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

A 64-year-old male enrollee requested authorization and coverage of catheter-guided sclerotherapy. The Health Plan  denied the request indicating that the requested procedure is not medically necessary for the treatment of the enrollees varicose veins.One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer upheld the Health Plans denial on the basis that the requested procedure is not medically necessary.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for bilateral Synvisc One injections. There is adequate evidence that intraarticular hyaluronic acid injections reduce pain and increase function in knee osteoarthritis, and the benefits are long-lasting as compared with intraarticular corticosteroids. Researchers conducted a systematic review of overlapping meta-analyses comparing viscosupplementation with other non-operative treatment modalities for knee osteoarthritis. The authors reported that the current highest level of evidence suggests that intraarticular hyaluronic acid is a viable option for patients with knee osteoarthritis which results in improvements in knee pain and function that can persist for up to 26 weeks. Viscosupplementation has a good safety profile, and its use should be considered in patients with knee osteoarthritis. This patient reports consistent relief with hyaluronic acid injections. All told, the requested bilateral Synvisc One injections are supported as medically necessary for treatment of this patients knee osteoarthritis.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: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the insertion of intrastromal cornea implants and riboflavin application with ultraviolet and riboflavin application with ultraviolet for treatment of the enrollees keratoconus without scarring of the right eye. Findings:  Three physician reviewers found that the use of Intacs and collagen cross-linking have become the standard of care in the treatment of keratoconus. Keratoconus is caused by an abnormally distensible corneal collagen matrix, which allows the cornea to become warped and distorted. Since the cornea is the primary refracting surface of the eye, this deformation causes a profound visual handicap. Collagen cross-linking helps to strengthen the collagen matrix of the corneal stroma and reduce the tendency to continue its progressive distortion. In this case, the use of Intacs and collagen cross-linking was clinically indicated to treat the patients progressive condition. Accordingly, the insertion of intrastromal cornea implants and riboflavin application with ultraviolet (UVA) performed was likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the services at issue were 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 ophthalmology 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: An enrollee has requested authorization and coverage for upper endoscopy.The American Gastroenterological Association (AGA) and the American Society of GI Endoscopy (ASGE) recommend that patients who have Barretts esophagus without dysplasia undergo endoscopic surveillance every 3 to 5 years, with 4-quadrant biopsies taken every 2 cm with white-light endoscopy. The AGA further states that the preponderance of evidence, virtually all derived from retrospective or poorly controlled studies, suggests that endoscopic surveillance can reduce mortality from esophageal adenocarcinoma through the early detection of treatable cancers when attention is paid to recommended biopsy techniques. In this case, the patient had an upper GI endoscopy performed, and the present request is for upper endoscopy approximately two and a half years later. The request for endoscopy at this time is based upon a family history of GI neoplasm involving two third-degree relatives (cousins). This family history does not, however, constitute extenuating circumstances that would warrant upper endoscopy surveillance sooner than every 3 to 5 years. Accordingly, the requested upper endoscopy is not medically necessary for the patients medical condition at this time.Final Result: The reviewer determined that the requested services are not medically necessary for treatment of the patients medical condition at this time. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is board certified in internal medicine, with subspecialty 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 Zepatier for treatment of the enrollees hepatitis C. Findings:  The physician reviewer found that according to the most recent 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. This recommendation applies to all patients, regardless of fibrosis stage. The guidelines recommend that treatment-naive, genotype 1b patients should be treated with regimens including or Zepatier, based on clinical trial results showing a 99% cure rate regardless of NS5A resistance. AASLD/IDSA guidelines cite data showing reduced survival with delayed treatment. For these reasons, Zepatier is medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested medication regimen 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: Upheld

