Persius/imr-appeals huggingface dataset:
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for nerve block peripheral injection for treatment of the enrollees knee pain.Findings:  Three physician reviewers found that the submitted documentation fails to demonstrate the superior efficacy of the requested services. The medical records lack documentation of a physical examination demonstrating knee pain due to neuralgia of the genicular nerves. Additionally, there is a lack of documentation of failed standard therapy with antidepressants and anticonvulsants for neuropathic pain. One study performed a double-blind, randomized clinical study comparing neurolysis using traditional radiofrequency to local anesthetic and corticosteroid block of the superolateral, superomedial, and inferomedial branches of the knee genicular nerves in patients who had total knee arthroplasty but still experience pain. The authors noted further clinical trials need to be undertaken, with a larger sample size, in order to demonstrate the efficacy of this technique and to detect the possible appearance of any long-term adverse effects. Final Result: Three 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: All three physician reviewers are board certified in anesthesiology with sub-specialty certification in pain medicine 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

The representatives of a 14-year-old female enrollee requested authorization and coverage of residential care. The Health Plan denied the request indicating that the requested services are not medically necessary for the treatment of the enrollees psychiatric disorders.One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer upheld the Health Plans denial on the basis that the requested treatment is not medically necessary.
Appeal type: Experimental/Investigational
Decision: Upheld

A 59-year-old male enrollee has requested minimally invasive total knee arthroplasty for treatment of osteoarthritis of the right knee.  Findings:  Three physician reviewers found that minimally invasive total knee arthroplasty is still in the experimental phase. There is no Class I long-term data demonstrating an advantage to the minimally invasive approach over conventional total knee arthroplasty. The long-term safety profile is unknown and current data suggests an increase in early complications.
Appeal type: Medical Necessity
Decision: Upheld

