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

Nature of Statutory Criteria/Case Summary: The patient has been diagnosed with osteoarthritis of bilateral knees. The patient reported bilateral knee pain. She reported little improvement with rest, ice, compression, elevation (RICE) therapy and nonsteroidal anti-inflammatory drugs (NSAIDs). Bilateral knee corticosteroid injections were performed. In an undated letter, the provider noted that the patient had previously received hyaluronic acid injections (both Synvisc One and Euflexxa) for both knees and had shown great improvement/pain relief from these injections. The patient had also completed physical therapy in the past, with no improvement. The patient has requested authorization and coverage for Synvisc injections for both knees. The Health Plan denied the request and reported that the requested services are not medically necessary for the treatment of this patient. At issue in this case is whether Synvisc injections for both knees are medically necessary for the treatment of the patients medical condition. Researchers reported, Intra-articular (IA) treatments were superior to nonsteroidal anti-inflammatory drugs, possibly because of the integrated IA placebo effect. A study reported, The American Medical Society for Sports Medicine recommends the use of hyaluronic acid (HA) for the appropriate patients with knee osteoarthritis (OA). In this case the patient has been previously treated with viscosupplementation injections that provided pain relief. She has tried and failed other conservative treatment, including NSAIDs, physical therapy, and corticosteroid injections. The medical evidence supports the requested services in this clinical setting. Therefore, Synvisc injections for both knees 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: Overturned

The patient has requested authorization and coverage for left breast oncoplastic reconstruction and contralateral right reduction mammoplasty. The patient presents significant abnormalities related to non-malignant disease. Her provider has recommended breast surgery to alter the contour of the breast given the severity of the deformity. Given the size of this area of enhancement, the patient would have significant deformity following partial mastectomy. The requested procedures are reconstructive in nature for treatment of this patient. The patients condition constitutes an abnormal structure of the body related to tumor or disease. In this case, there are inconclusive BRCA genetic results. The patient has an atypical lobular hyperplasia, which is significant in relation to the patients breast size. The requested procedures are being requested to create a more normal appearance to the extent possible. The surgery will likely provide more than a minimal improvement in the appearance of the patient as the large nature of the tumor has resulted in significant deformity of the breast and significant asymmetry with the opposite breast. All told, the requested left breast oncoplastic and contralateral right reduction mammoplasty are medically necessary and reconstructive in nature for treatment of this patient. Final Result: The reviewer determined that the requested services are medically necessary and reconstructive in nature for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in plastic 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 38-year-old female enrollee requested authorization and coverage of Remicade infusion therapy for the treatment of ankylosing spondylitis.  The health plan denied the enrollees request indicating that the requested treatment is experimental.Three physician reviewers performed an experimental/investigational Independent Medical Review.  Each of the three physician reviewers concluded that Remicade infusion therapy is likely to be more beneficial for treatment of the enrollees ankylosing spondylitis than any available standard therapy.  Because all three physician reviewers concluded that the requested treatment is likely to be more beneficial for treatment of the enrollees medical condition than any available standard therapy, the review organization overturned the health plans denial.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for autonomic testing for evaluation of the enrollees symptoms of lightheadedness and chest pain. Findings: All three physician reviewers found that the medical literature supports the use of autonomic testing in autonomic disorders, and specifically in conjunction with tilt table testing when making a diagnosis of POTS. A study reviewed the use of autonomic testing and found it to beneficial in making a diagnosis of POTS, and leading to effective treatments. Autonomic testing is not routinely performed in most cardiac or neurologic practices. However, it adds valuable information when evaluating for autonomic neuropathy, POTS, and other autonomic nervous system disorders which may be difficult to diagnose. Final Result: The reviewers determined that the testing 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: Reviewers 1, 2, and 3 are board certified in neurology 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: The patient has requested authorization and coverage for two pairs (4 units) of custom shoe inserts (for 6 total units/3 total pairs). Ahmed and colleagues note that in people with diabetes, offloading high-risk foot regions by optimizing footwear, or insoles, may prevent ulceration. The authors further note that custom-made insoles with metatarsal additions and a high degree of contact between the insole and foot reduce plantar pressures in a manner that may reduce ulcer occurrence. Patients are generally supplied with multiple custom diabetic shoe inserts and instructed to replace their inserts frequently, as the inserts are made of a soft, shock-absorbing material that wears out quickly, causing the insert to lose its effectiveness. In this case, the patient has a diagnosis of diabetes. Given that custom shoe inserts may help in the management of foot neuropathy, biomechanical changes of the foot, foot ulcerations, and lower extremity peripheral vascular disease in patients with diabetes, the requested equipment is medically indicated. Therefore, two pairs (4 units) of custom shoe inserts (for 6 total units/3 total pairs) are medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested equipment 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 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: Medical Necessity
Decision: Upheld

