Persius/imr-appeals huggingface dataset:
Appeal type: Experimental/Investigational
Decision: Upheld

A 41-year-old female enrollee has requested for INBONE total ankle replacement surgery for treatment of her medical condition status post shattered ankle sustained in a motor vehicle accident.  Findings:  Three physician reviewers found that Total ankle arthroplasty is an increasingly utilized medical procedure with good results in selected patients. Whether the long-term results (greater than 10 years) are durable, or are better than arthrodesis is a long running clinical debate that has yet to be concluded. Thus, the long-term superiority of arthroplasty over arthrodesis has not been established. Moreover, given this patients young age, the possibility that the arthroplasty will wear and require revision is very likely.
Appeal type: Medical Necessity
Decision: Upheld

The patient has requested authorization and coverage for continued hospitalization until her course of antibiotics is complete for her infection, and her heart rate is stabilized. The records provided for review document a history of glioblastoma multiforme, stroke, seizures, and sinus tachycardia. The patient has been diagnosed with a urinary tract infection (UTI) and she is currently on antibiotics. There is a lack of clinical indication for the patient to remain admitted to the hospital in order to complete her antibiotic dosing. Such medications can be safely administered in a long-term care setting such a skilled nursing facility or another long-term care facility. Moreover, prolonged hospitalization increases this immunocompromised patients risk to other infections. As such, an infection such as a UTI is treated without inpatient care in an outpatient setting when possible. For these reasons, the requested continued hospitalization until her course of antibiotics is complete for her infection and her heart rate is stabilized is not medically necessary for treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld

A 48-year-old female enrollee requested Azor 5 mg/40 mg tablet for medical treatment of her essential hypertension. Findings:  The physician reviewer found that based on the records provided, this patient has essential hypertension, intolerance to an ACE-inhibitor and chlorthalidone as well as ineffectiveness with losartan. However, there is no documentation that the patient has experienced an inadequate response or intolerable side effects to two standard angiotensin receptor blockers. In addition, there are other antihypertensive medication classes that have not reportedly been tried as well. Therefore, the specific use of Azor is not medically necessary, since other antihypertensive medications are available and would likely result in similar tolerability and effectiveness of blood pressure control in this patient.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: an enrollee has requested authorization and coverage for 30 treatments of light therapy for nerve rejuvenation. Findings:  The physician reviewer found that there are few peer-reviewed studies reporting any use of light therapy in neuropathy. Lavery and colleagues reported that there were no significant differences in measures for quality of life, Michigan Neuropathy screening instrument (MNSI), vibration perception threshold (VPT), Semmes-Weinstein monofilaments (SWM), or nerve conduction velocities in active or sham treatment groups. In addition, Khamseh and colleagues noted that low intensity laser therapy had positive effect on nerve conduction velocity in neuropathy, but additional studies were recommended to show benefit in regard to pain. 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 neurology 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: Upheld

