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

A 77-year-old male has requested a continuous passive motion (CPM) machine for treatment status post total knee replacement. Findings:  The physician reviewer found that review of the scientific evidence demonstrates that in most cases, the beneficial effects of the use of CPM have not been clinically established. Though admittedly there is a lack of high quality evidence supporting the use of CPM for most patients, the case-specific factors presented for the above patient warrant the use of a CPM device in this particular circumstance. This patient presents with a malunion of the femur as well as a pre-existing capsular change in response to the flexion deformity at the mid femur, and as such, the use of a CPM device is medically necessary in this case. Given the complexity of this patients presentation, the use of a CPM device to potentially reduce the need for manipulation under anesthesia and/or improve passive and active range of motion is medically reasonable and necessary and should be authorized.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested breast tomosynthesis for evaluation of her medical condition.  Findings:  Three physician reviewers found that breast tomosynthesis is a technique that was developed several years ago as a problem solving adjunct to routine mammography.  Applying the same basic concept as computed tomography (CT) scanning, the logic is that by separating the various layers of breast tissue, one can better detect abnormalities.  This has been shown to be most useful in the evaluation of dense breasts.  As noted by a researcher, this technology has the  potential to change conventional mammographic screening and diagnostic imaging with possible improvements in cancer detection, decreased callbacks, and fewer false positive biopsies.  As in this patients case, it is specifically those patients who have dense breasts that can benefit most from tomosynthesis.   The ability to separate out the overlapping structures enables the possibility of demonstrating an otherwise occult tumor.  Thus, breast tomosynthesis was likely to have been more effective than other modalities for evaluating this patient. Final Result: Three reviewers determined that the services at issue were likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned.  Credentials/Qualifications:   All three reviewers are board certified in diagnostic radiology and are actively practicing. All three reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has been diagnosed with bilateral knee osteoarthritis. On 2/24/20, the patient received bilateral knee Gelsyn injections. On 7/30/20, the provider noted prior viscosupplementation injections provided the patient with relief of symptoms for five to six months. The patient has also been treated with topical anti-inflammatory cream. The patient has requested authorization and coverage for a Gelsyn-3 injection series in both knees. The Health Plan denied the request and reported the requested service is not medically necessary for the treatment of this patient. At issue in this case is whether a Gelsyn-3 injection series in both knees is medically necessary for the treatment of the patients medical condition. Review of the current medical literature pertaining to viscosupplementation reveals mixed results. Although viscosupplementation may relieve knee pain in some patients with osteoarthritis, it is unknown which patients will benefit. Considering the foregoing, viscosupplementation can only be recommended for patients with a history of lasting benefit from prior injections and in carefully selected cases when everything else has been tried and the options are limited. In this case, the patient has a history of lasting benefit from prior viscosupplementation injections in both knees. Furthermore, the patients options are limited. The patient has tried and failed other conservative treatments, with the alternative being total knee arthroplasties of both knees. The medical evidence supports the requested service in this clinical setting. Therefore, a Gelsyn-3 injection series in both knees 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: Experimental/Investigational
Decision: Overturned

A 67-year-old female enrollee has requested acellular dermal sling (AlloDerm) for the treatment of her post-mastectomy wound infection and complications associated with chemotherapy in a staged breast reconstruction plan. Findings:  Three physician reviewers found that the use of acellular grafting is medically indicated in breast reconstructive surgery after cancer surgery and is not investigational. The description of the procedure in the published medical textbooks and well recognized peer-reviewed medical journals supports the safety and efficacy of its use. Further, the U.S. Food and Drug Administration (FDA), which regulates the use of AlloDerm, refers to it as banked human tissue and not a device. AlloDerm is intended for use in replacement or repair of damaged or inadequate integumental tissue. The FDA makes no distinction for its use in terms of body part or type of surgical procedure. In breast reconstruction surgery, AlloDerm is commonly used with tissue expanders as an inferolateral cover for the submuscularly placed expander to decrease the risk of implant exposure or displacement. Directly relating to this patient, these risks are inherently greater since she has already undergone radiation therapy.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Vertiflex Superion procedure (CPT code 22869). Interspinous process decompression offers an intermediate step in the continuum of care for patients with neurogenic intermittent claudication associated with lumbar spinal stenosis. There are many interspinous devices available. Current medical literature has not demonstrated that interspinous devices provide superior long-term symptomatic improvement over simple decompression. Although there is fair evidence that an interspinous spacer device is superior to nonsurgical therapy for one- or two-level spinal stenosis with symptoms relieved with forward flexion, insufficient evidence exists to judge the long-term benefits or risks. This patient has lumbar spinal stenosis. The standard of care for his condition remains simple decompression. For these reasons, the requested Vertiflex Superion procedure (CPT code 22869) is not 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 Vertiflex Superion procedure (CPT code 22869) is not 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 services are not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: Physician reviewers 1, 2, and 3 are board certified in 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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for hyaluronan intra-articular injections. The medical literature pertaining to viscosupplementation reveals mixed results. Although viscosupplementation may relieve knee pain in some individuals with osteoarthritis, it is not known 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 medical evidence does not support viscosupplementation as a standard treatment for osteoarthritis of the knees. Viscosupplementation can only be recommended in individuals with a history of lasting benefit from prior injections and in carefully selected cases where the options are limited.  In this case, the records document a history of lasting benefit from prior viscosupplementation. Furthermore, his options are limited. The patient has tried and failed other conservative treatment, and the alternative option is a total knee arthroplasty. Therefore, hyaluronan intra-articular injections are medically necessary for the 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: Medical Necessity
Decision: Upheld