The patient is a 55-year-old male who presented with severe bilateral leg edema, felt to be a combination of lymphedema and venous insufficiency.  A venous duplex study showed no evidence of deep venous obstruction.  The patient had not used conservative measures such as leg elevation, compression stockings, or exercise.  These measures were prescribed, as well as a pneumatic compression device.  The patient did not return to the provider to assess the results of the conservative therapies or the compression device. The patient has requested reimbursement for the cost of the pneumatic compression device.  The Health Plan denied his request based on a determination that the device was not medically necessary for the treatment of his venous stasis and lymphedema.Pneumatic compression devices or lymphedema pumps, are considered to be the `last resort` for managing lymphedema. It is generally held that symptoms must be severe and debilitating and conservative therapies must have been tried and failed before such a device is prescribed. Conservative therapies include limb elevation, custom compression garments, and exercise.  This patient apparently tried none of these therapies prior to the rental of the pneumatic compression pump.  The Medicare Coverage Issues Manual provides reasonable guidelines for determining the medical necessity of a pneumatic compression device. It states: Pneumatic compression devices are covered only when prescribed by a physician and when they are used with appropriate physician oversight, i.e., physician evaluation of the patient's condition to determine medical necessity of the device, assuring suitable instruction in the operation of the machine, a treatment plan defining the pressure to be used and the frequency and duration of use, and ongoing monitoring of use and response to treatment. The determination by the physician of the medical necessity of a pneumatic compression device must include: 1.The patient's diagnosis and prognosis; 2.Symptoms and objective findings, including measurements which establish the severity of the condition; 3.The reason the device is required, including the treatments which have been tried and failed; and 4.The clinical response to an initial treatment with the device. The clinical response includes the change in pre-treatment measurements, ability to tolerate the treatment session and parameters, and the ability of the patient (or caregiver) to apply the device for continued use in the home.The patient never returned for a clinical assessment of the results of the pump and no post-treatment measurements were made to document the success of the therapy.  Therefore, I have determined the device at issue was not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for conversion of Roux-en-Y gastric bypass to the duodenal switch. Mechanick and colleagues note that bariatric procedures are a safe and effective intervention for higher-risk patients with obesity, but that a team approach to perioperative care is mandatory, with special attention to nutritional and metabolic issues. In a systematic review on reoperative bariatric surgery, Brethauer and colleagues concluded that while current evidence supports additional treatment for persistent obesity, comorbid disease, and complications, the indications and outcomes for reoperative bariatric surgery are procedure-specific. In this case, the patient has persistent morbid obesity. The records document a comprehensive multidisciplinary evaluation, including a dietary evaluation. In this clinical setting, the requested service is medically indicated. Therefore, conversion of Roux-en-Y gastric bypass to the duodenal switch is medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested service is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in surgery with expertise in bariatric 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 56-year-old male enrollee has requested a prefabricated uploader knee brace and add-ons for treatment of his right knee pain. Findings:  The physician reviewer found that the submitted documentation fails to establish the medical necessity of the requested equipment. This patient is status post arthroscopy with a documentation of a MCL sprain. The use of a brace to unload the medial compartment has been shown to be inconsistent in changing knee kinetics. In addition the documentation submitted for review reports that the patient has a MCL sprain, which is stressed more with medial compartment unloading. Therefore, the requested equipment is not medically indicated in this clinical setting and not medically necessary for treatment of the patients medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement and prospective authorization and coverage for combination therapy using Opdivo (nivolumab) and Yervoy (ipilimumab). The U.S. Food and Drug Administration (FDA) has not approved Opdivo and Yervoy for the treatment of patients with triple negative breast cancer and this regimen is not supported by major drug compendia or the medical literature. Currently, the regimen of Opdivo and Yervoy is the subject of ongoing clinical trials. The current NCCN guidelines and peer-reviewed medical literature support treatment of metaplastic breast cancers similarly to other invasive breast cancers. Current data support therapies such as a PARP inhibitor, pembrolizumab, or Sacituzumab. All told, combination therapy using Opdivo (nivolumab) and Yervoy (ipilimumab) was not and is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Findings:  Two of the three physician reviewers found that combination therapy using Opdivo (nivolumab) and Yervoy (ipilimumab) was not and 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 medication regimen at issue was not and 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. Credentials/Qualifications: Physician reviewer 1 is board certified in medical oncology with subspecialty certification in hematology and is actively practicing. Physician reviewer 2 is board certified in internal medicine with subspecialty certification in medical oncology and is actively practicing. Physician reviewer 3 is board certified in internal medicine with subspecialty certifications in medical oncology and hematology 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: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for