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

A 53-year-old female enrollee has requested Orthovisc injections for treatment of her right knee osteoarthritis.  Findings:  The physician reviewer found that carefully conducted double-blinded studies published in the medical literature do not demonstrate any clinical effect from hyaluronan injections. In addition, there is a recognized incidence of aseptic inflammatory reactions due to allergic response and risk of iatrogenic infection within the joint. A recent meta-analysis of the efficacy of viscosupplementation concluded after review of a total of 89 trials involving 12,667 patients with knee osteoarthritis that viscosupplementation is associated with a small and clinically irrelevant benefit and that there is an increased risk of serious adverse effects (Navarro-Sarabia, et al). Several studies evaluating repeated treatment protocols have reported adverse events including inflammatory changes within the knee joint. Further, the risk of sensitization is expected to increase after repeated exposure to an antigenic substance. Overall, there is limited or no benefit demonstrated in well-designed, double-blinded studies, but there is the possibility of acute local reactions. All told, the requested Orthovisc injections are not supported as medically necessary for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: A 64-year-old male enrollee has requested authorization and coverage for Stat-A-Dyne WHFO splint. The requested Stat-A-Dyne WHFO splint is supported as medically necessary to improve and maintain this patients wrist, hand, and finger motion as his radial nerve recovers. The device has not been recommended for treatment of the patients fracture. The patients provider recommended the device for treatment of motion deficits related to radial nerve injury and paralysis. This is an appropriate indication for the requested device. Therefore, the Stat-A-Dyne WHFO splint is medically necessary for this patient with complete radial nerve palsy following open humerus fracture and radial nerve disruption. 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 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: Upheld

A 50-year-old female enrollee has requested meniscal allograft transplantation for treatment of her deteriorated meniscus.  Findings:  Three physician reviewers found that little is known of the long-term effects of meniscal allografts since the procedure is relatively new and no long-term results have been published. Complications of the procedure are not known (e.g., re-tear of meniscus, wear rates, incorporation of the meniscus). To date, it has not been shown that meniscal allograft transplantation is effective on a long-term basis, has an acceptable complication rate, and is beneficial to a particular patient group. Furthermore, at age 50 the patient is not an appropriate candidate for the procedure.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary:  An enrollee has requested Flector (diclofenac epolamine) patches and bilateral knee Supartz injections for treatment of her medical conditions. Findings:  The physician reviewer found that the Flector patch and bilateral knee Supartz injections are not medically necessary for treatment of the patients medical conditions. Flector is a topical non-steroidal anti-inflammatory drug (NSAID). Researchers performed a systematic review to address and summarize the evidence of effectiveness and safety in topical NSAIDs. The authors concluded that topical NSAIDs may vary significantly in their absorption kinetics and pharmacodynamic effects, based on the formulation chosen. In acute and chronic low back pain, widespread musculoskeletal pain and in peripheral neuropathic pain syndromes, the current evidence does not support the use of topical NSAIDs. Thus, the Flector patch is not supported as medically necessary in this clinical setting. In regards to bilateral knee Supartz injections, the medical literature supports the use of this injection for osteoarthritis of the knee. However, the medical records submitted for review does not indicate that the patient has osteoarthritis. Therefore, the request for bilateral knee Supartz injections is not medically necessary. 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 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: Experimental/Investigational
Decision: Upheld