The patient is a 17-year-old female who has been reported to have severe skeletal class III malocclusion with impacted maxillary canines. She has been evaluated by an oral and maxillofacial surgeon and orthognathic surgery has been recommended. The Health Plan has denied coverage for the requested procedure as not medically necessary.The Health Plans denial should be upheld. The letter submitted by the patients orthodontist and the panorex x-ray do not demonstrate the patient meets medically necessity criteria for the requested procedure. Furthermore, the submitted records do not document a functional deficit. Moreover, the degree of skeletal deformity and the secondary dental malocclusion are not documented by lateral skull x-rays, cephalometric analysis, models, and/or photographs. Based upon the information provided, medical necessity for the requested procedure has not been established. Therefore, the Health Plans denial should be upheld.
Appeal type: Experimental/Investigational
Decision: Upheld

A 55-year-old female enrollee requested radiofrequency ablation of multiple uterine leiomyomata, Acessa procedure for medical treatment of her uterine fibroids.  Findings:  Three physician reviewers found that the submitted documentation fails to demonstrate the superior efficacy of the requested service.  This patient was noted to have an enlarged uterus with multiple fibroids for an extended duration of time.  There was a lack of documentation of other therapies that had been considered.  The current medical evidence has not established the superior effectiveness of the requested service in this clinical setting.  All told, radiofrequency ablation of multiple uterine leiomyomata was not likely to have been of greater benefit than other treatment options.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patients parent has requested (1) reimbursement for all or any of the substance-related disorders, residential behavioral health level of care, child or adolescent and (2) prospective authorization and coverage for re-admittance to substance-related disorders, residential behavioral health level of care, child or adolescent.The Child and Adolescent Level of Care Utilization System (CALOCUS) provides a framework for determining the clinically appropriate level of care for a child or adolescent in mental health treatment. With regard to risk of harm, the records support a score of 4. The patient had a serious risk of harm, due to a history of self-harm, active suicidal ideation, PTSD symptoms, and ongoing mental health instability.  In terms of functional status, the records support a score of 4. The documentation noted serious functional impairment due depression, anxiety, PTSD, codependence on her mother and a lack of friends. With regard to comorbidity, the records support a score of 3. The patient had significant comorbidity, due to the presence of substance abuse including opioid and cannabis use disorders, PTSD, and a history of seizures and ovarian cyst. In terms of level of stress of the recovery environment, the records support a score of 4. The patient had a very stressful environment due to codependence on her mother. With regard to level of support of the recovery environment, the records support a score of 3 due to a codependent  relationship with her mother and a lack of friends. In terms of resiliency and treatment history, the records support a score of 5. The patient had poor resiliency and/or response to treatment due to poor insight and recovery history. With regard to treatment acceptance and engagement, the records support a score of 4. The patient reported her intention to continue with cannabis use and Suboxone maintenance once discharged. Thus, the patient has a total score of 27. In this case, the recommended level of care is medically monitored residence-based services. This is consistent with the level of care the patient received at the residential treatment center, and would receive upon re-admittance. Therefore, (1) all of the substance-related disorders, residential behavioral health level of care, child or adolescent and (2) re-admittance to substance-related disorders, residential behavioral health level of care, child or adolescent was and is medically necessary for the treatment of this patient. 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 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: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for implantation of a hypoglossal nerve stimulator for treatment of his obstructive sleep apnea. Findings:  Three physician reviewers found that obstructive sleep apnea is an increasingly prevalent clinical problem with significant effects on both personal and public health.  Continuous positive airway pressure (CPAP) has demonstrated excellent efficacy and low morbidity; long-term adherence rates approach 50%. Although traditional upper airway surgical procedures target the anatomic component of obstruction, upper airway stimulation tackles the twin goals of improving anatomic and neuromuscular pathology. After decades of trials demonstrating proof of concept of hypoglossal nerve stimulation in animal and human subjects, the three-year and four-year results of a large multicenter, prospective trial were published in January 2016 and February 2017. The STAR trial demonstrated that hypoglossal nerve stimulation led to significant improvements in objective and subjective measurements of the severity of OSA. This trial has demonstrated the hypoglossal nerve stimulator to be safe and effective in a small subset of patients with obstructive sleep apnea who have failed CPAP, have an AHI between 20 to 50, have nonconcentric airway collapse and a write out BMI less than 32. However, with an AHI greater than 50, this patient does not meet the criteria. Final Result: The reviewers determined that the services at issue were 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: Reviewer 1, 2, and 3 are board certified in otolaryngology 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: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for eight treatments of chiropractic manipulation. Chiropractic manipulation has been demonstrated to be helpful for the management of a variety of conditions such as neck and back pain. Current medical literature includes studies and guidelines to support the use of chiropractic care to improve symptoms in patients with acute and chronic neck and back pain. This patient presents with left-sided upper back pain with intermittent numbness in the bilateral upper extremities. The data supports the requested eight chiropractic visits to achieve functional improvement. All told, the requested eight treatments of chiropractic manipulation are likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Three of the three physician reviewers found the requested eight treatments of chiropractic manipulation are 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 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: Medical professional reviewers 1, 2, and 3 are board certified chiropractors 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

