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

The patient has requested authorization and coverage for Euflexxa injections to both knees. The patient has been diagnosed with osteoarthritis of both knees. The provider noted that the patient reported good results with previous Euflexxa injections and requested repeat injections. 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. Viscosupplementation can only be recommended in patients with a history of lasting benefit from prior injections and in carefully selected cases where the options are limited. A clinical trial found that viscosupplementation increased functional scores in patients with severe osteoarthritis of the knee, especially within three months of injection. In this case, the patient has a history of benefit from prior viscosupplementation injections. Furthermore, the patients options are limited, with the alternative being total knee arthroplasties. The medical evidence supports the requested services in this clinical setting. 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 49-year-old female enrollee has requested Euflexxa injections for treatment of her  right knee pain. Findings:  The physician reviewer found that review of the submitted documentation and relevant literature fails to demonstrate the medical necessity of the requested therapy. There is a lack of adequate randomized, controlled studies in the peer-reviewed literature demonstrating the clinical effect from hyaluronate injections. Rutjes and colleagues assessed the efficacy of viscosupplementation for adults with symptomatic knee osteoarthritis. This study reviewed a total of 89 trials involving 12,667 adults and concluded that in patients with knee osteoarthritis, viscosupplementation is associated with a small and clinically irrelevant benefit and that there is an increased risk of serious adverse effects (Rutjes et al). Moreover, this patient has a patellofemoral instability syndrome with valgus orientation of the knee and abnormal tracking of the patella in the trochlear. The MRI has documented chondromalacic changes at the lateral femoral condyle and facets of the patella. There are also abnormalities found in the lateral meniscus. In the face of these mechanical and alignment issues, hyaluronate injection is not clinically indicated as it is not likely to provide benefit. Based on the medical literature cited above, the requested therapy is not medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary:   An enrollee has requested intensive outpatient psychiatric treatment for treatment of her behavioral health condition. Findings:  The physician reviewer found that in this case, the patients diagnoses has caused significant intrapsychic distress and functional impairment. As in all conditions, the least restrictive level of care is preferred, and the determination of the ideal care setting is best made by the providers most familiar with the clinical situation and treatment needs. The patients psychiatrist has recommended continued treatment at the intensive outpatient level of care, which is a setting endorsed by the American Psychiatric Association for the treatment of OCD. Treatment at this time cannot reasonably be conducted in a less restrictive setting while less intensive treatment would result in inadequate care. The intensive outpatient setting is reasonably expected to both improve her condition and prevent a more serious episode of illness. Further, the intensive outpatient setting represents a safe and appropriate placement consistent with good medical practice. As such, the services at issue were and are medically necessary for treatment of the patients medical condition. Final Result: The reviewer determined that the services at issue were and are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.  Credentials/Qualifications: The reviewer is board certified in psychiatry and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

A 25-year-old female enrollee has requested an MRI of the whole body, leg or foot for evaluation of her foot pain. Findings:  The physician reviewer found that with the exception of x-rays, imaging has not been done.  Whole body MRI is not medically indicated for this patient since there is no history of malignancy. Whole body MRI, although not widely available, is generally reserved for the detection of skeletal metastases as well as other organ involvement.  This patient has a history of a foot neuroma.  Due to the fact that imaging of her feet has not been done despite symptoms which have persisted for over one year, bilateral MRI of the feet is medically indicated for the evaluation of this patient.  All told, in this patients case, evaluation with bilateral MRI of the feet is medically appropriate given her symptoms.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for computed tomography (CT) of the chest (CPT 71250). The records document that this patient presents with small 2 mm pulmonary nodules that have been overall stable from May 2016 to May 2018. The patient is a never smoker with no prior history of cancer. She has a history of exposure to second-hand smoke and a family history of lung cancer in her father. Based on the available information, the pre-test probably is low that the nodules initially observed on CT in 2016 represent an indolent neoplastic process, especially in light of their two-year stability on repeat imaging. As noted in the medical literature, pulmonary nodules in this clinical setting do not require continued surveillance with CT imaging (MacMahon, et al.; McWilliams, et al.). Therefore, the requested CT of the chest (CPT 71250) is not medically necessary for evaluation of this patient. Final Result: The reviewer determined that the requested services are not medically necessary for evaluation of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in internal medicine with subspecialty certifications in pulmonary disease and critical care 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 36-year-old female enrollee has requested authorization and coverage for transcranial magnetic stimulation for treatment of the enrollees major depressive disorder. Findings:  Two physician reviewers found that the patient has a history of post-traumatic stress disorder and major depressive disorder.  Her prior medication regimens included fluoxetine 40mg, sertraline 100mg, sertraline 200mg and Seroquel 200mg, and sertraline 200mg and Abilify 10mg.  The patient has received cognitive behavioral therapy.  She was admitted for acute psychiatric hospitalizationdue to suicidal ideation, and she was discharged five days later.  Her diagnoses at discharge included major depressive disorder, recurrent, severe, without psychotic features, and anxiety disorder, not otherwise specified.  The patient has requested coverage for transcranial magnetic stimulation.  The submitted documentation fails to demonstrate the superior efficacy of the requested services in this clinical setting.  After a request for transcranial magnetic stimulation was made, the patient was admitted to inpatient level of care for suicidal thoughts with plan.  During the hospitalization, she received therapy to address her social situation.  Additionally, changes in her medication regimen were made.  These interventions were beneficial and resulted in an improved condition.  In this patients case, standard interventions resulted in improvement.  Thus, the requested transcranial magnetic stimulation is not likely to be of greater benefit than other treatment options in this patients case.
Appeal type: Medical Necessity
Decision: Upheld

