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

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for high intensity shockwave therapy for treatment of the enrollees plantar fasciitis. Findings:  The physician reviewers found that the therapy at issue was likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. There is high quality peer-reviewed evidence to support the safety and efficacy of high-intensity ESWT in the treatment of recalcitrant plantar fasciitis. The documentation demonstrates evidence of at least five months of recent reasonable and/or comprehensive non-operative treatment. Therefore, the high intensity shockwave therapy has been established as likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Final Result: All three reviewers determined that the therapy at issue was 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 reviewers number one, two, and three are board certified in orthopedic surgery and 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: The patient has requested authorization and coverage for a Gelsyn-3 injection series in the right knee. Findings: Per the medical literature, although viscosupplementation may relieve knee pain in some individuals with osteoarthritis, it is not known as to which individuals will benefit. The current evidence is limited, and guidelines from organizations such as the American Academy of Orthopedic Surgeons indicate that the evidence is not conclusive. In light of the foregoing, viscosupplementation can only be recommended in individuals with a history of lasting benefit from prior injections, and in carefully selected cases where everything else has been tried, and the options are limited. In this case, the patient has not responded to corticosteroid injections and desires to postpone a total knee arthroplasty. Given the patients limited options and based on the current medical literature, the requested services are medically indicated. Therefore, a Gelsyn-3 injection series in the right knee is 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 26-year-old male has requested coverage for a continuous glucose monitoring system for treatment of his diabetes.  Findings:  The physician reviewer found that the documentation provided is not consistent with a diagnosis of diabetes mellitus type 1, which is indicated throughout the provider notes. The provider note indicates a recommendation that the patient take Victoza 0.3, which is not a medication approved by the Food and Drug Administration (FDA) for patients diagnosed with diabetes mellitus type 1, but rather for patients with diabetes mellitus type 2. Additionally, there is no evidence in the records provided of a positive GAD65 on islet cell hemoglobin test or of a very low c-peptide test. Further, the patients glucose log data shows only 6 results of a blood glucose level of less than 60 and only 2 results of less than 50 out of 160 total tests. The ratio of hypoglycemia to total tests is so low that it does not indicate a need for a continuous glucose monitoring system. Given that the patients symptoms are inconsistent with a diagnosis of diabetes mellitus type 1, the patient does not have frequent blood glucose level lows of less than 50, and the absence of documentation of true hypoglycemic unawareness, the requested continuous glucose monitoring system is not medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld

The enrollee is requesting reimbursement for residential treatment center (RTC) level of care. The enrollee has borderline personality disorder, major depressive disorder, generalized anxiety disorder, attention deficit hyperactivity disorder, and alcohol use disorder. The enrollees composite LOCUS score correlates with Level IV, medically monitored non-residential services.Final Result: The reviewer determined that the requested service was not medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The physician 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 similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

The parent of an eight-year-old male enrollee has requested  for occupational therapy (OT) for treatment of the enrollees sensory processing deficits.  Findings:  The physician reviewer found that the documentation provided for review fails to show the patient has a medical condition or functional deficits that interfere with age-appropriate activities of daily living. There is no clinical basis for the assumption that his motor skills will not improve with maturity. The evidence does not support the premise that OT intervention has improved, or will improve, this childs level of daily functioning.
Appeal type: Medical Necessity
Decision: Upheld

The patient has requested authorization and coverage for pregabalin capsules 25 mg. The U.S. Food and Drug Administration (FDA) approved indications for pregabalin include neuropathic pain associated with diabetic peripheral neuropathy, post-herpetic neuralgia, adult patients with partial onset seizures, fibromyalgia, and neuropathic pain associated with spinal cord injury. Medical literature studies showed limited evidence of benefit in neuropathic back pain or sciatica, neuropathic cancer pain, or polyneuropathy. The North American Spine Society (NASS) guidelines for diagnosis and treatment of lumbar disc herniation with radiculopathy concluded that there is insufficient evidence to make a recommendation for or against the use of gabapentin in the treatment of lumbar disc herniation with radiculopathy. This patient presents with acute on chronic low back pain radiating into the right leg suggestive of lumbar radiculopathy. The records do not document a trial of a duloxetine or venlafaxine, which have been shown to be effective for neuropathic pain. Overall, there is insufficient evidence in the peer-reviewed medical literature to support the use of pregabalin for lumbar radiculopathy. Therefore, the requested pregabalin capsules 25 mg is not medically necessary for 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 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: Urgent Care
Decision: Overturned