The patient is a 54-year-old female with a history of problems with snoring and moderate somnolence. A plan was made for testing with home oximetry as well as with Epworth scale. The latter resulted in a score of 11. It was also noted the patient had problems with choking at night. The patients provider recommended a laser uvulectomy for treatment of the patients hypertrophic and elongated uvula, which in the supine position results in partial obstruction of her pharyngeal airway and a choking sensation. The Health Plan has determined the requested procedure is not medically necessary for the patient. The patient has been diagnosed as having a hypertrophic and elongated uvula that results in symptoms of snoring and choking at night. Her physician states that she has partial obstruction of her pharyngeal airway. In addition, the patient has a history of difficulty with eating and the presence of moderate somnolence. Though these findings suggest mild obstructive sleep apnea, the requested procedure has not been proven to be effective in the treatment of obstructive sleep apnea. Furthermore, laser uvulectomy is not medically warranted for treatment of the patients snoring or choking sensation. Therefore, I have determined the requested procedure 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 47-year-old female enrollee requested authorization and coverage of cervical discectomy with fusion. The Health Plan denied the request indicating that the requested procedure is not medically necessary for treatment of the enrollees back and neck pain.One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer overturned the Health Plans denial on the basis that the requested procedure is medically necessary.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement and prospective authorization and coverage for levofloxacin and azithromycin daily intravenous (IV) infusions. The Health Plan has denied this request indicating that the medications at issue were not and are not medically necessary for treatment of the enrollee, who has a history of Lyme disease. This patient was diagnosed with Lyme disease per the submitted clinical documentation.  The provider recommended treatment for at least six weeks or possibly longer. However, the standard duration of therapy for Lyme disease is two weeks of IV therapy with an additional four weeks for patients with severe cases. In this patients case, the patient has already been treated with several weeks of IV therapy. Moreover, guidelines to suggest that additional treatment with azithromycin and levofloxacin is beneficial are lacking. Therefore, the proposed duration and regimen are not medically indicated for treatment of the patients medical condition. As such, levofloxacin and azithromycin daily IV infusions were not and are not medically necessary for the treatment of this patients medical condition.Final Result: The reviewer determined that the medications at issue were not and 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 internal medicine with sub-specialty certification in infectious disease and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Activ-L4-5 disc replacement surgery: lumbar arthroplasty procedure. While lumbar spinal fusion has long been considered the gold standard for the treatment of lower back pain related to isolated degenerative disease, a wealth of current medical literature supports the use of lumbar disc arthroplasty for the treatment of this condition. Researchers note that while lumbar fusion may result in adjacent segment degeneration and acquired spinal instability, total disc replacement significantly improves the state of lumbar function and alleviates the pain of degenerative disc diseases, improving the patients quality of life. The authors conclude that lumbar disc arthroplasty is superior to lumbar fusion in improved clinical success, reduced pain, patients' satisfaction, shortened hospital stay, operating time and a lessened rate of complications. Researchers found in a comparison of the efficacy and safety of total disc replacement, lumbar fusion, and conservative care in the treatment of single-level lumbar degenerative disc disease, that Activ-L substantially improved ODI success, back pain, and patient satisfaction when compared with other therapies for single-level lumbar degenerative disc disease. In this case, the patient has tried and failed several nonsurgical therapies including medications, physical therapy, spinal injections, and activity modifications. In this clinical setting, an abundance of medical literature supports the use of lumbar disc arthroplasty for the preservation of motion at the treated segment, preservation or improvement in spinal alignment, and for avoiding the potential of adjacent segment disease. Therefore, an Activ-L4-5 disc replacement surgery: lumbar arthroplasty procedure is likely to be more beneficial for treatment of the patients condition than any available standard therapy.Findings: Three of the three physician reviewers found the requested Activ-L4-5 disc replacement surgery: lumbar arthroplasty procedure is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the requested service is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: Physician reviewer 1 and 2 are board certified in neurological surgery and are actively practicing. Physician reviewer 3 is board certified in orthopedic surgery and is actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An  enrollee has requested reimbursement for lipoprotein testing provided. Findings:  The physician reviewer found that based on the records provided the patient is with increased coronary risk. In this circumstance guidelines for the management of cardiac risk and dyslipidemia have been established, are periodically updated by expert committees and are endorsed by several national organizations. These guidelines do not recommend routine performance of specialized tests in the context of assessing coronary risk including lipoprotein-associated phospholipase A2 (Lp-PLA2), sub-classifications of low-density lipoprotein (LDL), high-density lipoprotein (HDL) subclasses, lipoprotein(a), C-reactive protein (CRP), high sensitivity CRP, insulin, fibrinogen, genetic testing and homocysteine . Treatment change or addition based on the results of screening with these specialized tests has not been shown to improve cardiac outcome incremental to that achievable by treatment based on standard risk factor profiling and basic lipid analysis. Randomized trials testing treatment with therapy available to reduce homocysteine levels have not shown significant outcomes benefits . Even though results of some of these specialized tests may be abnormal and considered independent risk markers for coronary disease, there is a lack of controlled trials that demonstrate outcome benefits by treating routinely obtained abnormal results. Final Result: The reviewers determined that the testing 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 therefore, the lipoprotein testing provided was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Credentials/Qualifications: Physician reviewer 1,2 & 3 are board certified in internal medicine with sub-specialty certification in cardiovascular disease 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

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for skilled nursing facility (SNF) services. Based on the records provided for review, the requested SNF services are not medically necessary for treatment of this patient. The patient ambulated 100 feet x 2 with stand by assistance and a two-wheeled walker. She required standby assistance for toileting and transfers as well as supervision for lower body dressing. She was then ambulating 125 feet x 2 with a two-wheeled walker while on oxygen at two liters. She then ambulated 175 feet with supervision and a two-wheeled walker. She transferred with supervision and a two-wheeled walker while on oxygen at two liters. The documentation does not demonstrate that the patient requires skilled nursing services with the specialized skill, knowledge and judgment of a skilled professional nurse. The patient does not have a tracheostomy tube, enteral feedings, complex wound care or other SNF level skilled nursing need. The patients current functional level does not require ongoing SNF level skilled therapy services or skilled therapy services on a daily basis. All told, the requested SNF services are not medically necessary for treatment of this patient. 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 physical medicine and rehabilitation with subspecialty certification in neuromuscular 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 bilateral knee Euflexxa 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, the patient has a documented history of lasting benefit from viscosupplementation with Euflexxa injections to both knees in the past. In addition, the patients provider has recommended repeat injections of Euflexxa into both knees. The patients remaining treatment option is bilateral total knee arthroplasties. For these reasons, the requested bilateral knee Euflexxa 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: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Entyvio once every four weeks. The patient has objective evidence of disease activity after initial response to Entyvio therapy. Continuation of Entyvio every eight weeks, or a change to an alternative therapy, may result in worsening disease or disease complications such as disease flare, fistula, stricture, need for hospitalization, or need for additional surgery. For these reasons, Entyvio once every four weeks is supported as medically necessary for the treatment of this patients Crohns disease.Final Result: The reviewer determined that the requested medication dosage 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