A 47-year-old male has requested coverage for past and future Orthovisc injections for treatment of his right knee osteoarthritis.  Findings:  The physician reviewer found that the use of hyaluronan is poorly documented in the literature. The articles published lend little support to hyaluronan in treating osteoarthritis of the knee. While there is an advantage to delay joint replacement as long as possible, the use of repeated hyaluronan injections is not without risk of possible allergic reaction or infection as complications. As a method of delaying joint arthroplasty, it is not reasonable to persist in a treatment which is poorly supported by double-blinded studies. The literature does not demonstrate that the hyaluronic acid molecule will disrupt the effect of inflammatory cytokines effecting osteoblastic and osteoclastic and chondrolytic changes within the knee joint. In addition, the processes of chronic inflammation and of degenerative osteoarthritis are not likely to be altered by the hyaluronic acid macromolecule. In the study by Strand and colleagues, subjective visual analog scales were used to assess the efficacy of single injection as compared to patients receiving phosphate buffered saline. While the design of the study is stated to be randomized, the method of blinding or whether blinding took place is not discussed. In the article authored by Colen and colleagues, consisting of a review of the use of hyaluronic acid in joints other than the knee joint, it was concluded that there is no strong evidence that hyaluronic acid is superior to other treatments of osteoarthritis such as corticosteroids, physiotherapy or other conservative measures. All told, the repeated Orthovisc injections are not supported as medically necessary for this patient.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for a pelvic floor electric stimulation device. Several randomized controlled trials have reported mixed results with electrical stimulation for treating fecal incontinence. One study evaluated patients with fecal incontinence treated with a home electric stimulation device for eight weeks. The authors found that there was no statistically significant difference between groups in patient reports of symptom changes. In addition, systematic reviews of randomized controlled trials have not revealed that electrical stimulation is superior to control interventions for treating fecal incontinence. All told, the requested pelvic floor electric stimulation device is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.One reviewer found that the requested pelvic floor electric stimulation device is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Final Result: Two of the three reviewers determined that the requested equipment is 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:  One reviewer is board certified in internal medicine with sub-specialty certification in gastroenterology and is actively practicing. One reviewer is board certified in internal medicine with sub-specialty certification in gastroenterology and is actively practicing.  One reviewer is board certified in internal medicine with sub-specialty certification in gastroenterology and is 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: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: enrollee has requested authorization and coverage for hypoglossal nerve stimulation.  Findings:  The physician reviewer found that the patient has obstructive sleep apnea and has not been able to tolerate the CPAP device due to nasal obstruction. The patient had a drug-induced sleep endoscopy which showed anterior-posterior collapse and no concentric collapse. Per the records, at this time, the patient has not had treatment for his nasal obstruction to allow him to tolerate the CPAP device (nasal pillows). The medical evidence supports treatment of his nasal obstruction prior to pursuing the requested services. Therefore, hypoglossal nerve stimulation is not likely to be more effective than other treatment options. Final Result:  Two of Three reviewers determined that 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: Physician reviewers 1, 2 and 3 are board certified in otolaryngology 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 breast tomosynthesis for evaluation of her medical condition.  Findings:  Three physician reviewers found that peer reviewed literature supports the use of tomosynthesis in this clinical setting. Per Skaane and colleagues, the use of mammography plus tomosynthesis in a screening environment resulted in a significantly higher cancer detection rate and enabled the detection of more invasive cancers. Ciatto and colleagues state that integrated two dimensional and three dimensional mammography improves breast cancer detection and has the potential to reduce false positive recalls. For these reasons, the tomosynthesis used to screen this patient for breast cancer was likely to be more beneficial than any available standard therapy.  Final Result: Three reviewers determined that the services at issue were likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned.  Credentials/Qualifications:   All three reviewers are board certified in diagnostic radiology and are actively practicing. All three reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a 12-year-old male has requested approval for ABA therapy beginning at the date at issue, and forward, for treatment of his autism.   Findings:  The physician reviewer found that ABA therapy has a 40-year, scientifically documented history of substantially improving motor, verbal, and interactive social skills in autistic children. Myers, et al. states, The effectiveness of ABA-based interventions in ASDs has been well documented through five decades of research by using single-subject methodology and in controlled studies of comprehensive early intervention programs in university and community settings.  Children who receive early intensive behavioral treatment have been shown to make substantial, sustained gains in IQ, language, academic performance, and adaptive behavior as well as some measures of social behavior, and their outcomes have been significantly better than those of children in control groups. Additionally, in regard to older children and even adults, Myers et al. reports, published research evaluating comprehensive educational programs for older children and adolescents with ASDs is lacking. However, there is empirical support for the use of certain educational strategies, particularly those that are based on ABA, across all age groups to increase and maintain desirable adaptive behaviors, reduce interfering maladaptive behaviors or narrow the conditions under which they occur, teach new skills, and generalize behaviors to new environments or situations. As autism is a lifetime diagnosis, with an uncertain prognosis, the duration of therapy remains uncertain and must be determined on an individual basis. This 12-year-old patient has demonstrated measurable social and communication improvements while receiving ABA therapy. Two years ago, he was only able to perform at a one to two-year level; however the following year, he was performing at a three to five-year level. While progress has been slow, this patient has clearly demonstrated improvement during ABA treatment. An individualized educational plan dated last year noted good progress in communication, ability to follow instruction, expressive language, and social skills. Accordingly, it is medically necessary that the patient receive ABA therapy for 10 hours per week with 16 hours of monthly supervision.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for psychiatric residential treatment center services. The submitted documentation supports the medical necessity of the services at issue. The American Psychiatric Association guidelines recommend either inpatient or residential treatment level of care when lower levels of care have been tried and failed. Additionally, comorbid conditions are an important factor to be considered when deciding on a level of care. This patient had ongoing urges to purge and feelings of guilt around mealtimes. Given the severity of the patients illness, evidenced most strikingly by her 15 suicide attempts and her recent violent attempt, residential treatment was medically appropriate. In cases such as this, an evidence-based, objective, instrument such as the American Association of Community Psychiatrists Level of Care Utilization System (LOCUS) is indispensable in determining necessary and appropriate level of care for adults. The patient has a composite score of 24. This score correlates with residential treatment. Therefore, psychiatric residential treatment center services 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 psychaitry and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

