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

A 54-year-old female enrollee requested residential treatment center services for medical treatment of her polysubstance dependence, depression, and anxiety.  Findings:  The physician reviewer found that the records indicate that this patient had completed detoxification and was not at imminent risk for withdrawal. She denied suicidal and homicidal ideation and did not pose a danger to herself or others. She had no history of self-harm behaviors. Her medical conditions include hypertension and atrial fibrillation, which were stable on medications. She participated in her treatment plan, had the support of her boyfriend, and was motivated to change. She required further treatment to develop coping skills to prevent relapse although she no longer required 24-hour nursing and medical monitoring. The patient could have safely and effectively continued at a lower level of care such as partial hospitalization program or intensive outpatient program along with community based 12-step meetings. Thus, the residential treatment center services were not medically necessary for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld

A 55-year-old female enrollee has requested Orthovisc injections for treatment of her knee pain. Findings:  The physician reviewer found that although the value of viscosupplementation with hyaluronans has been generally accepted, some questions remain. The procedure is most suitable for patients with mild to moderate knee osteoarthritis, and is more efficacious in non-radiologically severe osteoarthritis with no or mild effusion. The value of repeated courses of therapy remains unclear, although some reports have shown favorable results. Studies of this problem are in progress, but the results are not yet available.  In this case, the knee is described as showing bone-on-bone degenerative changes, which are beyond the mild to moderate osteoarthritis generally considered as suitable for viscosupplementation. The submitted medical documentation fails to establish the medical necessity of the requested services.  All told, Orthovisc injections are not medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for anesthesia services for evaluation of the enrollees colonoscopy. Findings:  The physician reviewer found that there is a lack of sufficient support in the medical literature for the services at issue in this clinical setting. The medical literature supports the use of conscious sedation for endoscopic procedures. The patient reports to having anxiety, however is not on an anxiolytic. In this case, there is a lack of documentation supporting anesthesia services for this patient. For the reasons provided, the anesthesia services provided were not medically necessary for evaluation of the patients medical condition. Final Result: The reviewer determined that the services at issue were not medically necessary for evaluation of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in internal medicine with 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

A 50-year-old female enrollee has requested upper eyelid blepharoplasty treatment of her excess skin. Findings:  The physician reviewer found that the submitted documentation supports the medical necessity of the requested services.  Upper eyelid blepharoplasty is medically indicated based on the patients functional visual loss and photographic evidence of upper eyelids blocking the field of vision.  Functional eyelid surgery is indicated for disorders which result in impairment of visual function or for conditions that carry the potential for injury or impairment of the eye itself.  The most common functional indication for blepharoplasty is a superior visual field defect secondary to redundant upper eyelid tissue that overhangs the eyelid margin.  Blepharoplasty may be indicated to treat the sequelae of several inflammatory disorders of the orbits or eyelids.  In this case, the patient complained of difficulty reading, driving and working, associated with the upper eyelids blocking vision.  She was found to have bilateral upper eyelid dermatochalasis on examination.  The findings were supported by visual field tests that showed superior visual field loss and improvement with eyelid taping.  All told, the requested upper eyelid blepharoplasty is medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested the services of an anesthesiologist during a colonoscopy for treatment of her medical condition.  The physician reviewer found that the services of an anesthesiologist were not medically necessary for the patients screening colonoscopy. The patient did not present with a significant history that would require services of an anesthesiologist. The standard of care for administering monitored anesthesia care for a minimally invasive procedure, such as a colonoscopy is airway difficulty, large fluid shifts and co-morbid conditions that would put the patient at risk during the procedure. There is no documentation of co-morbid conditions that would place the patient at risk for complications requiring the need for monitored anesthesia care. A colonoscopy may be safely and effectively performed with conscious sedation of a benzodiazepine alone or with a narcotic in an office-based setting and without the need of monitored anesthesia care with propofol. McQuaid and Laine performed a systematic review of randomized controlled trials to compare efficacy, safety, and efficiency of agents used for moderate sedation in esophagogastroduodenoscopy (EGD) or colonoscopy. The authors concluded that moderate sedation provides a high level of physician and patient satisfaction and low risk of serious adverse events with all currently available agents. Midazolam-based regimens have longer sedation and recovery times than propofol. For the reasons provided, the services at issue were not medically necessary for treatment of the patients medical condition. Final Result: The reviewer determined that the services at issue were not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.  Credentials/Qualifications: The reviewer is board certified in anesthesiology with sub-specialty certification in pain 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: An enrollee has requested authorization and coverage for anesthesia for dental work.Findings:  The physician reviewer found that general anesthesia for special needs patients who cannot tolerate routine dental procedures is considered a safe and effective practice.  These needs can be either medical or psychological.  Common indications for general anesthesia in these patients are a lack of cooperation and cognitive impairment, of which this patient has both.  Dental caries is a common problem in these patients.  Evidence suggests the prevalence of untreated dental caries is higher among people with intellectual disability.  Additionally, it would be difficult, if not impossible, to diagnose and/or determine the length or extent of treatment required for the dental procedure without having the ability to perform an examination due to lack of patient cooperation. General anesthesia is often employed to facilitate extensive dental treatment in patients who do not have the psychological or emotional maturity required to cooperate in an office setting. The combination of an inability to cooperate and the likely need for an extensive dental procedure makes general anesthesia an appropriate treatment modality for this patient.  All told, the requested anesthesia for dental work is medically indicated for the treatment of this patient.Final Result: The reviewers 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: Physician reviewer is board certified in anesthesiology 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