A 51-year-old female enrollee has requested a second opinion consultation with an out-of-network oncologist/surgeon for an evaluation of her for possible lymphoma. Findings:  The physician reviewer found that with the information provided, there is no medical necessity for the out-of-network evaluation as resources are available within the network for ongoing care of the patient. This patient needs the left axillary lymph node biopsied by a surgical excision (as noted in the pathology report, if continued clinical concern exists, an excisional biopsy would be warranted due to a potentially false negative result). These services can be provided within the network, and therefore, the requested consultation is not clinically indicated.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary:  An enrollee has requested percutaneous tibial nerve stimulation for treatment of her medical condition. Two physician reviewers found that there is evidence in the peer-reviewed literature from randomized trials and prospective observational trials supporting the clinical utility and impact on patient management of percutaneous tibial nerve stimulation in patients with urinary urgency and frequency.  However, most trials have a small number of patients with short term follow-up.  Percutaneous tibial nerve stimulation is considered a third-line therapy.  In this patients case, the indications for the procedure are unclear.  The patient has no overt symptoms of severe overactive bladder.  The patients voiding diary and urodynamic study do not support the diagnosis.  At this time, there is lack of adequate documentation supporting the diagnosis of refractory overactive bladder needing third-line therapies.  All told, percutaneous tibial nerve stimulation was not and is not likely to be superior over other treatment options. Final Result: Two reviewers determined that the requested services were not and are not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld.  Credentials/Qualifications:  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.
Appeal type: Medical Necessity
Decision: Upheld

A 36-year-old female enrollee requested authorization and coverage for a referral to a dermatologist for the treatment of acne.  The health plan has denied this request indicating that the requested referral is not medically necessary for treatment of the enrollees medical condition.One physician reviewer performed a medical necessity Independent Medical Review.  The physician reviewer upheld the Health Plans denial on the basis that the requested referral is not medically necessary.
Appeal type: Medical Necessity
Decision: Overturned

Findings:  The physician reviewer found that The patient has requested authorization and coverage for IVIG Octagam 2 gm/kg (125 gm total dose) over five days repeated monthly. Treatment of severe and refractory calcinosis cutis and scleroderma must be individualized based on clinical findings and presentation. In this case, the patients presentation is advanced and rare, and current medical literature draws mainly from case reports and findings from similar immune-mediated conditions that may cause severe calcinosis cutis. Waldman and colleagues note that the best supporting data for the use of IVIG in refractory calcinosis cutis is in the setting of dermatomyositis, which shares many similarities to scleroderma in terms of management. In this case, the records document findings consistent with severe and refractory calcinosis cutis and worsening scleroderma. The patient has tried and failed treatment with hydroxychloroquine and mupirocin. Fagni and colleagues note that with the COVID-19 pandemic, treatment with immunosuppressives, such as cyclophosphamide, are associated with increased hospitalization if a patient is infected with COVID-19 and may result in significant morbidity and mortality. Therefore, IVIG Octagam 2 gm/kg (125 gm total dose) over five days repeated monthly are medically necessary for the 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.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has been diagnosed with medial and patellofemoral compartment osteoarthritis of the  knee. The provider noted the patient received two weeks of benefit from a prior knee cortisone injection. The patient was noted to be attempting weight loss. Physical examination findings included knee medial femoral condyle tenderness. The provider noted a knee magnetic resonance imaging (MRI) revealed moderate medial and patellofemoral compartment osteoarthritis. The provider also noted x-rays revealed moderate knee medial compartment and patellofemoral osteoarthritis. The patient has been treated with knee arthroscopic surgery. The patient has requested authorization and coverage for a Synvisc-One injection in the knee. The Health Plan denied the request and reported the requested service is not medically necessary for the treatment of this patient. At issue in this case is whether a Synvisc-One injection in the knee is medically necessary for the treatment of the patients medical condition. Review of the current medical literature pertaining to viscosupplementation reveals mixed results. Although viscosupplementation may relieve knee pain in some patients with osteoarthritis, it is unknown which patients will benefit. Considering the foregoing, viscosupplementation can only be recommended for patients with a history of lasting benefit from prior injections and in carefully selected cases when everything else has been tried and the options are limited. In this case, the patients options are limited. The patient has tried and failed other conservative treatments as well as arthroscopic surgery, with the alternative being knee arthroplasty. The medical evidence supports the requested service in this clinical setting. Therefore, a Synvisc-One injection in the  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. Findings:  The physician reviewer found that
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary:  An enrollee has requested Prolia injections for treatment of her osteoporosis.  Findings:  The physician reviewer found that the submitted documentation demonstrates Prolia is medically necessary for this patient. The patient has severe osteoporosis. Recent studies show that patients such as this patient are at a high risk for fracture, as calculated by the FRAX score. Based on the patients submitted medical records, she should continue osteoporosis treatment.  Prolia is approved by the Food and Drug Administration (FDA) for the treatment of osteoporosis in postmenopausal women at high risk of fracture. Prolia reduces the incidence of vertebral fractures by about 68%, hip fractures by about 40%, and non-vertebral fractures by about 20% over 3 years. Based on the submitted records along with the results of available scientific studies, the request for Prolia injections is medically necessary to treat this patients medical condition.Final Result: The 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: Physician reviewer number three is board certified in internal medicine with sub-specialty certification in endocrinology 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: Overturned