A sixty-two year-old female with excess abdominal skin following a substantial weight loss is requesting authorization for an abdominoplasty.  Reviewers Findings:  The reviewing physician found that the records provided do not establish medical necessity for the proposed abdominoplasty.  The reviewing physician found that the Health Plan denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary:  An enrollee has requested Sovaldi for treatment of her hepatitis C virus. Findings:  The physician reviewer found that the proposed treatment is medically necessary and is considered the standard of care for the treatment of the patients with hepatitis C virus (HCV) genotype 2. Per the American Association for the Study of Liver Diseases/Infectious Disease Society of America (AASLD/IDSA) guidelines, all patients with chronic active HCV are eligible for treatment and should be treated with U.S. Food and Drug Administration (FDA) approved antiviral therapy regardless of fibrosis score. Successful hepatitis C treatment results in sustained virologic response (SVR), which is tantamount to virologic cure, and as such, is expected to benefit nearly all chronically infected persons. The evidence supports treatment in all HCV-infected persons, except those with limited life expectancy (less than 12 months) due to non-liver-related comorbid conditions. The goal of treatment of HCV-infected persons is to reduce mortality and liver-related health adverse consequences, including end-stage liver disease and hepatocellular carcinoma, by the achievement of virologic cure. Combination therapy with Sovaldi and ribavirin has been approved by the FDA based upon a large trial involving proposed genotype 2 and 3 patients. This regimen has also been endorsed by the AASLD/IDSA in their recent guidelines for the treatment of HCV patients. The initial phase three studies (FISSION, FUSION and POSITRON) demonstrated that the Sovaldi regimen was well-tolerated, safe and efficacious. As such, the requested Sovaldi is medically necessary for treatment of the patients medical condition.  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: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for laparoscopic vertical sleeve gastrectomy for treatment of the enrollee, who has a history of morbid obesity. Findings:  The physician reviewer found that the submitted documentation supports the medical necessity for the services at issue in this clinical setting. This patient documents a BMI of 40.5 kg/m2 and she has completed a multidisciplinary evaluation, which did not reveal any obvious dietary, behavioral or medical barriers to surgery. She has failed dietary efforts including supervised weight loss. Per the submitted documentation, this patient meets standard nationally accepted criteria for bariatric surgery as established by the National Institutes of Health guidelines as well as the American Society for Metabolic and Bariatric Surgery. Therefore, the requested laparoscopic vertical sleeve gastrectomy is medical necessary for treatment of this patients medical condition. 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 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

The parent of a 16-year-old male enrollee requested authorization and coverage for lock down residential treatment center services. The Health Plan denied this request indicating that the requested services are not medically necessary for treatment of the enrollees obsessive compulsive disorder (OCD), oppositional defiant disorder (ODD), anger issues and bipolar disorder.  Findings:  The physician reviewer found that the patients diagnosis includes bipolar disorder co-morbid with substance abuse/dependence. The patient has required two psychiatric hospitalizations within 12 months. Progress notes by the patients treating physician during a recent hospital stay indicate the patient remained anxious, angry, labile and intrusive. The progress notes indicate that due to the patients impulsivity, prior threats and history of running away, he would benefit from a locked unit in terms of residential treatment. Medical records indicate the patient was anxious, impulsive and unpredictable with no coping skills. The nursing notes consistently indicate a runaway (AWOL) risk during his hospital stay. Given the clinical factors described above, including the patients history of aggressive and assaultive behavior and concerns about him having a gun, along with a well documented history of repeat run away episodes, residential treatment in a secure locked unit is considered clinically appropriate and medically necessary.This finding is consistent with Child and Adolescent Level of Care Utilization System (CALOCUS) placement criteria which indicates that Level 6 is defined as secure 24 hour service with psychiatric monitoring, this can occur in a highly programmed RTC. Factors supporting Level 6 placement include ambivalence toward treatment, poor resilience and response to treatment, severe functional impairment such as assaultive behavior, minimal control over impulses that may result in abusive behaviors, running away, and AWOL risk. Also, the American Academy of Child and Adolescent Psychiatry (AACAP) practice parameters note that for patients with bipolar disorder, disruptive behavior is often present and intervention strategies should be based on the specific symptom presentation of the patient including co-morbid conditions.