Nature of Statutory Criteria/Case Summary: An  enrollee has requested reimbursement for the Afirma Gene Expression Classifier (GEC) genetic testing. When FNA cytopathology is indeterminate, repeat FNA and or thyroid surgery are the standard options to obtain a definitive pathological diagnosis. In this patients case, the initial FNA cytology was as indeterminate. Thus, FNA could have been repeated, and if cytology was still indeterminate, surgical resection should have been considered. Thus, the Afirma GEC molecular test was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.One reviewer found that the Afirma GEC molecular test was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Final Result: Two of the three reviewers determined that the testing 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:  One reviewer is board certified in internal medicine with sub-specialty certification in endocrinology, diabetes and metabolism and is actively practicing. One Reviewer is board certified in internal medicine with sub-specialty certification in endocrinology, diabetes and metabolism and is actively practicing.  One Reviewer is board certified in internal medicine with sub-specialty certification in endocrinology, diabetes and metabolism and is 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

The parent of a 12-year-old female enrollee has requested subtalar arthroereisis using a Maxwell-Brancheau arthroereisis type implant for the treatment of the enrollees pes planovalgus deformity. Findings:  Two physician reviewers found that the use of arthroereisis with an implant has been discussed in the podiatric literature, and a variety of implants have been utilized. Most of the reports are anecdotal, and there is a paucity of controlled studies. There are theoretical benefits from this approach, but there remains the need for further study. The procedure remains of unproven efficacy at this time.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: At issue is whether the MaterniT21 PLUS (Core) that was provided was likely to have been more beneficial for evaluation of the patients condition than any available standard therapy. A review of the records indicates the patient was estimated to be 16.9 weeks gestation by ultrasound and underwent a prenatal screen. The results from that screen indicated an increased risk for Down syndrome. The provider ordered a MaterniT21 PLUS (Core).Findings:  Three physician reviewers found that the American College of Obstetricians and Gynecologists (ACOG) Practice Bulletin Number 163, states that women with a positive screening test result for fetal aneuploidy should be offered further counseling and cell-free deoxyribonucleic acid (DNA) screening or diagnostic testing by chorionic villus sampling or amniocentesis. There are a wide variety of screening test options, and no one screening test is superior to other screening tests in all test characteristics (ACOG). This patient had a positive quad screen, which indicated that she was at an increased risk of having a fetus affected by a genetic disorder. Confirmation with cell free fetal DNA screening was appropriate to assess for aneuploidy.Final Result: The reviewers determined that the requested evaluation was likely to have been more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: Physician reviewers 1, 2 and 3 are board certified in obstetrics and gynecology 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

A 47-year-old male enrollee has requested Novarel HCG for treatment of his hypogonadism.  Findings:  The physician reviewer found that Novarel HCG is generally prescribed for patients that wish to pursue fertility.  In this case, the patient is relatively young, and treatment with testosterone will cause testicular atrophy and subsequent infertility that will be difficult to reverse.  In order to preserve fertility and optimize sexual function, Novarel HCG was prescribed.  This treatment has been chosen as a result of the patients prior failure or suboptimal response to the standard treatments of testosterone replacement with transdermal testosterone (Androgel) and testosterone injections.  In this patients case, the current medical evidence supports the medical necessity of Novarel HCG for a period of 12 months.  There is a lack of data regarding the safety and efficacy of chronic Novarel HCG therapy for the treatment of male hypogonadism.  All told, Novarel HCG was and is medically necessary for the treatment of this patient for a period of 12 months.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for a power wheelchair for treatment of amyotrophic lateral sclerosis. Findings:  The physician reviewer found that the patient is reported to have amyotrophic lateral sclerosis, a disorder which inexorably causes loss of physical functions such as swallowing, intelligibility of speech, ventilatory function and limb control.  Treatment generally revolves around optimal supportive and palliative care, including non-invasive ventilation support, percutaneous enteral feeding in the setting of dysphagia, custodial level assistance for basic self-care, wheelchairs as needed for mobility, and supportive bedding and other strategies for the prevention and management of pressure sores.  In this case, the records do not indicate that the patient is able to safely, reliably and independently operate a power wheelchair via any means, such as with head control, eye control, mouth control, or upper limb control.  A recent in-home physical therapy evaluation, notably, recommended a manual tilt-in-space wheelchair as best fitting for his overall needs. Final Result: The reviewer determined that the requested equipment 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 physical medicine and rehabilitation 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.