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

Findings:  The physician reviewer found that the enrollee has a history of osteoarthritis of both knees. She has failed other treatments, including physical therapy, weight loss attempts, nonsteroidal anti-inflammatory drugs, and corticosteroid injections. However, she benefitted from viscosupplementation in the past. She has recurrence of pain in both knees and the provider has requested repeat viscosupplementation with Hyalgan. Review of the recent literature with regard to use of viscosupplementation for management of osteoarthritis of the knees continues to support the use of viscosupplementation for osteoarthritis of the knees. According to researchers, intra-articular hyaluronic acid provides a moderate symptomatic benefit to knee osteoarthritis patients without major safety concerns. In addition, another research reported on a systematic review of overlapping meta-analyses comparing viscosupplementation with other nonoperative treatment modalities for knee osteoarthritis. The researchers found that the current highest level of evidence suggests that intra-articular hyaluronic acid is a viable option for knee osteoarthritis. Moreover, intra-articular hyaluronic acid results in improvements in knee pain and function that can persist for up to 26 weeks. Intra-articular hyaluronic acid has a good safety profile, and its use should be considered in patients with knee osteoarthritis. As such, the request for Hyalgan injections of both knees is medically necessary for treatment of this patients knee osteoarthritis.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 residential treatment center services. Diagnoses include bipolar disorder, depression, and substance abuse. He presented for admission to residential treatment complaining of depression and reporting homelessness. At admission, he denied suicidal or homicidal ideation, and although agitated, there was no evidence of a desire to be aggressive or violent towards others. He was capable of caring for himself and performing all activities of daily living. He demonstrated capability and willingness to participate in treatment. There are no other emotional, behavioral, or cognitive factors requiring 24/7 nursing and medical monitoring. He was medically and psychiatrically stable to the point that he did not require this type of structured setting, the medication management was of an outpatient nature. The medication noncompliance issues could have been dealt with on an ambulatory level of care as they were chronic in nature and were not acutely life threatening. Lack of social support does not require residential level of care. 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 geriatric 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: Overturned

Nature of Statutory Criteria/Case Summary:  An enrollee has requested authorization and coverage for Humira. There is sufficient support for the requested medication in this patients case. Granuloma annulare (GA) is a non-infectious condition characterized by annular papules. Generalized GA can be disfiguring because of the extensive dissemination of the lesions. Generalized GA may lead to scarring most pronounced on sun-exposed areas. Recently, tumor necrosis factor (TNF)-alpha inhibitors have been reported to improve GA. Humira (adalimumab) is an alternative agent that binds to membrane-bound and soluble TNF-alpha, showing great promise in treating recalcitrant, generalized GA. The medical evidence indicates that Humira may be an effective and well-tolerated treatment for GA. It may be particular benefit for patients who have generalized or disseminated GA. Therefore, Humira 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 dermatology 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 40-year-old male enrollee requested authorization and coverage of a series of Synvisc injections. The Health Plan  denied the request indicating that the requested therapy is not medically necessary for treatment of the enrollees knee pain.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: Medical Necessity
Decision: Upheld

A 55-year-old male enrollee has requested hernia surgery for treatment of his hernia. Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested services in this clinical setting.  The current medical evidence does not support the requested services in this patients case.  He has end stage liver cirrhosis, and the medical records document a left inguinal hernia.  The documentation noted that the hernia is reducible.  Given this patients significant liver disease, surgical treatment is associated with significant risks including bleeding, ascitic leak, and infection.  As the hernia is reducible, conservative management is indicated.  All told, hernia surgery is not medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Overturned

A 37-year-old female enrollee has requested anesthesia and hospital services for extraction of wisdom teeth for treatment of the enrollees medical condition. Findings:  The physician reviewer found that the patient has Goldenhar syndrome and is need of having her wisdom teeth removed. Given that her oral surgeon has recommended that the procedure be accomplished under general anesthesia rather than local anesthesia, performance of this procedure in a setting with an available anesthesiologist is prudent and consistent with sound clinical judgment. Goldenhar syndrome is a rare congenital deformity which has associated facial and oral anomalies that have been known to cause airway management challenges. Involving an anesthesiologist is appropriate in the event a complication secondary to airway management develops.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement and prospective authorization and coverage for skilled nursing facility (SNF) level of care services including occupational therapy and physical therapy services. Based on the documentation provided for review and medical literature, this patient does not require SNF services with the specialized skill, knowledge and judgment of a skilled nurse to administer medical treatment. The records do not indicate that the patient has a tracheostomy tube, enteral feedings, complex wound care or other SNF level skilled nursing need. This patients functional level with limited weight bearing did not require skilled therapy services with the specialized skill, knowledge and judgment of a qualified therapist. The patient does not require daily skilled nursing, skilled therapy services, or a combination of these services. Although the patient is likely to benefit from occupational therapy and physical therapy services, the patient does not require these services on a daily basis. For these reasons, SNF level of care services including occupational therapy and physical therapy services were not and are not medically necessary for treatment of this patient. Final Result: The reviewer determined that the services at issue were not and 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 physical medicine and rehabilitation with subspecialty certification in neuromuscular 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