A 61-year-old male enrollee has requested for emergency services. Findings:  The physician reviewer found that the patient was diagnosed with an upper respiratory infection, the signs and symptoms that he presented with are consistent with a variety of more serious and potentially life-threatening diseases that need to be ruled out. Some of these possible diseases include meningitis (fever, headache, myalgias), pneumonia (cough, fever, congestion), sinusitis (headache, fever, congestion), influenza (myalgias, fever), gastroenteritis (diarrhea, vomiting, fever), bacteremia/sepsis (all presenting symptoms plus abnormal vital signs of high heart rate and low blood pressure), and other infectious disorders.
Appeal type: Medical Necessity
Decision: Upheld

A 43-year-old female has requested decongestive lymphatic surgery, vascular endothelial growth factors test, a food inflammation and water retention test, ongoing refills of Lovaza, and a computed tomography (CT) angiogram for treatment of her Dercums disease and lipedema.  Findings:  The physician reviewer found that based on review of the available records, the patient presents with Adiposis Dolorosa, which is a rare disorder described only in case reports in the available peer-reviewed medical literature. According to the medical literature, there is no specific proven treatment for the disease. Specifically, analgesic medications have limited effectiveness, steroids do not have proven benefit, surgical excision may provide temporary relief but recurrence rates are high. In addition, liposuction has been evaluated, however not in any properly designed, prospective randomized studies (Berntorp, et al). All told, the requested decongestive lymphatic surgery, vascular endothelial growth factor test, food inflammation and water retention test, Lovaza, and computed tomography (CT) angiogram are not supported as medically necessary in evaluating and treating this patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld

A 50-year-old female enrollee has requested for the prescription medication Lyrica for treatment of her foot pain.    Findings:  The physician reviewer found that Lyrica is generally used for treatment of neuropathic pain syndromes associated with diabetes, as well as post-herpetic neuralgia, and fibromyalgia. Lyrica is not a common medication for central nervous system neuropathic pain syndromes such as MS, nor is it FDA approved for this indication. In addition, it appears that this patient has not had a trial of formulary neuropathic pain medications. Such a trial would be appropriate prior to off-label utilization of Lyrica.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: A enrollee has requested authorization and coverage for orthopedic shoes (orthopedic footwear L3221 x 2) and orthotics (L3020 x 2; foot insert) for treatment of the enrollees ankle joint pain, knee pain, and plantar fasciitis. Findings:  The physician reviewer found that based on the available documentation the requested biomechanical orthotics are not medically necessary for treatment of this patients foot pain. Review of guidelines indicate orthopedic foot wear including shoes, inserts, or modifications to shoes for patients without diabetes are not supported as medically necessary. Some bracing is considered necessary if on a shoe that is an integral part of a medically necessary leg brace. These criteria are not documented in the records provided for review. Moreover, the requested foot orthotic is not likely to alleviate the patients foot pain. All told, the requested orthopedic shoes (orthopedic footwear L3221 x 2) and orthotics (L3020 x 2; foot insert) are not medically necessary for treatment of this patients diffuse foot and metatarsal head pain. 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 podiatry 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 reimbursement for the digital breast tomosynthesis for evaluation of the enrollees breast cancer screening. Findings:  2/3 of the physician reviewers found that Tomosynthesis is a technique that was developed as a problem solving adjunct to routine mammography. In this case, the patient has heterogeneously dense breasts. While one could make the argument that her mammogram has not changed since the last study, 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. Given the support cited above, the breast tomosynthesis was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.  Final Result: 2/3 of the reviewers determined that the diagnostic procedure at issue was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: Physician reviewer number one is board certified in diagnostic radiology 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.Physician reviewer number two is board certified in diagnostic radiology 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.Physician reviewer number three is board certified in diagnostic radiology 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 patient has a history of idiopathic hypersomnolence with excessive daytime sleepiness. In addition, it appears the patient may have an established diagnosis of hypothyroidism. The patients daytime sleepiness is interfering with her ability to drive safely and her job performance. The submitted information indicates the patient has failed traditional alternative treatments. The patient indicates that she has tried stimulants in the past but experienced side effects. A request has been made for authorization and coverage for Provigil. The Health Plan has denied this request on the basis that Provigil is not medically indicated for treatment of the patients clinical condition.The submitted information documents that the patient has been tried on Provigil and it has been effective for treatment of her excessive daytime sleepiness. The submitted records also document that traditional alternative treatments have not been effective or have caused intolerable side effects. In light of these factors, continued treatment with Provigil is medically reasonable and appropriate. Therefore, I have determined that the requested medication is medically necessary for treatment of the patients medical condition. The Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Overturned

