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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Proton Beam Radiation Therapy, 30 treatments given twice daily for a total of 60 concurrent treatments.The medical literature does not support that the requested services are medically necessary in this setting. The ASTRO Model Policy for Proton Beam Therapy does not support the use of proton beam radiation therapy in the management of potentially resectable head and neck malignancies outside the context of a prospective clinical trial. In this case, the patient has recurrent oropharyngeal cancer. At this time, there are insufficient high quality clinical outcomes published to permit definitive conclusions regarding the relative safety and efficacy of proton radiotherapy in the setting of oropharyngeal cancer, as compared to standard of care photon-based radiotherapy. Accordingly, the requested proton beam radiation therapy, 30 treatments given twice daily for a total of 60 concurrent treatments, is not medically necessary for treatment of the patients medical condition.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 radiation oncology 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 sensors (HCPCS A9276) for use with the enrollees existing interstitial continuous glucose monitoring system.Zhou and colleagues indicate that, Glycemic variability (GV) is emerging as an important metric to consider when assessing glycemic control in clinical practice. The authors found, Accumulating evidence has suggested that GV, representing either short-term (with-day and between-day variability) or long-term GV, was associated with an increased risk of diabetic macrovascular and microvascular complications, hypoglycemia, mortality rates and other adverse clinical outcomes. According to Zheng and colleagues, continuous glucose monitoring systems (CGMS) have been used to manage diabetes by measuring interstitial fluid glucose levels to provide information about glucose levels, which identify fluctuations that would not have been identified with conventional self-monitoring. The immediate feedback and glucose trending provided by CGMS offer marked advantages in early intervention and limitation of glycemic excursions, as compared with traditional finger stick testing. Clinical studies have shown a significant decrease in hypoglycemic events with use of the CGMS as compared with finger stick testing alone. Therefore, the requested sensors for use with the patients existing interstitial continuous glucose monitoring system is medically necessary for treatment of the patients medical condition.Final Result: The reviewer determined that the requested device is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in internal medicine with sub-specialty certification in  endocrinology, diabetes, and metabolism and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

The patient is a 42-year-old woman with a reported family history of breast cancer who presented with a palpable breast abnormality. An excisional breast biopsy was performed by her surgeon and an assistant surgeon was utilized during the procedure. The operative notes do not document any unusual or extraordinary aspects to the performance of the procedure. The Health Plan denied coverage for the assistant surgeons services citing a lack of medical necessity. According to the guidelines offered by the American College of Surgeons, the use of assistant surgeons for procedures should not be billed unless the most recent Medicare claims database indicates that the procedure has used an assistant in more than 5% of cases and an assistant is medically necessary. The procedure at issue does not meet guidelines of sufficient complexity to require the use of an assistant surgeon and therefore, was not medically necessary. Accordingly, I have determined the services at issue were not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/ Case Summary: The patient has psoriasis and psoriatic arthritis. The patient is complaining of stiffness to her fingers and wrists in the morning, has dystrophic nail changes over the last three months, and psoriasis for the last two years. The provider reports the patient has plaque psoriasis affecting about ten percent of her body surface area (BSA). The provider also reports that treatment with methotrexate, cyclosporine, acitretin or ultraviolet B is contraindicated. The provider reports oral disease-modifying anti-rheumatic drugs are suboptimal as the patient wishes to have a child. Drugs that are teratogenic such as methotrexate, cyclosporine, and acitretin should be avoided in this patients situation. Authors reviewed the non-biologic agents available to treat psoriasis and found that methotrexate, cyclosporine and acitretin all have significant adverse effects related to pregnancy. They also note that there are no adverse reports of the use of Otezla during pregnancy. The reviewer states that Otezla would be preferable considering this situation with this patient's need for psoriasis treatment and the desire to conceive a child. Final Result: The reviewer determined that the requested medication is medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The physician 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 similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

A 54-year-old male enrollee has requested a PET/CT scan for the evaluation of his gastrointestinal stromal tumor (GIST).Findings:  The physician reviewer found that research indicates PET/CT allows an early evaluation of the patients response to treatment with imatinib, is a valuable tool in patients with gastrointestinal stromal tumors and improves staging (and) accurately separates responders from non-responders in an early phase, and is helpful during follow-up. PET/CT is superior to CT in evaluating the response to treatment, and is particularly effective for patients treated with imatinib mesylate therapy.
Appeal type: Medical Necessity
Decision: Upheld