Findings:  The physician reviewer found that the patient has requested authorization and coverage for Xeljanz 10 mg tablets (two times a day). Conventional treatment options for alopecia areata include immunosuppressants that are administered either locally or systemically, with the most common approach involving the use of intralesional and topical steroids. Given the potential for side effects, these therapies are only recommended for short-term use. Other immunosuppressive agents used in the treatment of patients with alopecia areata include methotrexate, cyclosporine, and azathioprine, which lack adequate randomized controlled clinical trial supporting their safety and tend to require close patient follow-up. Current studies have demonstrated the effectiveness of monotherapy with oral corticosteroids, cyclosporine, and JAK inhibition therapy for the treatment of alopecia areata. The records provided for review document that this patient has widespread long-term disease. Moreover, there is adequate report that the patient has failed conventional treatment with oral steroids. For these reasons, the requested Xeljanz 10 mg tablets (two times a day) are medically necessary for treatment of this patient.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.
Appeal type: Experimental/Investigational
Decision: Upheld

A 34-year-old female enrollee requested authorization and coverage of an adjustable gastric band for the treatment of obesity.  The health plan denied the enrollees request indicating that the requested treatment is ivestigational.Three physician reviewers performed an experimental/investigational Independent Medical Review.  Two of the three physician reviewers concluded that an adjustaable gastric band is not likely to be more beneficial for treatment of the enrollees obesity than any available standard therapy.  Because two of the three physician reviewers concluded that the requested treatment is not likely to be more beneficial for treatment of the enrollees medical condition than any available standard therapy, the review organization upheld the health plans denial.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested Norco for treatment of the enrollees chronic pain. Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested medication.  This patient has a contraindication to the use of chronic opiates for pain given his history of alcohol abuse.  Additionally, he has received medications from two providers at the same time, which is another red flag in terms of chronic opiate administration.  The current medical evidence does not support the requested medication in this clinical setting.  All told, the requested Norco is not medically indicated for the treatment of this patient.Final Result: The reviewer determined that the requested medication is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is board certified in anesthesiology with sub-specialty certification in pain 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: Upheld

A 47-year-old female has requested Botox injections for treatment of her migraine headaches and neck pain.   Findings:  The physician reviewer found that  Botox injections are not medically necessary for the treatment of this patients chronic migraine as the medical records do not demonstrate that a positive response to previous injections, for example with a reduction in medications. Additionally, the patients medical records do not show an indication for Botox injections. In the medical literature, Matthew and colleagues performed a randomized double blinded, placebo controlled trial on Botulinum toxin type A (Botox) for the prophylactic treatment of chronic daily headaches. The trial resulted in patients having on average, approximately, seven more headache-free days compared to baseline. The authors cautioned that the primary time point difference, however, for Botulinum Type A when compared to placebo was not statistically significant. Silberstein and colleagues studied the safety and efficacy of different concentrations of Botox for prophylactic use in chronic tension type headaches. The efficacy of Botox was demonstrated as more patients than the placebo group had a greater than 50% decrease in tension headache days. For the primary endpoint, however, the mean change from baseline in the number of tension type headache free days per month, there was no statistically significant difference between placebo and four Botox injected groups. In a more recent study by Aurora and colleagues, the safety and efficacy of multiple treatments of Botox as prophylactic treatment of episodic migraine headaches was assessed. The study concluded that, there were no statistically significant between-group differences in the mean change from baseline in the frequency of migraine episodes per 30-day period. All told, Botox injections for chronic migraines may provide some relief but a statistically significant difference between treatment groups and placebo groups was not obtained to prove that Botox is medically necessary. Given the lack of a true pathological diagnosis that is considered an indication for Botox injections, the requested therapy is not medically necessary for treatment of the patients medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for amniotic membrane graft in the setting of pterygium excision surgery. Pterygium is a fibrovascular growth over the cornea, most often from nasal side. Progressive conditions may require excision. In order to lower the chance of recurrence, the two most common techniques are to cover the bare sclera with a conjunctival autograft or with an amniotic membrane graft. In this case, amniotic membrane was used which is a well-established technique. There is good evidence in the literature that amniotic membrane graft improves the outcomes by reducing recurrence (Rosen, et al.). Thus, the amniotic membrane graft in the setting of pterygium excision surgery was likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: Two of the three 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:  One reviewer is board certified in ophthalmology and is actively practicing. One Reviewer is board certified in ophthalmology and is actively practicing.  One Reviewer is board certified in ophthalmology 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