An enrollee has requested authorization and coverage for eight infusions of Tepezza. Findings:  The physician reviewer found that Tepezza (teprotumumab) is a newly approved therapy for active thyroid eye disease. Ting and Ezra state that teprotumumab may herald a new era in the treatment of thyroid eye disease and could offer an alternative to surgery and its associated complications. Ju and Yang state that teprotumumab is a human insulin-like growth factor-I receptor monoclonal inhibitor antibody which is indicated for treating thyroid eye disease. They note that clinical trials indicated that proptosis response of teprotumumab was 83%, and clinical activity score, diplopia, and quality of life were also better than placebo. In this case, the patient has severe or sight threatening thyroid eye disease which appears to have had progression of her proptosis and lid retraction for which another orbital decompression is planned. The patient continues to have pain, conjunctival redness and eyelid swelling and redness, which are all signs of inflammation (based on these findings, her clinical activity score is 4 out of 7). Accordingly, the patients condition is active with signs of inflammation. Therefore, the use of Tepezza in this patient with active disease who has failed prior therapies is medically necessary. Accordingly, the requested eight infusions of Tepezza are medically necessary to treat the patients medical condition.Final Result: The reviewer determined that the requested services are medically necessary to treat the patient's medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in ophthalmology 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 parent of an enrollee has requested Lupron Depot for treatment of the enrollee's gender dysphoria. Findings:  The physician reviewer found that review of the submitted documentation demonstrates the patient has been receiving support from a licensed mental health professional. The patients therapist has assessed the patient with gender dysphoria. The patient has been experiencing early pubertal changes that have resulted in an increase of his gender dysphoria. There is no evidence of any psychiatric comorbidities that would interfere with his diagnostic workup or treatment. All told, the patient is an appropriate candidate for hormone therapy. As such, the requested Lupron Depot is medically necessary for treatment of the patients medical condition. Final Result: The reviewer determined that the requested therapy is medically necessary for treatment of the patients medical condition. The Health Plans denial should be overturned.  Credentials/Qualifications: The reviewer is board certified 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

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for removal and/or biopsy of skin lesions. For approaching melanocytic lesions, criteria such as the algorithm presented by the American Academy of Dermatology (AAD), and evaluation of gross features such as bleeding, pain, and growth, are critical (Tsao, et al.). The AAD algorithm for the evaluation of nevi assesses asymmetry, border, color, diameter, and evolution (ABCDE) suggest that biopsy is indicated for this patient as a bleeding and painful nevus is a sign of potential evolution. This patients clinic notes from 1/5/22 do not document the patient complaints of a bloody and painful scalp lesion. The patients physical examination noted scattered tan and brown macules on the scalp, trunk, and extremities. No sizes or specific descriptions corresponding to particular nevi were included in the records. Given the patients history of sun damage-induced lesions on his face including actinic keratoses, recent history of basal cell carcinoma on his trunk, family history of melanoma, and the self-described concern about pain and bleeding, it is prudent to perform a biopsy of the concerning skin lesions. In this clinical setting with concerning symptoms such as bleeding, pathological examination is recommended for diagnosis. Given these findings, the requested removal and biopsy of skin lesions 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 dermatology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

A 53-year-old male enrollee has requested for Omnaris nasal spray for treatment of her allergies. Findings:  The physician reviewer found that there is no clear evidence to support that one steroid spray is more effective than another in the treatment of seasonal or perennial allergic rhinitis.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for endoscopic Maze ablation reconstruction of the atria. Findings:  The physician reviewers found that the surgical Maze procedure is indicated in atrial fibrillation in patients whose atrial fibrillation cannot be controlled with medication. The technique has evolved such that thoracoscopic procedures are preferred in terms of patient outcome. Patients with persistent atrial fibrillation are at higher risk of stroke and embolic events, and this patient has failed medical management and cardioversion. Hence, for this patient, endoscopic Maze ablation reconstruction of the atria is likely to be more beneficial for treatment of the patients medical condition than other standard procedures. Final Result: 3 of 3 reviewers determined that the requested services are 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: All three physician reviewers are board certified in thoracic 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.