The parents of a 16-year-old female enrollee have requested for an inpatient hospitalization level of care for treatment with the medication Clozaril for treatment of the enrollees behavioral health condition. Findings:  The physician reviewer found that the need for inpatient hospitalization to initiate Clozaril treatment and to wean her off of her other medications is not medically necessary. There are no indications of any life-threatening behaviors or medical problems that would place the patient at risk, or any evidence that she is unable to follow an outpatient monitoring regimen.
Appeal type: Medical Necessity
Decision: Upheld

A 49-year-old female enrollee requested authorization and coverage for uterine artery embolization (UAE). The health plan has denied this request indicating that UAE is not medically necessary for treatment of the enrollees menorrhagia, pelvic pain, and dysmenorrhea.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: Overturned

Nature of Statutory Criteria/Case Summary:  An enrollee has requested 12 weeks of Harvoni for treatment of his hepatitis C.   Findings:  Three physician reviewers found that the current medical evidence supports the requested medication in this clinical setting.  The requested treatment regimen is likely to prevent further progression of disease.  Per the American Association for the Study of Liver Diseases and Infectious Diseases Society of America, all patients with chronic hepatitis C should be treated, except those with limited life expectancy less than 12 months due to non-liver related comorbid conditions.  All told, the requested 12 weeks of Harvoni is medically indicated for the treatment of this patient.   Final Result: Three reviewers 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 three reviewers are board certified in internal medicine with sub-specialty certification in gastroenterology and are actively practicing. All three reviewers are expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The enrollee has requested authorization and coverage for pain medications, Fentanyl Patch 125 mcg/hour every two days and Norco 10/325 one pill up to eight pills per day. The Health Plan has denied this request indicating that the requested medication dosages are not medically necessary for treatment of the enrollees chronic low back pain.The submitted documentation fails to demonstrate the medical necessity for the requested medication dosages in this clinical setting. In the documentation submitted for review, there is a lack of objective treatment goals for pain and function. The need to use opioids as the primary medication treatment strategy for pain has not been established. The CDC guidelines state that when starting opioid therapy for chronic pain, clinicians should prescribe immediate release opioids instead of extended release/long acting (ER/LA) opioids. They should carefully reassess evidence of individual benefits and risks when considering increasing dosage to greater than or equal to 50 MME per day, and should avoid increasing dosage to greater than or equal to 90 MME per day or carefully justify a decision to titrate dosage to greater than or equal to 90 MME per day.  In this case, the patient was recently taking 230 MME/day and 380 MME/day before the taper was started. There is no medical evidence based rationale provided by the provider or the patient for the requested dosages. Risk and benefit analysis must be done to justify the requested level of 380 MME/day. It is unclear what the plan is for any unseen future pain insults the patient would experience while on 380 MME/day. Moreover, non opioid medications classes have not been optimized or tried. For all these reasons, Fentanyl Patch 125 mcg/hour every two days and Norco 10/325 one pill up to eight pills per day are not medically necessary for treatment of the patients medical condition.Final Result: The reviewer determined that the requested medication dosages are not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is board certified in anesthesiology with 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: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for knee surgery for the right knee. In a systematic review of the efficacy of arthroscopic meniscectomy in patients with meniscal tears and degenerative changes in the knee, researchers concluded that there was a benefit from arthroscopic meniscectomy, particularly if the osteoarthritis is mild. Researchers noted that while the role of arthroscopic debridement in the painful degenerative knee is controversial, arthroscopy may provide good symptomatic relief and sustained benefits in significantly symptomatic patients, especially in the presence of mechanical symptoms secondary to degenerative meniscal tears or chondral flaps, and those with symptomatic patellofemoral osteoarthritis. In this case, the patient has severe pain from osteoarthritis of the right knee. The documentation reflects mechanical symptoms, such as locking and giving out. Given current medical literature, the requested service is medically indicated. Therefore, knee surgery for the right knee is medically necessary for the treatment of this patient. 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: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for bilateral Monovisc injections. 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 routine 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, there is a history of good response to viscosupplementation in the past, and inadequate response to medications, physical therapy, and cortisone injections. The provider has recommended repeat viscosupplementation of both knees with Monovisc injections. Based on this patients prior excellent response to viscosupplementation, treatment with bilateral Monovisc injections to the knees is appropriate for treatment of this patients osteoarthritis of both knees. All told, the requested bilateral Monovisc injections are medically necessary for treatment of this patient. 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: Urgent Care
Decision: Overturned

