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 a Monovisc injection in the left knee.An exhaustive review of the current medical literature pertaining to viscosupplemention 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 patient has tried NSAIDs, corticosteroid injection, and physical therapy. The patients young age is a relative contraindication to joint replacement surgery. Further, the patients options are limited. The provider has recommended viscosupplementation with Monovisc injection for pain relief and postponing the need for joint replacement. Therefore, the requested Monovisc injection in the left knee is medically necessary for treatment of the patients medical condition.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 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: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for digital breast tomosynthesis for evaluation of the enrollee, who presented for a breast screening mammogram. Findings:  Two physician reviewers found that the patient was evaluated with screening mammogram and breast tomosynthesis. There was no evidence of malignancy. The patient requested reimbursement for the digital breast tomosynthesis portion of the examination. The Health Plan has denied reimbursement. Per the Health Plan, the service at issue was investigational for the evaluation of this patient. Breast tomosynthesis provides advantages to radiologists interpreting mammograms, especially in women with dense tissue.  This tomographic method often allows the reader to separate dense glandular elements from underlying mass/architectural distortion, resulting in a decrease in callbacks and increase in diagnostic accuracy and detection of small cancers compared to two dimensional imaging alone. As such, the addition of digital breast tomosynthesis to the usual two dimensional protocol was likely of greater benefit to the patient than had her examination been performed using two dimensional imaging alone. Final Result: The reviewers determined that the service at issue was 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. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for dopamine transporter scan (DaTscan). The clinical diagnosis of classic Parkinsons disease is based on four primary features: bradykinesia, tremor, rigidity, or postural instability. While most patients present with clear clinical symptoms, there is a subset of patients who present with a less clear clinical findings or fail to respond to standard of care treatment (Seifert and Wiener). To facilitate in the differentiation between essential tremor and Parkinsons disease, the U.S. Food and Drug Administration approved DaTscan imaging technique. A prospective, observational study by Graebner and colleagues examined the impact of DaTscan in a movement disorder center over the course of 18 months. Clinical impacts were observed following imaging in a total of 24 patients, including changes in medications for 18 patients and psychological impacts for 11 patients. The authors concluded that DaTscan imaging may be a useful adjunct to clinical history and examination in well selected patients. In this case, the patient was noted to have a tremor with features of both essential tremor and parkinsonism. Based on current peer-reviewed medical literature, DaTscan was indicated to help differentiate between essential tremor and parkinsonism in this clinical setting. Therefore, the DaTscan was 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 DaTscan was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Final Result: The 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: Physician reviewers 1, 2, and 3 are board certified in neurology 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: Upheld

A 53-year-old male enrollee has requested Oxycodone Hcl 30mg #180 per month and OxyContin ER 80mg #90 per month for treatment of his chronic pain syndrome.  Findings:  The physician reviewer found that Baron and McDonald reported that high dose and short acting opiates might contribute to pain sensitization via opioid-induced hyperalgesia, decreasing patient pain threshold and potentially mask resolution of a pre-existing pain condition. In this retrospective study, the majority of patients undergoing detoxification of high dose opiates for chronic pain reported a significant decrease in pain at the end of the study, further supporting the theory of opioid-induced hyperalgesia. High dose opiates are more likely to cause adverse outcomes. Ballantyne and Mao reported that prolonged use of high dose and short acting opiates might induce tolerance, and abnormal pain sensitivity. The aim of current guidelines is to protect patients from the adverse effects of opioid therapy.  All told, the requested Oxycodone Hcl 30mg #180 per month and OxyContin ER 80mg #90 per month is not medically necessary for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned

The enrollees parent is requesting reimbursement for residential treatment center (RTC) services. The enrollee has diagnoses of anxiety disorder, oppositional defiant disorder, and cannabis use disorder. The enrollees composite CALOCUS score correlates with Level IV, medically monitored, community-based services. However, the enrollee requires a higher level of care; Level V, non-secure, 24-hour services with psychiatric monitoring.Final Result: The reviewer determined that the requested services were medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The physician 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 similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Dupixent solution pen injection 300 mg/2 mL. The U.S. Food and Drug Administration (FDA) has approved Dupixent for the treatment of patients with moderate-to-severe atopic dermatitis whose disease is not adequately controlled with topical prescription therapies. A recent consensus article of atopic dermatitis experts defined moderate-severe atopic dermatitis as greater than 10% body surface area (BSA) involvement and/or involvement of highly visible areas or those important for function, and significantly impaired quality of life (Boguniewicz, et al.). The records provided for review document that this patient has significant itching from his atopic dermatitis on his face. The patients symptoms were improved with betamethasone, which is not a long-term treatment option due to the risk of ocular toxicity. The patients condition was not well controlled with topical pimecrolimus. The patients symptoms were also controlled when the patient attempted treatment with Dupixent. The location of the patients disease involvement and symptoms meets the current criteria for moderate-to-severe disease. In addition, Dupixent has the highest-quality trial evidence for safety and efficacy in atopic dermatitis (Siegels, et al.). Moreover, immunosuppressant treatment with medications such as methotrexate, mycophenolate, azathioprine, and cyclosporine may increase the patients risk of developing an infection, especially given the COVID-19 pandemic. All told, the requested Dupixent solution pen injection 300 mg/2 mL is medically necessary for 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: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Repatha SureClick 140 mg/mL. Findings:  The physician reviewer found that The American College of Cardiology (ACC) has developed an expert consensus decision pathway regarding the role of non-statin therapies for low density lipoprotein (LDL) cholesterol lowering in patients for management of atherosclerotic cardiovascular disease risk. As noted by the ACC, Repatha may be considered when the goals of therapy have not been achieved on maximally tolerated statin and ezetimibe in higher risk patients with clinical atherosclerotic cardiovascular disease or in the setting of familial homozygous or heterozygous hypercholesterolemia. The records provided for review indicate that this patient has a contraindication to statin therapy given his unexplained elevated liver function tests. In addition, the magnitude of the patients LDL cholesterol elevation is consistent with familial hypercholesterolemia, which is further supported by the positive family history of early coronary artery disease. For these reasons, the requested Repatha SureClick 140 mg/mL is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Findings: Two of the three physician reviewers found the requested medication is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the requested medication is 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 reviewer 1 is board certified in internal medicine with subspecialty certification in cardiology and is actively practicing. Physician reviewer 2 is board certified in internal medicine with subspecialty certifications in cardiovascular disease and adult congenital heart disease and is actively practicing. Physician reviewer 3 is board certified in internal medicine with subspecialty certifications in cardiovascular disease and clinical cardiac electrophysiology and is actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

A 38-year-old male enrollee requested authorization and coverage of a continuous passive motion unit. The Health Plan denied the request indicating that the requested equipment is not medically necessary for treatment of the enrollee status post patellar tendon surgical repair. One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer upheld the Health Plans denial on the basis that the requested equipment is not medically necessary.
Appeal type: Medical Necessity
Decision: Upheld

The parent of a 7-year-old male enrollee has requested direct applied behavioral analysis (ABA), supervision and treatment planning for treatment of the enrollees autism.  Findings:  The physician reviewer found that the medical literature supports the utility of ABA therapy for patients with autism. ABA therapy has been documented, in multiple studies, to significantly improve motor, verbal, and social interactive skills in young autistic children. However, there is a lack of peer-reviewed literature studying the appropriate intensity of ABA therapy beyond the early intervention stage. In the case of this patient, he was diagnosed as autistic and began receiving behavioral interventions early in life. Most recently, the submitted clinical documentation reflects that the patient made limited progress with ABA therapy. There is a lack of evidence that the patient has made adequate gains to support an increase in the intensity of ABA services to the level requested. Although continuation of ABA therapy is medically necessary, the frequency of direct ABA therapy and supervision is reasonable and appropriate. Further, the need for treatment planning is not substantiated. All told, the medical necessity of the requested services has not been established.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: an enrollee has requested authorization and coverage for Vemlidy 25 mg oral tablets, daily for six months. 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. 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 physician 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 open treatments with rib fracture with internal fixation. Findings:  Two of the three physician reviewers found Rib fractures are common in patients with blunt chest trauma. Over the past decade, a renewed interest in rib fixation has occurred. Stabilization of the chest wall in this setting, particularly when a flail segment is present and when conservative treatment has failed, is associated with significant reductions in respiratory failure, pneumonia, and intensive care unit (ICU) stay. Non-united rib fractures are a known indication for internal fixation, particularly when multiple fractures are present. Plating is the surgical technique most commonly used. Internal fixation has been used for many years with documented good results. The two surgical procedures were necessitated by broken plates and nonunion with associated pain and clicking. All told, open treatments with rib fracture with internal fixation were likely to be more effective 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 orthopedic surgery 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