An 81-year-old female enrollee has requested an electric wheelchair for treatment of her history of falls. Findings: The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested equipment in this patients case.  The records forwarded for review do not establish that the patient would be bed or chair confined without a power mobility device.  The records indicate that she has functional strength in the upper limbs.  She has no focal neurological deficits.  She is able to ambulate functionally.  An electric wheelchair would be used for community mobility.  In addition, the records do not establish that the patients mobility needs, including community mobility needs, could not be met with a walker with a seat, or a manual wheelchair.  Manual wheelchair use has been shown to provide significant health benefits over electric wheelchair use for persons with mobility impairments.  Thus, the requested electric wheelchair is not medically indicated in this clinical setting.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary:  An enrollee has requested authorization and coverage for hyaluronic acid injection.An exhaustive review of the current medical literature pertaining to viscosupplementation reveals mixed results. Evidence from eight systematic reviews and six randomized controlled trials indicates that although viscosupplementation may relieve knee pain in some individuals with osteoarthritis, it is not known as to which individuals will benefit. Different studies have tried mixing hyaluronic acid with corticosteroids, platelet rich plasma, and other agents to make it more effective. The current evidence is limited, and guidelines from organizations such as the American Academy of Orthopedic Surgeons indicate that the evidence is not conclusive. In light of the foregoing, viscosupplementation can only be recommended in individuals with a history of lasting benefit from prior injections, and in carefully selected cases where everything else has been tried, and the options are limited. In this case, the patients options are limited. The patient has tried other conservative treatments, including corticosteroid injections, which provided little improvement. The alternative is a total knee arthroplasty in the presence of mild osteoarthritis. Therefore, the requested hyaluronic acid injection is medically necessary for the treatment of the patients medical condition.Final Result: The reviewer determined that the requested services are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in 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 19-year-old female enrollee has requested residential treatment center (RTC) services for treatment of her eating disorder.   Findings:  The physician reviewer found that the residential treatment center (RTC) services provided from the time period specified were not medically necessary for treatment of the patients medical condition. On admission and throughout her stay the patient denied suicidal/homicidal ideation. Her vital signs were stable, and ideal body weight was 100%. She had ALT elevation of 118 but all other liver function, electrolyte, and complete blood count (CBC) values were essentially within normal limits. The ALT subsequently reverted to within normal limits. She reported that she has days in which she ate 3 meals per day with snacks and engaged in binging/purging behavior 3-4 times per week prior to admission. In sum, this patient could have been safely and effectively treated at a lower level of care. She was not at imminent risk to develop a serious medical complication from her eating disorder during the dates of service in dispute. The changes in her medications, her binging/purging behaviors, and her ALT elevation were all elements that could have been managed on an outpatient basis and did not require 24-hour supervision in a residential setting. Based on the medical literature cited above and the documentation submitted for review, the services at issue were not medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld

A 44-year-old female enrollee requested authorization and coverage of an abdominoplasty for the treatment of lower abdominal panniculus.  The health plan denied the enrollees request indicating that the requested procedure 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 procedure is not medically necessary.
Appeal type: Medical Necessity
Decision: Upheld

A 35-year-old male enrollee has requested an MRI of the spine for an evaluation of his back pain. Findings:  The physician reviewer found that the patients imaging studies for musculoskeletal pain show fairly minor changes.  An MRI of the lumbar spine was performed for complaints of back pain. The findings were modest to mild facet arthropathy and minimal disc changes. The patient has been approved for physical therapy, and the records do not demonstrate that he has seen an orthopedic specialist or neurologist. An MRI of the spine is not medically indicated for evaluation of this patient. This patient does not have any of the worrisome symptoms listed in the paper by Rankine and colleagues. These include progressive neurologic deficit, associated fevers, systemic illness, history of cancer or unexplained weight loss.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Grafix core, grafixpl core, Grafix Prime, grafix pl prime, and application for treatment of the enrollees burn wound. Findings:  The physician reviewers found that Grafix has been mostly used to assist in healing with chronic wounds such as diabetic foot ulcers. The use of Grafix in burn treatment is more limited and these products have not become the standard of care in this clinical setting. The patient had a chronic wound from a full-thickness burn sustained three months previously. The medical history received for review indicated that no debridement of the burn had been performed except for the application of enzymatic ointment because of patient sensitivity. A formal wound debridement was performed after infiltration of local anesthetic, and slough was debrided. The wound that resulted from the debridement of the full-thickness burn was effectively an acute wound. The use of Grafix to potentially augment wound healing is not supported by large studies and its use for an acute full-thickness wound following debridement remains of unproven efficacy at this time. In sum, Graphix core, grafixpl core, Grafix Prime, grafix pl prime and application are not likely to be more efficacious than the standard techniques for the treatment of this patients wound.Final Result: Two of the three reviewers determined the requested services are not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications:  All three reviewers are board certified in plastic surgery 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