The representative of a 57-year-old male enrollee has requested Provigil for the treatment of his medical condition status-post basilar artery aneurysm. Findings:  The physician reviewer found that this patient has had subarachnoid hemorrhage, complicated by midbrain ischemia, with residual hypersomnolence. Literature shows that midbrain ischemia can induce a variable degree of damage to waking and non-REM sleep networks, producing abnormal waking and sometimes hypersomnia that can be reduced by modafinil. He has reportedly tried Ritalin treatment, with excessive side-effects of blood pressure elevation. Modafinil has apparently been beneficial and well tolerated, resulting in improved ability to function in rehabilitation therapies. Participation in rehabilitation therapies is necessary to optimize the patients recovery post stroke, and as modafinil has been tolerated and beneficial in promoting alertness, its use is medically reasonable and appropriate for treatment of his post stroke hypersomnolence.
Appeal type: Medical Necessity
Decision: Upheld

The patient is a three-year-old male with an expressive speech delay. He has a history of otitis media but there is no documentation of an effusion. Audiology was reportedly within normal limits. Initial speech evaluations were performed by two different providers in June 2004 and December 2004. The evaluations document mild to moderate speech delay. It appears the patient has been receiving speech therapy since February 2005. A request has been made for authorization and coverage for continued speech therapy at a frequency of three times per week. The Health Plan has denied this request on the basis that continued therapy is not medically necessary for treatment of the patients condition.In reviewing the submitted documentation, the June 2005 progress report does not demonstrate that progress has been made in this case. Additionally, the evaluations provided do not report the progress made on each goal. Furthermore, review of the relevant literature does not demonstrate that an increased frequency of speech therapy (above and beyond the therapy being provided by the school district) results in a superior clinical outcome in cases such as this. Therefore, I have determined the requested therapy is not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned

A 31-year-old female enrollee has requested the medication Subutex for treatment of her migraine headaches. Findings:  The physician reviewer found that the available medical records suggest Subutex is keeping the patient in some kind of functional balance. She is having a difficult time transitioning from Subutex to Suboxone. Switching to Subuxone is a regular medical option, but this patient is still dealing with active addiction issues despite IOP treatment. She may require a high level of care or more structured care with addiction and psychiatric issues as the main focus. In the meantime, Subutex should be continued for two months from the date of this decision. Contemporaneously, attempts should be made to have an addiction psychiatrist assess the overall care plan and devise other treatment strategies to help the patient maintain sobriety and manage her pain.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for DecisionDx-Melanoma Genetic Testing. Melanoma staging is characterized by the American Joint Committee on Cancer (AJCC) system that defines cutaneous melanoma stages 0-IV. As patients diagnosed with stage I or II melanoma are generally viewed as having a low risk of metastasis, treatment planning is limited to surgical excision of the primary tumor followed by routine skin examinations and clinical examination. In contrast, patients diagnosed with stage III melanoma receive complete lymph node dissection, active surveillance measures and often, referral to medical oncology for adjuvant medical therapy and clinical trial participation. However, there is a lack of peer-reviewed published studies confirming the role of DecisionDx-Melanoma Genetic Testing in this clinical setting. All told, the DecisionDx-Melanoma Genetic Testing was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Findings:  Three physician reviewers found the DecisionDx-Melanoma Genetic Testing was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that DecisionDx-Melanoma Genetic Testing was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.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.