a CT scan with contrast of the lower lumbar spine.American College of Radiology (ACR) Appropriateness Criteria for low back pain indicate that for a patient with chronic low back pain with radiculopathy, progressive symptoms, and a history of lumbar surgery, CT of the lumbar spine with IV contrast may be appropriate, however, CT is most appropriate in postfusion patients or when an MRI is contraindicated.In this case, while the patient has chronic low back pain with radiculopathy, progressive symptoms, and a history of lumbar surgery, he is not postfusion, and ACR guidelines indicate that MRI scan is the study of choice to evaluate a patient of this kind when not contraindicated. This patient has already had an MRI scan. An extremely detailed MRI report concerning the nature of the patients pathology is included in the submitted documentation. Under these circumstances, the requested CT scan with contrast of the lower lumbar spine is not medically necessary to treat the patients medical condition.Final Result: The reviewer determined that the requested services are not medically necessary to treat the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is board certified in neurological 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

A 50-year-old female enrollee has requested laparoscopic Roux-en-Y gastric bypass surgery for treatment of her obesity.  Findings:  The physician reviewer found that the patient meets generally accepted criteria for bariatric surgery. She presents with a BMI that exceeds 35 as well as co-morbid medical conditions related to her obesity including gastroesophageal reflux disease, hypertension, hyperlipidemia, joint pain, and stress urinary incontinence. She has failed multiple medically-managed weight loss attempts. In addition, she failed a surgical attempt at weight loss with a laparoscopic adjustable gastric band placed more than five years ago. Laparoscopic adjustable gastric band surgery has been demonstrated in recent years to be associated with a very high weight loss failure rate (Victorzon, et al.). For this reason, there has been a dramatic decline in the use of laparoscopic adjustable gastric banding as a primary treatment of obesity (Nguyen, et al.). Repeat bariatric surgery should be considered for patients who fail to achieve or maintain clinically significant weight loss following laparoscopic adjustable gastric banding if the patient meets generally accepted criteria for bariatric surgery. Roux-en-Y gastric bypass after failed laparoscopic gastric banding surgery has been demonstrated to be safe and is associated with clinically significant weight loss (Robert, et al.; Elnahas, et al.; and Perathoner, et al.). Based upon the submitted clinical documentation as well as the relevant peer-reviewed scientific evidence, the requested laparoscopic Roux-en-Y gastric bypass is medically necessary for this patient.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a 7-year-old male has requested 12 occupational therapy sessions for treatment of his autism.  Findings:  The physician reviewer found that the patients self-help skills and fine motor abilities are significantly impaired, when compared with his same age peers. Although his progress during weekly occupational therapy sessions has been slow, gradual improvements have been documented. Thus, the patients self-help and fine motor abilities have not plateaued. There is substantial peer reviewed medical literature indicating that occupational therapy is a necessary component of the various therapeutic treatments included in the treatment plan for a patient diagnosed with autism (Myers, et al. and Case-Smith and Arbesman). Occupational therapy has been proven to improve motor function in autistic children (Dawson and Watling). In a study examining the long-term effects of occupational and physical therapies in children with autism, the authors found that over a seven year period the group treated with therapy demonstrated far greater improvements in motor skills, adaptive skills and social skills than the untreated group (Turner, et al.). In sum, it is medically appropriate and necessary for this patient to receive the requested 12 sessions of occupational therapy.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a female enrollee requested inpatient mental health services for medical treatment of her major depressive disorder and suicidal ideation. Findings:  The physician reviewer found that the records indicate the patient was assaulted only two weeks before admission and was receiving treatment for the exacerbation of her underlying depression as a result. Further, the notes during the treatment period in dispute show that the patient was continuing to receive appropriate management with training in coping strategies to deal with her depression and thoughts of suicidal ideation and self-harm and the addition of lamotrigine to help her mood. For these reasons, the inpatient mental health services were medically necessary for treatment of this patients medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for blood test (advanced lipoprotein testing).Findings:  Three physician reviewers found that in this circumstance, primary prevention 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 currently 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, insulin, insulin resistance testing, 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.  Although 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: Three reviewers determined that the the services at issue were 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: All three physician reviewers 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.