A 47-year-old male has requested authorization for right hip arthroscopy with femoral neck osteoplasty, labral repair, and acetabuloplasty for treatment of his right hip labral tears.  Findings:  Two physician reviewers found that the patient has a history of right hip pain. Radiographs taken two years ago demonstrated superior joint space narrowing with sclerosis and osteophyte formation. The patients symptoms reportedly started following sporting activities. In an evaluation performed a year later, the provider noted the presence of symptoms including locking, catching and continuous post-activity pain. The records do not document physical therapy or intra-articular steroid injections to relieve pain. The provider noted pain localized in the groin area with slightly diminished abduction on the right hip and on internal rotation. Hip impingement is a fairly recently recognized pathologic process. Femoroacetabular impingement (FAI) may be an early cause of osteoarthritis. Treatment of FAI includes physical therapy and anti-inflammatory medications. In the event that conservative measures fail, surgery may be an option. Overall, there is a paucity of prospective, properly randomized clinical trials demonstrating the long-term safety and efficacy of the proposed procedure, especially as compared to conventional alternatives. Philippon and colleagues recommended that arthroscopic management of FAI and osteoplasty techniques be performed only in high performance athletes and high demand patients. Espinosa and colleagues concluded that although preliminary outcomes are promising, long-term follow-up is still needed to establish the role of hip arthroscopy.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for platelet rich plasma injection for treatment of his elbow pain. Findings:  Two physician reviewers found that The submitted documentation fails to demonstrate the superior efficacy of the requested services.  This patient presented with complaints of left elbow pain.  His symptoms were worse with grasping/gripping and lifting, and improved with rest. Clinical examination findings documented medial epicondylar tenderness and pain with resisted arm motion.  X-rays demonstrated mild humeroulnar osteoarthritis.  The patient was diagnosed with primary left elbow osteoarthritis and partial tear of the common flexor tendon. Detailed evidence of a recent, reasonable and/or comprehensive nonoperative treatment protocol trial and failure has not been submitted.  The current medical evidence does not support the requested services in this clinical setting.  There is a lack of evidence that conservative treatment had failed.  Final Result: The 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: Reviewers 1, 2, an 3 are 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: Overturned

A 27-year-old female enrollee has requested for p53 genetic analysis for evaluation of his medical condition.   Findings:  Two physician reviewers found that testing for p53 mutations is important as it may alter treatment recommendations since radiation is contraindicated in patients with the p53 mutation. Such testing would also indicate whether the patient is at increased risk of second primary breast cancer as well as determine the need for a screening strategy for other malignancies.
Appeal type: Medical Necessity
Decision: Upheld

The representative of a 32-year-old female enrollee has requested acute level of care services for the treatment of the enrollees Huntingtons disease. Findings:  The physician reviewer found that this patient has end-stage Huntingtons disease and has chronic pain from severe myoclonus. The documentation from the patients hospital course indicates that it was appropriate to discharge her to a less intensive setting. The patient is receiving maximal comfort measures and has a G-tube for nutritional support. On the dates of service at issue, the patient did not require inpatient hospital services for continued care. The patient has been evaluated by multi-specialty services and has completed her course of antibiotic therapy for her colitis. There was no documentation provided necessitating continued inpatient acute level of care services for treatment of the patients Huntingtons disease.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for transcranial magnetic stimulation (TMS) therapy. Findings:  The physician reviewers found that there is sufficient evidence in the published, peer-reviewed medical literature to support the use of TMS in this clinical setting. TMS is approved by the United States Food and Drug Administration.  Further, the American Psychiatric Association endorsed TMS for the acute phase treatment of major depressive disorder after failure of at least one antidepressant trial.  It is a well-tolerated, noninvasive brain stimulating therapy with fewer barriers than electroconvulsive therapy, which the patient has considered but elected not to pursue.  The record reflects that the patient is enduring significant affective impairment consistent with the acute phase of a depressive episode, has pursued evidence-based non-pharmacologic interventions, and has failed at least one antidepressant trial.  Considering the case in its entirety within the context of the current practice guidelines and relevant peer reviewed literature, TMS therapy is reasonably expected to improve the patients condition and prevent a more serious episode of illness.  All told, TMS is likely to be superior to the available standard therapy in the treatment of this patient. Final Result: 2 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 psychiatry 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.