A 62-year-old female enrollee has requested Gleevec 400mg. for treatment of her stage 4 adrenocortical carcinoma. Findings:  Three physician reviewers found that adrenocortical carcinoma is difficult to treat because it is chemotherapy-resistant. A study showed that cisplatin in combination with etoposide and doxorubicin may have an effect in some patients with metastatic disease(Berruti and colleagues).  In this patients case, she has only one functioning kidney, so the oncologist is appropriately hesitant about this therapy.  There is a small series on the use of Gleevec for various solid tumors by Gross, et al.  There were four adrenocortical carcinomas that showed no response to Gleevec. The use of gene array or immunohistochemistry to direct the choice of chemotherapy is not yet proven, especially since this is a measure of expression and not a confirmed somatic mutation. All told, there is inadequate evidence demonstrating that Gleevec is likely to be effective for the treatment of adrenocortical carcinoma.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary:   An enrollee has requested Harvoni and ribavirin for 24 weeks for treatment of his hepatitis C virus. Findings:  The physician reviewer found that according to the most recent 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 nonliver-related conditions. According to the guidelines, patients with cirrhosis are considered highest priority for treatment. In patients with decompensated cirrhosis and/or liver transplant candidacy or hepatocellular carcinoma, guidelines recommend treatment with Harvoni with ribavirin for 12 weeks. The Harvoni recommendation is based on the SOLAR-2 trial, which demonstrated efficacy in this population, and evidence for increased survival with treatment (Flamm, et al; Jezequel, et al).  According to the AASLD/IDSA guidelines, the significance of a positive HCV RNA test result at week 4 that remains positive but lower, at week 6 or week 8 is unknown; there is no recommendation to stop therapy or extend therapy based on the 4 week viral load at this time.  In summary, AASLD/IDSA guidelines support 12 weeks of Harvoni and ribavirin in this case, and because ribavirin was started late, four additional weeks of Harvoni and ribavirin would be appropriate. However, there is no support for the requested 12 additional weeks of Harvoni and ribavirin. For these reasons, the requested treatment with Harvoni to be used with ribavirin for another 12 weeks is not supported as medically necessary for the treatment of this patients hepatitis C infection.  Final Result: The reviewer determined that the requested treatment duration is 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.
Appeal type: Medical Necessity
Decision: Upheld

A 63-year-old female enrollee requested authorization and coverage of sclerotherapy of both legs.  The Health Plan  denied the request indicating that the requested procedure is not medically necessary for treatment of the enrollees spider veins.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: The patient has requested authorization and coverage for lumbar/sacral facet joint block injection (CPT 64493). Findings:  The physician reviewer found that Manchikanti and colleagues noted that, the evidence for lumbar facet joint nerve blocks using local anesthetics with or without steroid for managing chronic low back pain of facet joint origin is fair to good for short- and long-term improvement. The best evidence for the use of medial branch blocks is for diagnostic purposes leading to a radiofrequency ablation procedure. Cohen and colleagues evaluated the effectiveness of lumbar medial branch blocks and facet joint injections. The authors found that facet blocks might provide prognostic value before radiofrequency ablation. This patients records document the presence of chronic low back pain, which is not radiating into the lower extremities. The patient does not complain of signs or symptoms suggestive of neurogenic claudication. The most recent MRI performed in August 2020 shows significant degenerative disc disease involving L4-L5 with a pars defect at L4 along with severe facet arthropathy involving the L4-5 level. There is evidence of moderate canal stenosis, but this is not symptomatic as there are no reports of neurogenic claudication. The patient has not previously been treated with diagnostic injections of the facet joints/medial branches to help establish the source of her chronic back pain. The current peer-reviewed medical literature supports the use of diagnostic injections to establish whether the pain is facet joint related and whether the patient would be a candidate for radiofrequency ablation procedure in the future. Based on the medical records reviewed and the current evidence-based medical literature, the requested lumbar/sacral facet joint block injection (CPT 64493) is medically necessary for 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 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 39-year-old female enrollee has requested bariatric surgery (Lap band or Roux-en-Y) without losing 10% of body weight for the treatment of her morbid obesity. Findings:  The physician reviewer found that the patient has required Actos, leading to further weight gain. She has tried and failed conventional weight loss programs. The surgery is medically necessary and will significantly improve her insulin sensitivity. She will manifest moderate weight loss and improvement in comorbidities, which is the prime reason for the surgery.  The Health Plans denial is inappropriate. Bariatric surgery, specifically Roux-en-Y, is medically warranted for this patient.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Nurtec 75 mg disintegrating tablets. Per the American Headache Society (AHS), calcitonin generelated peptide monoclonal antibodies (CGRP mAbs) are biologic agents that have demonstrated efficacy, safety, and tolerability for the preventive treatment of episodic and chronic migraine in phase 2 and phase 3 randomized, placebocontrolled trials. The U.S. Food and Drug Administration (FDA) has approved Nurtec ODT, an orally administered CGRP receptor antagonist, for the acute treatment of migraine with or without aura in adults and preventive treatment of episodic migraine in adults. The FDA approved Nurtec based on results of a randomized, double-blind, placebo-controlled trial by Croop and colleagues. The authors found that when taken every other day, Nurtec was effective for preventive treatment of migraine without unexpected or serious safety issues noted. In this case, the patient has a history of migraines. She is not an ideal candidate for treatment with many standard preventative medications due to her medical history. Moreover, treatment with Nurtec has resulted in improvement in the frequency of the patients migraines to near resolution. For these reasons, the requested Nurtec 75 mg disintegrating tablets are 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 neurology 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