The patient is 48-year-old female with a history of low back pain who previously found lumbar traction not helpful. The patient has been using an inversion table, which she reports has been beneficial. The patient has requested authorization and coverage for a home inversion table for pain control. The Health Plan has denied this request at this time. The Health Plan recommends the patient attempt a one-month trial of inversion traction in a clinic setting and upon completion of that trial authorization of an inversion table would be considered.The Health Plans denial should be upheld. The submitted evidence does not include objective documentation that use of an inversion table has been beneficial for the patient. As is standard of care with physical therapy equipment modalities, a trial should be undertaken by the patient to clearly demonstrate efficacy prior to authorization. The Health Plans recommendation that the patient undergo a trial of inversion traction in a clinical setting is medically reasonable and appropriate. Therefore, I have determined that the requested equipment is not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Experimental/Investigational
Decision: Overturned

A 53-year-old male enrollee has requested laparoscopic sleeve gastrectomy for treatment of his morbid obesity. Findings:  Two physician reviewers found that the laparoscopic sleeve gastrectomy has been shown to be an efficacious surgical procedure for the treatment of obesity. The procedure is approved as a primary treatment for morbid obesity in the well-selected patient by the American College of Surgeons and the American Society for Metabolic and Bariatric Surgery (ASMBS) based on the available medical literature documenting safety, efficacy and the availability of 5-year data. There are multiple studies involving a total of 2,570 patients with intermediate term follow-up reported in the literature at 3, 4, and 5-year intervals. The reports describe treatment of patients with preoperative body mass indices ranging from 35 to 69. The percentage of excess weight loss (%EWL) ranges from 33% to 85% with an overall mean percentage of excess weight loss of 55%. Detailed description of resolution or marked improvement in weight-related co-morbidities was reported in 10 studies, including 754 patients with follow-up to 5 years in a small number of patients. These studies demonstrate comparable rates of improvement and remission of diabetes, hypertension, hyperlipidemia, and sleep apnea to rates seen with other restrictive procedures. Major complication rates reported in these studies were relatively low.
Appeal type: Medical Necessity
Decision: Upheld

A 63-year-old male enrollee has requested a power wheelchair for treatment of his left-sided paralysis.   Findings:  The physician reviewer found that the submitted documentation fails to establish the medical necessity of the requested power wheelchair. Although this patient has weakness and joint pathology, based upon the documentation provided the patient can ambulate household distance with a cane and a walker. In addition, the patient is not considered bedbound or chair bound without power mobility. Finally, a power chair is indicated for individuals who require a primary means of ambulation and not a means of community transportation. Given that the patient is not bedbound without power mobility, is able to ambulate household distance with a cane and walker, and has no access to his apartment with a power wheelchair, the requested equipment is not medically necessary in this clinical setting. All told, the medical necessity of the requested equipment has not been established.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: A male enrollee has requested authorization and coverage for Repatha . In this setting, there is adequate data in randomized controlled trials that have demonstrated safety and efficacy at lowering cholesterol and improved cardiac outcomes using inhibitors. This patient meets the criteria for Repatha since he cannot tolerate statins. Thus, the requested Repatha is supported as medically necessary for treatment of this patients medical condition.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 cardiovascular disease 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.Findings:  The physician reviewer found that
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested Zepatier and ribavirin for treatment of his hepatitis C.  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. Per guidelines, genotype 1 patients who have failed Sovaldi and ribavirin therapy should be treated with Harvoni and ribavirin for 12 weeks. These guideline recommendations are based on multiple studies showing the effectiveness of treatment with Harvoni after treatment failure with Sovaldi (Osinusi, et al; Reddy, et al). The guidelines state that there are no published data on retreatment of sofosbuvir-containing treatment failures with non-sofosbuvir based [direct-acting antiviral] DAA regimen. Guidelines further state that given the lack of available data recommendations cannot be made. For these reasons, the requested treatment with Zepatier and ribavirin has not been established as medically necessary for the treatment of this patients hepatitis C infection.  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 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.