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

A 62-year-old female enrollee has requested authorization and coverage for a fourth series of Orthovisc injections for treatment of the enrollees right knee osteoarthritis. Findings:  The physician reviewer found that the current medical evidence does not support the medical necessity of the requested services in this patients case.  The value of viscosupplementation in the treatment of osteoarthritis of the knee is generally accepted, and is most suitable for patients with milder involvement.  The question of repeated courses of treatment remains the subject of controversy, with some reports being favorable, and others reporting problems.  There is a paucity of evidence demonstrating the efficacy and safety of repeat treatments.  In this case, the patient has had three prior series of injections.  However, the radiographic reports indicate that the osteoarthritis is now more severe.  There is a lack of documentation of other treatment, such as physical therapy.  All told, a fourth series of Orthovisc injections is not medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for residential treatment center (RTC) level of care services. Per the American Society of Addiction Medicine (ASAM) criteria, this patient did not meet Level 3.5 criteria for clinically managed high-intensity residential services. ASAM criteria focuses on six dimensions to determine the appropriate level of care, which includes: (1) intoxication and withdrawal potential; (2) biomedical conditions; (3) emotional, behavioral and cognitive conditions; (4) readiness to change; (5) relapse, continued use, or continued problem potential; and (6) recovery environment. The patient was admitted for alcohol and benzodiazepine withdrawal management. He was treated with a Librium taper. He had finished the Librium taper and his CIWA was 8 with stable vital signs. He reported ongoing symptoms of withdrawal including restlessness, anxiety, poor concentration, and insomnia. The patient has chronic back pain, which has been a trigger for his use of alcohol and other substances. The provider noted that the patient experienced mild to moderate symptoms that should not have interfered with his recovery treatment. The patient has a long history of depression, suicidal ideation, and at least one suicide attempt. The patient was reportedly suicidal with thoughts of overdosing while in the RTC. He participated in groups and able to attend to his activities of daily living. The patient was willingly engaged in treatment as a proactive participant, aware of having an addiction problem, and was committed to addiction treatment and changing his substance use. The patient engaged in frequent use of alcohol and benzodiazepines. He was experiencing significant cravings to drink alcohol, which was treated with naltrexone. This is his first treatment attempt. The patient lives with his girlfriend, who is sober. Using the ASAM criteria, the patient did not meet the criteria for biomedical, readiness to change, or recovery environment requirements. Thus, the RTC level of care services were not medically necessary for treatment of this patient. Final Result: The reviewer determined that the services at issue 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 with expertise in addiction 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: Experimental/Investigational
Decision: Upheld

Physician 1The patient is a 54-year-old morbidly obese, type 2 diabetic who is suffering bilateral knee pain, low back pain, and neck pain. The patient has MRI confirmation of advanced degenerative joint disease. Ligaments and tendons of his left and right knees are grossly intact. Meniscal derangement is complex. Based upon the submitted records, the patient is independent with activities of daily living and driving. It has been recommended the patient undergo prolotherapy. The Health Plan has denied authorization for prolotherapy on the basis that it is considered experimental.The efficacy of prolotherapy for patients such as this patient has not been established. The ligament/tendon structure of the patients knees is grossly intact. In addition, the patients morbid obesity complicates any treatment approach for his knees including total replacement. Furthermore, conventional treatment with quarterly cortisone injections has been successful in relieving the patients pain. Therefore, I have determined that the requested therapy is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Plans denial should be upheld.Physician 2The patient is a 54-year-old obese male with bilateral knee arthritis. The patients pain has been refractory to physical therapy and pain management. The patient wishes to undergo prolotherapy for treatment of his knee pain. The Health Plan has denied authorization for the requested therapy on the basis that it is considered experimental. There is no peer-reviewed, case-controlled literature demonstrating the safety and efficacy of prolotherapy in the treatment of arthritis of the knee. Prolotherapy introduces a chemical irritant to cause proliferation of the tissue. There is no documentation regarding dose and tissue response and safety of this therapy. Furthermore, there is no evidence demonstrating that prolotherapy stabilizes joints. Therefore, I have determined that the requested therapy is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Plans denial should be upheld.Physician 3The patient is a 54-year-old male with long-standing degenerative joint disease, resulting in knee pain. A request had been made for prolotherapy. The Health Plan has denied the patients request indicating the requested therapy is considered experimental.Prolotherapy is of unknown efficacy. There are no long-term, prospective studies that show the therapy to be effective. Furthermore, long-term risks and complications are not known. The requested therapy cannot be recommended given the lack of information regarding its usefulness and effectiveness. Therefore, I have determined that the requested therapy is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned

A 42-year-old female enrollee requested authorization and coverage of gastric bypass surgery. The Health Plan denied the request indicating that the requested procedure is not medically necessary for treatment of the enrollees morbid obesity.One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer overturned the Health Plans denial on the basis that the requested procedure is medically necessary.
Appeal type: Medical Necessity
Decision: Overturned