A 55-year-old female enrollee has requested 14 additional physical therapy (PT) sessions for the treatment of her multiple sclerosis. Findings:  The physician reviewer found that eight (8) additional physical therapy visits are medically necessary to improve the patients balance, establish safe all-day use of the right AFO and meet the goal of ambulation without a cane. Although there is no documentation of recent injury, the patients physician does document recent changes including worsening spasticity and worsening gait/balance. The patients multiple sclerosis appears to be progressive and thus supports the medical necessity of additional physical therapy. Medicare guidelines allow use of outpatient supervised skilled physical therapy until progress is continuing and the skills of a physical therapist are no longer required to safely achieve this progress. All told, eight (8) additional physical therapy sessions should allow the patient to achieve safe, independent gait; the ability to tolerate the AFO up to 8 to 10 hours per day (the length of a work day); and establish a safe home exercise program.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollees parent has requested authorization and coverage for whole body positron emission tomography with computed tomography (PET/CT) for attenuation (CPT code 78816). Fibromyxoid sarcoma often displays aggressive and malignant behavior with high rates of local recurrence and metastases. PET/CT is sensitive for the detection of metastatic disease. Due to fibromyxoid sarcomas relatively benign histology, the neoplasm also demonstrates decreased sensitivity to chemoradiation therapy. Therefore, prompt detection of metastatic disease is critical for appropriate patient care. According to the American College of Radiology (ACR) appropriateness criteria, PET/CT may be appropriate depending on individual patient circumstances (Roberts, et al.). PET/CT has been emerging as a primary tool for diagnosing metastatic disease in many musculoskeletal tumors. This patient has known positive margins. Considering the high and atypical metastatic potential of fibromyxoid sarcoma and the patients young age, PET/CT is appropriate. PET/CT would change the management of this patient especially if the imaging reveals distant metastases. Therefore, the requested whole body PET/CT (CPT code 78816) is likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Findings:  Three of the three physician reviewers found the requested whole body PET/CT (CPT code 78816) is likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the requested services are 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: Physician reviewers 1, 2, and 3 are board certified in diagnostic radiology 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: Upheld

The enrollees parent requested reimbursement for a tryptase blood test. The enrollee was evaluated for food allergies. She had developed hives after eating bananas, and again after being bathed with a body wash that contained corn. The enrollee was prescribed an epinephrine injectable and scheduled for food allergy testing. She then underwent a Tryptase blood test. Literature reports tryptase testing is indicated for the evaluation of acute anaphylaxis and mast cell disorders. This enrollee has no indications of either of these; therefore, tryptase was not likely to be more beneficial than any other available treatment.Final Result: Three of the three reviewers determined that the requested service was not likely to have been more beneficial than any available standard therapy for treatment of the enrollees medical condition. Credentials/Qualifications: Three reviewers are board certified in allergy and immunology 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

A 45-year-old male enrollee has requested laparoscopic banding bariatric surgery for the treatment of his morbid obesity. Findings:  The physician reviewer found that the medical literature has consistently shown the Lap Band is efficacious and is associated with less morbidity than the Roux-en-Y gastric bypass or the duodenal switch procedure. The Lap Band procedure offers the potential for significant weight loss and is medically appropriate for this patient.
Appeal type: Medical Necessity
Decision: Upheld

A female enrollee requested Subsys for medical treatment of the her chronic daily headaches.  Findings:  The physician reviewer found the patient has been diagnosed with intractable headaches and has been treated with a combination of medications including Subsys. There is a lack of controlled studies supporting the safety and efficacy of Subsys in the treatment of intractable headaches. Therefore, the request for Subsys is not supported as medically necessary.
Appeal type: Medical Necessity
Decision: Upheld

The parent of a 14-year-old male enrollee has requested for psychiatric residential treatment services for treatment of the enrollee behavioral health problems. Findings:  The physician reviewer found that there is nothing to indicate that the patient warranted continued residential treatment services. He had been taken off of self-harm precautions, was no longer considered a threat to others and his medications were stable. The patients clinical progress from the time he was initially admitted was significant. His need for 24-hour monitoring had ceased and his dangerous and aggressive behaviors had substantially improved. The patient could have been safely treated in a less restrictive setting by that time.