Nature of Statutory Criteria/Case Summary: An enrollee has requested a wearable external defibrillator for treatment of her medical condition.   Findings: Three physician reviewers found that in this circumstance, there is potential for recovery of left ventricular function over time with therapy and there was no indication for immediate placement of a defibrillator such as documented sustained or inducible ventricular tachycardia, syncope or aborted sudden cardiac arrest. Placement of a prophylactic defibrillator is not recommended until a period of time (>90 days) where continued left ventricular dysfunction (ejection fraction  35%) is documented to persist in spite of appropriate treatment (Russo, et al). A prophylactic defibrillator (wearable or implantable) before this time has not been demonstrated to improve outcome. At this time prophylactic wearable external defibrillator would be indicated only if accepted criteria for an implantable defibrillator were met and an implantable defibrillator could not be placed, needed to be significantly delayed, such as due to infection or required explanation. Therefore, in this circumstance the request for a wearable external defibrillator has not been established as likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.  Final Result: Three reviewers determined that the requested services are 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: All three reviewers are board certified in internal medicine with sub-specialty certification in cardiovascular diseases 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: Experimental/Investigational
Decision: Upheld

A 46-year-old female enrollee has requested bilateral injection therapy of veins x 7 (sclerotherapy  CPT code 36471) for treatment of her varicose veins.  Findings:  Two physician reviewers found that in the peer-reviewed medical literature, both direct and ultrasound guided primary venous sclerotherapy continue to receive HAYES reviews with C and D ratings. In addition, Tisi and colleagues review suggests that the current place of sclerotherapy in modern clinical practice is limited to the treatment of accessory recurrent varicose veins following surgery and thread veins. All told, the use of sclerotherapy in treating this patients medical condition is not likely to be more beneficial than use of standard available therapies.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the anterior optical coherence tomography (OCT) performed.  Findings:  The physician reviewers found that the standard test for evaluating the anterior chamber angles is gonioscopy. Anterior segment optical coherence tomography is a newer imaging modality that can be used to visualize and document the extent of narrow angles . In clinical practice, anterior segment optical coherence tomography is used in addition to gonioscopy and not instead of gonioscopy. Thus, without documentation of the results of gonioscopy to first determine the degree of narrow angles, the anterior segment optical coherence tomography was not clinically indicated. Therefore, the anterior optical coherence tomography performed was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Final Result: The reviewers determined that the service at issue was 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: Physician reviewers 1, 2, and 3 are board certified in ophthalmology 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

A 56-year-old female has requested a repeat series of Hyalgan injections for the treatment of osteoarthritis.  Findings:  Two physician reviewers found that conservative treatment has not been effective for this patient. A repeat series of Hyalgan injections is the best treatment alternative at this time. This therapy can reasonably be expected to decrease her pain and postpone the need for surgical intervention.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for endovenous ablation therapy of incompetent vein (CPT 36475) of the right leg.Findings:  The physician reviewer found that  compression therapy for patients with symptomatic varicose veins, and endovenous thermal ablation for treatment of an incompetent great saphenous vein. In this case, while patient has seen no improvement using compression, the records do not show evidence of bilateral deep vein thrombosis or deep venous insufficiency, and do not describe significant reflux in the vein to be treated. The vein is unremarkable in size. The patient has other health factors, including chronic back pain and morbid obesity, that would hamper appreciable benefit from the requested procedure. The documentation did not reflect lifestyle or mobility limitations due to symptoms from varicose veins. In this clinical setting, the requested procedure is not medically indicated. Therefore, endovenous ablation therapy of incompetent vein (CPT 36475) of the right leg is not medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested service is 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 general surgery and in vascular 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 reimbursement and prospective authorization and coverage for the brand name medication, NuvaRing. The U.S. Food and Drug Administration (FDA) describes the NuvaRing as an estrogen/progestin combination hormonal contraceptive that is used continuously for three weeks, followed by a one- week ring-free interval. It is highly effective when used consistently and correctly. In this case, the patient reports poor tolerance with the generic medication and requests the brand name NuvaRing. Given that the records do not document contraindications to estrogen or progestins and the wide range of individualized tolerance to hormonal contraceptive options, the requested medication is medically indicated. Therefore, the brand name medication, NuvaRing, was and is medically necessary for the treatment of this patient.Final Result: The reviewer determined that the medication at issue was and 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 obstetrics and gynecology 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.