Nature of Statutory Criteria/Case Summary:  An enrollee has requested emergency room services on an emergent or urgent basis. The physician reviewer found that review of the submitted documentation demonstrates that a prudent layperson would have sought immediate medical attention on the date in question. Upon review of the submitted medical records, the patient presented with worsening swelling and throbbing of a left hand laceration that occurred the day before. The physical exam was significant for tenderness of the left palmar laceration and the patient was noted to be in an extensive amount of pain. Given the patients severe pain and the possibility of serious deterioration and compromise of her hand due to infection that could spread to nearby vital structures such as joints, nerves and tendons, a prudent layperson in this circumstance would reasonably believe she was suffering from a serious medical condition. In sum, the patient was suffering from a serious medical condition that was likely to place the patients health in serious jeopardy, cause serious impairment to body functions or cause serious dysfunction to a body organ or part. Thus, the services met prudent layperson criteria for emergency care. Final Result: The reviewer determined that the patients symptoms met prudent layperson criteria for emergency care. Therefore, the Health Plans denial should be overturned.  Credentials/Qualifications: The reviewer is board certified in emergency 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

The parent of a four-year-old female enrollee has requested for occupational therapy for treatment of the enrollees fine motor delay.  Findings:  The physician reviewer found that to support the need for occupational therapy, studies have shown benefits that prevent a deterioration or reversal of function and a significant improvement in activities of daily living. Feldman and colleagues concluded that reducing waiting times for rehabilitation services may allow rehabilitation specialists to better address psychosocial problems for these children. A study by Tang and colleagues showed children who received only institutional-based therapy (IT) improved in developmental level by 2.11 months compared with 3.11 months for those who received a combination of IT and home activity program (HAP). Consistent with these findings, the authors concluded that home therapy alone is not as effective as a combined program. Nearly 60% of the studies reported statistically significant improvements at follow-up as reported by Riethmuller and colleagues. For these reasons, the requested occupational therapy is medically necessary.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested digital breast tomosynthesis for evaluation of the enrollees breast cancer screening. Findings: Three physician reviewers found that the diagnostic procedure at issue was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. There is sufficient support in the peer-reviewed literature for the use of tomosynthesis in the routine screening population. According to the study by Skaane and colleagues, Detection rates, including those for invasive and in situ cancers, were 6.1 per 1000 examinations for mammography alone and 8.0 per 1000 examinations for mammography plus tomosynthesis. Thus, the addition of tomosynthesis allows better characterization of possible masses, spiculation, and architectural distortion. For the reasons provided, the digital breast tomosynthesis was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Final Result: Three reviewers determined that the diagnostic procedure 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 physician 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: Medical Necessity
Decision: Upheld

A 59-year-old female enrollee has requested magnetic resonance imaging (MRI) of the lumbar spine without dye for evaluation of her back pain. Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested MRI of the lumbar spine without dye.  The current medical evidence does not support the requested diagnostic procedure in this clinical setting.  There is no documentation that the patient has failed conservative therapy including anti-inflammatory medications, muscle relaxants, and physical therapy.  Additionally, physical examination does not demonstrate findings that would indicate that the patient is a candidate for surgery or an epidural steroid injection, including unequal reflexes or motor weakness.  All told, the requested MRI of the lumbar spine without dye is not medically indicated for the evaluation of this patient.
Appeal type: Experimental/Investigational
Decision: Overturned

A 61-year-old male enrollee has requested reimbursement for total ankle arthroplasty for treatment of his right ankle arthritis.   Findings:  Two physician reviewers found that the only alternative to total ankle arthroplasty would have been ankle arthrodesis, which would have adversely affected the biomechanics of the adjacent joints, particularly the compromised knee. Over time, ankle arthrodesis often leads to significant secondary arthritis of the adjacent joints. Ankle replacement gave this patient the best chance of preserving joint mechanics and gait pattern and resuming an active lifestyle.
Appeal type: Medical Necessity
Decision: Upheld

This patient is a 63-year-old male who has significant osteoarthritis of both knees.  He has greater severity on the right side with bone on bone articulation. The medical records provided indicate the patient has had various treatments for this including medication and a series of Synvisc injections to both knees. He next received a series of prolotherapy injections to his knees from June 2005 through October 2005. The patient reports he has been pain free since the therapy, but the clinical records do not document this outcome.A critical review of prolotherapy in the treatment of osteoarthritis, low back pain and other musculoskeletal conditions reveals that the clinical efficacy of the therapy remains inconclusive.  Although the patient reported pain relief, the use of prolotherapy for pain control is still considered investigational and it is not consistent with the current standard of care.  Therefore, I have determined the therapy at issue was not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.