A 25-year-old female enrollee has requested laparoscopic duodenal switch surgery for treatment of her morbid obesity. Findings:  The physician reviewer found that based on the records provided, this patient is morbidly obese. She has failed prior dietary efforts and completed a thorough multidisciplinary evaluation that did not reveal any obvious metabolic, medical, dietary or behavioral barriers to surgery. The patient is requesting a standard primary treatment of morbid obesity that is covered by standard national guidelines including the American Society for Metabolic and Bariatric Surgery (ASMBS) and the Centers for Medicare and Medicaid Services (CMS). The patient indicates that she has been preparing for bariatric surgery for two years and is committed to follow-up and dietary restrictions.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for air ambulance transportation services. The records provided for review document that this patient presented with a history of severe anorexia and bulimia. She required specialized treatment for her eating disorder to include weight restoration and medical stabilization. Per Mattison and colleagues, patients with unstable medical conditions, including those with an evolving, unpredictable, or rapidly changing medical condition should not fly on commercial aircraft. At the time of transfer, the patient did not meet criteria for commercial air travel as she required monitoring of her cardiac status due to malnutrition and risk of arrhythmias and hypotension as well as hourly monitoring of her glucose. The patient also required assistance with transfers due to weakness from malnutrition. Ground ambulance transportation was not recommended for this patient due to the cross-country distance, which took 29 hours in travel duration. Air transport is appropriate in cases of rough terrain or a long distance, as in this patients clinical scenario (Sirbaugh, et al.). Based on the information provided for review, the air ambulance transportation services were medically necessary for 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 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

A 25-year-old female enrollee is requesting a Laparoscopic conversion from Gastric Banding (LAGB) to Roux-en-Y Gastric Bypass (RYGBP) for the treatment of her medical condition.  Findings:  The physician reviewer found that the LAGB has been documented to be a source of dietary intolerance with dysphagia without any overt findings on diagnostic studies. When dietary and behavioral non-compliance are ruled out, it is thus reasonable to consider conversion to another type of bariatric procedure such as the RYGBP. This patient was evaluated as a revisional candidate instead of a patient seeking the RYGBP as a primary candidate with a BMI of 30. Merely removing the LAGB is likely to result in significant weight regain and will most likely return the patient back to her baseline BMI. For this reason, it is important and medically necessary to remove the LAGB as well as to provide her with a bariatric tool to prevent complete weight regain and worsening of her weight related co-morbid conditions. Accordingly, I have concluded that the requested revisional bariatric surgery to RYGBP is medically indicated and appropriate for management of this patients condition and should be approved.
Appeal type: Medical Necessity
Decision: Overturned

A 72-year-old male enrollee requested authorization and coverage of a PET scan. The Health Plan denied the request indicating that the requested PET scan is not medically necessary for evaluation of the enrollees lungs.One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer overturned the Health Plans denial on the basis that the requested PET scan is medically necessary.
Appeal type: Medical Necessity
Decision: Upheld

A 64-year-old woman with multiple non-specific symptoms had an IGF-1 test and an arginine stimulation test with GH levels. The results were suggestive but not unequivocally diagnostic of adult growth hormone deficiency (AGHD). An insulin tolerance test was normal (though barely), but no glucose levels are noted. Other hormone testing does not indicate other pituitary hormone deficiency. A request has been made for authorization and coverage for growth hormone therapy. The Health Plan has denied this request indicating that the requested therapy is not medically necessary for treatment of the patients growth hormone deficiency.The patients symptoms are non-specific and not diagnostic of AGHD. The patient is not described as having excess central obesity. Her IGF-1 is in the normal range for her age and for the lab at which it was performed (Quest Lab). IGF-1 is not considered sensitive enough to use as a diagnostic tool for AGHD. The article cited above by Hartman et al. specifically states the presence of AGHD could be predicted with 95% accuracy by the presence of three or more pituitary hormone deficiencies (PHDs) or a serum IGF-I concentration less than 84 g/liter measured in the Esoterix assay. Furthermore, an insulin tolerance test, the gold standard for making a diagnosis of AGHD, is reported as normal though there is no indication of the adequacy of hypoglycemia achieved.Based upon the equivocal results provided, I have determined the requested therapy is not medically necessary for treatment of the patients medical condition at this time. The Health Plans denial should be upheld at this time. However, the patient should undergo further testing including a repeat insulin tolerance test with documentation of adequate hypoglycemia (a glucose of less than 55 mg/dl) at some point during the testing. In addition, a repeat IGF-1 test should be performed under the Esoterix assay. Once these results are obtained, the patients request for growth hormone therapy should be reconsidered.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Vemlidy for treatment of the enrollees hepatitis B virus. Findings:  The physician reviewer found that Guidelines for the treatment of hepatitis B from the American Association for the Study of Liver Disease (AASLD) recommend entecavir and tenofovir compared with alternatives for the treatment of chronic Hepatitis B. In comparison with tenofovir disoproxil fumarate (Viread), which the patient is taking, the Vemlidy formulation of tenofovir is effective for hepatitis B, but is associated with lower incidence of side effects such as osteopenia and renal disease. Viread and Vemlidy are both effective for the treatment of hepatitis B, however the Vemlidy form is safer for long-term use. For this reason, the request for Vemlidy is medically necessary for the treatment of the patients chronic hepatitis B. 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 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

