cardiovascular events based on the WISE study. Much of this angina is felt to be likely related to abnormal vasodilatory reserve due to both endothelial and non-endothelial depending factors in the coronary arteries, and recently, testing to assess this has become more prevalent. There is also increasing data that EECP therapy improves endothelial dysfunction in patients with symptomatic CAD.This patient has a history of a systemic inflammatory syndrome (SLE) which could be playing a role in the documented endothelial dysfunction, leading to lack of coronary vasodilatory reserve. This could be the cause of her persistent anginal symptoms. Based on the results of the WISE trial, this places the patient at higher risk for long-term cardiovascular events.  She has been maintained on proper medical therapy without relief and nitroglycerin is being utilized to its fullest extent with limited relief as well for her life limiting symptoms. The data regarding EECP suggests usefulness in these isolated cases of significant endothelial dysfunction. Given the failure of conventional medical therapy and the clinical documentation of significant coronary macro and microvascular dysfunction, a trial of EECP is a reasonable next course of action in this particular patient.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Norco 10/325 110 pills per month and Zofran 8mg 40 pills per month. The Health Plan has denied this request indicating that the requested medications are not medically necessary for treatment of the enrollees rheumatoid arthritis. At issue in this case is whether the requested medications, Norco 10/325 110 pills per month and Zofran 8mg 40 pills per month, are medically necessary for treatment of the enrollees medical condition.The Centers for Disease Control clinical practice guidelines do not support the use of opiates in non-malignant pain. The American College of Rheumatology Guideline for the treatment of rheumatoid arthritis also does not include opiates as a treatment modality. The opiates should be tapered and the restricted dispensing is appropriate. As the opiate is tapered, there should be less need for the Zofran and this should be tapered along with the opiate. Therefore, the requested medications Norco and Zofran are not medically necessary.Final Result: The reviewer determined that the requested medications 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 subspecialty 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: Experimental/Investigational
Decision: Upheld

A 26-year-old female enrollee requested authorization and coverage of nuchal translucency screening. The Health Plan  denied the request indicating that the requested genetic screening is considered investigational for evaluation of the enrollees medical condition. Three physician reviewers performed an experimental/investigational Independent Medical Review. All three of the physician reviewers concluded that the requested genetic screening is not likely to be more beneficial for treatment of the enrollee's medical condition than any available standard therapy. Because all three of the three  physician reviewers concluded that the requested genetic screening is not likely to be more beneficial for treatment of the enrollee's medical condition than any available standard therapy, the Health Plans denial has been upheld.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary:  An enrollee has requested Victoza for treatment of the enrollees diabetes.   The physician reviewer found that the submitted documentation supports the medical necessity of the requested medication.  This patient has uncontrolled diabetes.  He is already on basal insulin and requires post prandial control.  Per the medical records, he has been treated with Victoza in the past with good response.  The records indicate that the provider recently ordered laboratory testing to assess the patients current metabolic status as well as hemoglobin A1c level.  Although the results of this testing were not provided for review, the hemoglobin A1c level is not critical to determine the necessity of Victoza.  It is more important to control this patients diabetes to prevent complications.  In this patients case, the requested medication Victoza is medically indicated for this patient so that he can regain diabetes control.  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 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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Roux-en-Y gastric bypass surgery for treatment of the enrollees obesity. Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested services.  Not all patients will be determined to be appropriate candidates for bariatric surgery despite meeting body mass index metrics to meet definition for morbid obesity. Although this patient is an adult with morbid obesity, she was not determined to be an appropriate candidate after completion of a multidisciplinary evaluation at this time. Per the records, she was not found to have obtained psychological clearance. Therefore, the risks of surgery outweigh the potential benefits at this time. All told, the requested Roux-en-Y gastric bypass surgery is not medically necessary for the treatment of this patient. 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 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: The parent of an enrollee has requested reimbursement for RTC services.  The American Academy of Child and Adolescent Psychiatry and the American Association of Community Psychiatrists Child and Adolescent Level of Care Utilization System (CALOCUS) provides a reliable framework for determining the appropriate level of care for adolescents needing mental health treatment. Using CALOCUS, treaters score patients on a scale of 1-5 using a six-pronged Dimensional Rating System. The six dimensions include: (1) risk of harm; (2) functional status; (3) medical, addictive and psychiatric comorbidity; (4) recovery environment (a. stressors and b. supports); (5) treatment and recovery history; and (6) engagement. The composite score is then used to determine the level of care needed. Per CALOCUS, RTC level of care requires a composite score of at least 23.Regarding the six CALOCUS dimensions, the patient has a low risk of harm; has not expressed any suicidal or homicidal ideation or intent (score = 1). Regarding functional status, has had some issues with inappropriate peer relationships as well as a history of school refusal (score = 3). There are no comorbidities noted (score = 1). The patient has a positive recovery environment and a stable housing situation (score = 2) and the patients parents are involved and supportive (score = 2). The patient has had no documented treatment success (score = 3), participates in therapy but has poor coping skills and often will not comply with rules (score = 3) and has parents who work actively and constructively with clinicians (score = 2). For a CALOCUS composite score of 17, the recommended level of care is high-intensity outpatient therapy. Therefore, the RTC services provided were not medically necessary for this patient.Final Result: The reviewer determined that the requested services were not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in psychiatry and specializes in child and adolescent psychiatry, and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

A 53-year-old male enrollee has requested daily use of Cialis 5mg for treatment of his medical condition.  Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested medication. In this patients case, the clinical notes do not document the diagnosis of benign prostatic hypertrophy (BPH). The medical records noted that there were no lower urinary tract symptoms (LUTS), which is a symptom of BPH. Moreover, BPH has not been fully evaluated or addressed as there is no documentation of a digital rectal exam, which should be done to diagnose BPH. Although the patient indicates that he has BPH, the urologists diagnosis did not indicate BPH, and the current medical evidence does not support daily use of Cialis 5mgin this setting. All told, daily use of Cialis 5mg is not medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld

A 47-year-old female enrollee has requested authorization and coverage for revision bilateral mastopexies with bilateral breast capsulorrhaphies.  The Health Plan has denied this request indicating that the requested procedure is not medically necessary for treatment of the enrollees breast ptosis and breast asymmetry.  Findings:  The physician reviewer found that revision bilateral mastopexies with bilateral breast capsulorrhaphies is not medically necessary for the patients medical condition. A submitted photograph shows a slightly larger right than left breast.  There is minimal drooping of the breasts, more so on the right. There is no visible capsular contracture.  The visible mastopexy scars around the areola and extending vertically downward from the areola are not hypertrophic or keloid. This is within the accepted normal human anatomic variation for the appearance of female breasts.  The current condition does not constitute an abnormal structure of the body, as the degree of asymmetry and ptosis is within the range of normal appearance. All told, the requested revision bilateral mastopexies with bilateral breast capsulorrhaphies is not reconstructive in nature and is not medically necessary for the treatment of this patient.