The parent of a two-year-old male enrollee has requested for group occupational therapy for treatment of the enrollees feeding issues.  Findings:  The physician reviewer found that this patient has oral motor and oral sensory deficits that are impacting his ability to tolerate an age-appropriate diet.  He demonstrates delays in self-help skills and feeding skills.  Successful feeding interventions incorporate the services of occupational therapy, speech therapy, and nutrition in treating patients.  With its focus on teaching self-help skills, including feeding skills, and development of fine and gross motor skills, occupational therapy is well-suited to affect positive change in this clinical setting.  The current medical evidence supports the requested therapy for the treatment of this patient.  All told, group occupational therapy is medically indicated in this case.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Percocet 10 mg/325 mg, one tablet every four hours, #180 per month. The Centers for Disease Control and Prevention (CDC) guidelines state that when opioid therapy is used, a patients regimen should include nonpharmacologic therapy and nonopioid pharmacologic interventions. Additionally, the CDC noted that, Clinicians should continue opioid therapy only if there is clinically meaningful improvement in pain and function that outweighs risks to patient safety. The American Society of Interventional Pain Physicians (ASIPP) guidelines recommend providers to establish physical diagnosis and assess pain levels and disability to support medical necessity of treatment with opioids. In this case, the patient has chronic low back pain due to lumbar radiculopathy with recent increased pain and disability due to complications related to pain pump implantation. She is scheduled for hardware revision of the lumbar spine. The records document that the patient has tried and failed all forms of conservative therapy as well as advance pain management procedures including spinal cord stimulators and pain pumps. The providers notes state that the patient has not shown any aberrant or drug seeking behavior. Treatment with Percocet has enabled the patient to perform of activities of daily living. In addition, the provider reported that there is no evidence of adverse drug reactions or aberrant behavior identified. The providers documentation is consistent with the guidelines from the CDC and ASIPP for the safe prescribing of opioid therapy. Given this support, the requested Percocet 10 mg/325 mg, one tablet every four hours, #180 per month is medically necessary for 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 anesthesiology with subspecialty certification in pain management 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 53-year-old female enrollee has requested general anesthesia during esophagogastroduodenoscopy and colonoscopy procedures for evaluation of her medical condition.  Findings:  The physician reviewer found that the applicable medical literature suggests that monitored anesthesia care is medically necessary in a patient with anticipated intolerance to standard sedatives. The patient in this case has a history of requiring a larger dose of sedatives to achieve the same result as the average person. Clearly, the actual dose of Propofol administered the patient during the procedures was substantial. In fact, the dose was the equivalent of about three times the normal dose for most patients her age and size. It was therefore likely and foreseeable that she would not have tolerated conscious sedation well. For these reasons, the choice to administer monitored anesthesia care during the EGD and colonoscopy procedures on the date in question was medically appropriate and necessary.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested percutaneous tibial nerve stimulation for the treatment of her medical condition.   Findings:  Three physician reviewers found that there is a lack of support for the services at issue in this clinical setting.  Current guidelines recommend percutaneous tibial nerve stimulation as a third-line option for the treatment of overactive bladder in patients who have failed and/or cannot tolerate first-line and second-line treatment options. In this case, records provided do not document that first-line and second-line treatments have failed.  Thus, percutaneous tibial nerve stimulation was not likely to have been of greater benefit than other modalities.   Final Result: Three reviewers determined that the services at issue were 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 urology 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.