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for photodynamic therapy. Findings:  Three physician reviewers found that actinic keratoses are premalignant lesions of the skin which have the potential to develop into squamous cell carcinoma if left untreated. The use of photodynamic therapy is a well-established and effective treatment option for actinic keratoses. The medical evidence supports photodynamic therapy for actinic keratoses of the head and neck. Thus, photodynamic therapy was likely to have been more efficacious than other treatment options. Final Result: The reviewers determined that the services at issue were likely to be more beneficial for treatment 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 dermatology 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: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Norco 10/325 (30 tablets/30 day supply) until hip surgery may be performed.In this case, the patient has advanced joint disease affecting the left hip, and she has been evaluated by two orthopedic surgeons who both recommended total hip replacement. The procedure has been postponed due to the COVID-19 pandemic. In the interim, the patient has tried and failed conservative care including ibuprofen, Tylenol, gabapentin, and activity modification which were advised by her treating provider. The patients current pain levels are reportedly 10 out of 10 on the Visual Analogue Scale (VAS), and the patients pain is adversely impacting her ability to perform her activities of daily living and her quality of life. The patient has requested one Norco tablet per day as needed for pain because non-opioid medications have failed to provide relief until she is able to have her surgery. CDC guidelines advise providers to explore non-opioid and non-pharmacologic treatment of pain as an initial step, however, when these measures fail to provide relief, they do not discourage the use of sensible prescribing of opioids to low risk individuals with documented pathology. CDC guidelines also acknowledge that the use of a short course of opioid therapy has been shown to be effective in managing pain, which is the situation in this case, since the medication is requested as a bridge until the patients joint surgery can be performed. Similarly, Federation of State Medical Boards guidelines also recommend opioid therapy for patients who are unresponsive to conservative care and in such cases to use the lowest possible dose, which is the case in this situation. The patient has end stage hip disease with pain scores rated as 10 out of 10 with impairment of her activities of daily living. In addition, ASIPP guidelines provide risk stratification for opioid dosing noting that the levels below 40 mg of morphine equivalents is low risk for adverse outcomes. Consistent with this guidance, the patient is requesting the equivalent of 10 mg daily. Under these circumstances, the requested medication, Norco 10/325 (30 tablets/30 day supply) until hip surgery may be performed, is medically necessary to treat the patients medical condition.Final Result: The reviewer determined that the requested medication is medically necessary to treat the patients medical condition. Therefore, the Health Plans denial should be overturned.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: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Synvisc One injection to the left knee. Evidence from systematic reviews and randomized controlled trials indicate that although viscosupplementation may relieve knee pain in some patients with osteoarthritis, data has not established which patients will benefit. Guidelines from the American Academy of Orthopedic Surgeons (AAOS) indicate that the data on safety and efficacy of viscosupplementation remain inconclusive. As such, the AAOS does not currently recommend viscosupplementation as standard treatment for osteoarthritis of the knees. Viscosupplementation is reserved for patients with a history of lasting benefit from prior injections and in cases where the remaining options are limited. In this case, the patient has a diagnosis of osteoarthritis of the left knee. She has reportedly obtained excellent benefit from hyaluronic acid injections in the past. The provider noted the patient is attempting to delay total knee replacement surgery and is a candidate for repeat injections. Therefore, the request for Synvisc One injection to the left knee is medically necessary for treatment of osteoarthritis of the patients left knee.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

The patient has requested reimbursement and prospective authorization and coverage for residential treatment center (RTC) services. Per the American Society of Addiction Medicine (ASAM) criteria, this patient meets Level 3.5 criteria for Clinically Managed High-Intensity Residential Services. For dimension 1, the records document that the patient is experiencing moderate to severe withdrawal symptoms as evidenced by his CIWA scores. The patient does not meet the criterion for dimension 2, given the lack of biomedical conditions. For dimension 3, the patient has comorbid depression, PTSD and ADHD, which are all associated with more severe substance disease. The patient meets the criteria for dimension 4, as he is in the early stage of dealing with trauma. He is currently in a stage of unpreparedness without having developed the necessary recovery skills. For dimension 5, the patient continues to work to identify triggers and causes as well as strategies to change to be able to live a sober life outside of the structure of RTC. The patient continues to report cravings. The patient meets dimension 6, as he is still learning triggers and coping skills. Given the patients current level of function, he requires a structured supportive treatment environment. The patient requires a safe and stable living environment in order to develop his recovery skills. He meets the criteria for ASAM Level III treatment, which is similar to the services provided at the current RTC. Given these findings, the RTC services were and are medically necessary for treatment of this patient. Final Result: The reviewer determined that the services at issue were and 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 psychiatry with expertise in addiction 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.