The parent of a five-year-old male enrollee has requested for speech therapy for treatment of the enrollees delayed speech. Findings:  The physician reviewer found that multilingualism may affect the way in which a child learns each language in that the early expression of a language is very likely to vary somewhat from that seen in children in a monolingual environment. This difference in language is not a deficit. Syntactic systems may remain undifferentiated for a time. A variety of speech and language standardized tests are available for Spanish speakers. It is important to remember that children who are bilingual cannot have a communication disorder in one language alone, their deficit would be present in both languages.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Epclusa. The Health Plan has denied this request indicating that the requested medication is not medically necessary for treatment of the enrollees hepatitis C virus.Findings: The physician reviewer found that according to the 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 non-liver-related conditions. The guidelines recommend that all patients should be treated, regardless of fibrosis stage. The guidelines recommend that non-cirrhotic treatment naive genotype 1 patients should be treated with Epclusa for 12 weeks, and the medication is U.S. Food and Drug Administration (FDA)-approved for all patients with chronic hepatitis C genotype 1 regardless of fibrosis stage (Feld, et al). AASLD/IDSA guidelines cite data showing reduced survival with delayed treatment (Jezequel, et al). For these reasons, treatment of hepatitis C is needed, and the requested treatment with Epclusa is medically necessary for the treatment of the patients hepatitis C infection.Final Result: The reviewer determined that the requested medication is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in internal medicine with sub-specialty certification in gastroenterology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld

A 53-year-old male enrollee requested hyaluronan (Supartz) injections to the ankle for medical treatment of his ankle pain.  Findings:  Three physician reviewers found that current medical evidence has not established the superior efficacy of the requested services in this patients case.  There is a lack of evidence demonstrating that the requested services are superior to other treatments of osteoarthritis such as corticosteroids, physiotherapy, or other conservative measures.  The peer-reviewed literature indicates that additional studies are required to support the effectiveness of hyaluronan injections for ankle osteoarthritis treatment.  Therefore, the requested hyaluronan (Supartz) injections are not likely to be of greater benefit than other treatment modalities.
Appeal type: Experimental/Investigational
Decision: Overturned

A 40-year-old female enrollee has requested hip arthroscopy surgery for treatment of her left hip impingement and labrum tear.  Findings:  Two physician reviewers found that this patient has a positive crossover sign, which is a reliable clinical finding in the documentation of a relative acetabular retroversion. She has an alpha angle of approximately 90 degrees.  Physical examination noted findings of pain on internal rotation at 90 degrees flexion. There are additional physical findings which help to establish and support the diagnosis proposed of femoral acetabular impingement. The presence of either cam or pincer type acetabular impingement is likely to be associated with early development of degenerative osteoarthritis of the hip. The use of extra-articular approaches in the management of femoroacetabular impingement syndrome is likely to either delay or in some cases obviate the need for joint replacement by reason of an early and progressive osteoarthritis. The importance of delaying total joint replacement in the relatively young patients who experience this condition is very important because there are predictable problems of response to wear debris with loosening and subsidence after joint replacement. In the article published by Sink and colleagues, the typical clinical presentations of femoroacetabular impingement syndrome were noted. Findings of decreased flexion and limited internal rotation were noted on physical examination. In article by Bredella and Stoller, the basic types of femoroacetabular impingement are discussed. The authors noted that repetitive mechanical trauma to the hip joint causes mechanical wear of the labrum and to the anterior articular cartilage. In this patients case, she has positive MRI findings and positive crossover sign. The authors feel that the presence of these changes will lead to progressive osteoarthritis of the hip if untreated. Thus, in this patients case, the requested procedure is likely to be of greater benefit than other methods of treatment.
Appeal type: Medical Necessity
Decision: Upheld

The parent of a 17-year-old female enrollee has requested for continued residential psychiatric treatment for treatment of her dysthymic disorder and oppositional defiant disorder.  Findings:  The physician reviewer found that Practice Parameters by the American Academy of Child and Adolescent Psychiatry for the treatment of children and adolescents with substance use disorder emphasize the need to address substance use disorders in family therapy along with the provision of psycho-education. Additionally, the guidelines indicate that community intervention settings, when feasible, may offer optimal treatment gains. In summary, given the progress following 3 months of clinical intervention and given the presentation at the time of residential placement, this patients inability to participate in a less restrictive level of care is not documented. Additionally, the residential setting does not provide consistent documentation of a comprehensive treatment approach including after care planning for the patients substance use disorder.
Appeal type: Medical Necessity
Decision: Upheld

A 30-year-old female enrollee has requested a Lymphopress pump for the treatment of her lymphedema. Findings:  The physician reviewer found that the patient has no documented history of chronic venous insufficiency. There is no evidence of venous stasis, diabetic or arterial ulcers not clinically amenable to revascularization or other surgical intervention. In addition, no history of claudication pain is noted. Lastly, the patient had a positive response to lower extremity elevation.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested reimbursement for residential treatment for treatment of his behavioral health conditions.  Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the services at issue.  The family therapy note noted that the patient had developed insight into the nature of his problems and expressed good motivation to continue to do therapeutic work. He had already developed some coping strategies, was doing well in school and had a good pass with his father.  Based upon the records provided, the patient did not meet criteria for continued treatment in a 24-hour facility during the period in dispute. He was highly motivated towards his ongoing recovery and was not experiencing any behaviors or actions that could not be managed outside of a 24-hour setting. Final Result: The reviewers determined that the services at issue were not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.  Credentials/Qualifications: The reviewer is board certified in psychiatry with sub-specialty certification in child and adolescent psychiatry and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

A 62-year-old male enrollee has requested a portable air concentrator (backpack) for treatment of his chronic obstructive pulmonary disease (COPD). Findings:  The physician reviewer found that the submitted documentation establishes the medical necessity of the requested equipment. This patient requires continuous oxygen therapy. His room air oxygen saturation is less than 88% and he currently uses three liters per minute of oxygen via nasal cannula. The patient is also physically unable to push a portable tank without severe pain. The patient has documented physical limitations to pushing or pulling an oxygen tank with wheels, while he uses a cane. The requested backpack air concentrator will likely improve his mobility and decreases his pain associated with ambulation.  The patient indicates that he usually goes out in the early morning or early evening, so the backpack unit is being requested for more than physician visits. In addition, the home health companys request to surrender his home oxygen unit with humidifier that he uses around the house in order to obtain the backpack unit is not medically reasonable or appropriate in this clinical setting. Based on the medical literature cited above and the documentation submitted for review, the requested portable air concentrator (backpack) is medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient is requesting authorization and coverage for Repatha pen injectors. She has been diagnosed with type 2 diabetes mellitus and hyperlipidemia. The patient reported chest pain. The patients medical record states she failed multiple statins. Per the provider, treatment with ezetimibe was suboptimal. The patient had reportedly declined to restart statin therapy due to intolerance. The Health Plan denied the request and reported the requested medication is not medically necessary for the treatment of this patient. The American College of Cardiology reports that proprotein convertase subtilisin-kexin type 9 inhibitors should be used for patients with a very high risk of atherosclerotic cardiovascular disease (ASCVD) or established ASCVD. Medical literature states, Clinical ASCVD includes acute coronary syndrome, those with a history of myocardial infarction, stable or unstable angina or coronary arterial revascularization, stroke, transient ischemic attack, or peripheral artery disease, including aortic aneurysm, all of atherosclerotic origin. Very high-risk individuals include patients with a history of multiple major ASCVD events or one major ASCVD event and multiple high-risk conditions. The guidelines indicate that patients that do not meet the criteria for very high risk and have intolerance to high dose statin medication should be tried on a lower dose statin medication with ezetimibe. The guidelines recommend treatment with PKSK9 inhibitors for patients with familial hypercholesterolemia and in patients at very high risk for ASCVD. This patient has diabetes, which places her at risk for ASCVD, but there is no documentation of the patient having experienced a major ASCVD event or that she has familial hypercholesterolemia. There is a mention of chest pain, but no indication that the chest pain is cardiovascular in origin. There is no documentation of a cardiovascular evaluation that indicates that this patient has ASCVD. The medical evidence does not support the requested medication in this clinical setting. Therefore, Repatha pen injectors are not medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested medication 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 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: Experimental/Investigational
Decision: Upheld

An enrollees parent has requested authorization and coverage for Gammagard (J1569). The records provided for review do not support a diagnosis of Ehlers-Danlos syndrome. Specifically, there is no report that the patient has clinical evidence of other features of dysautonomia such as gastrointestinal dysmotility, neurogenic bladder or complex regional pain syndrome, although she does have abdominal pain, constipation and weight loss. In addition, the records provided for review do not demonstrate that the patient has exhausted standard therapies for her medical condition. The provider recommended increasing water and salt intake, use of compression stockings, physical therapy, and propranolol 10 mg. The records do not describe use of these modalities or their outcome. In addition, there is no report of a diagnostic work-up to include anti-neuronal antibodies, Sjogrens syndrome, and antiphospholipid antibodies (Schofield and Chemali). One study evaluated the sera of patients with postural orthostatic tachycardia syndrome (POTS) found organ-specific autoantibodies, particularly thyroid-specific, to be more common in patients with POTS. The preliminary nature of these findings prohibit conclusions on immunomodulatory or immunosuppressive treatments (Blitshteyn). All told, the requested Gammagard (J1569) is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Findings:  Three physician reviewers found the requested Gammagard (J1569) 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 medication is 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.