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

Nature of Statutory Criteria/Case Summary: An enrollee has requested magnetic resonance imaging (MRI) of the back for evaluation of his medical condition. Findings: The physician reviewer found that the submitted documentation fails to establish the medical necessity of the requested services. The physician emphasized the importance of a focused history and thorough physical examination before any imaging is ordered. In addition, for patients with acute lower back pain and without any risk factor for serious spine abnormalities, imaging within the initial weeks should not be performed. The American College of Radiology (ACR) has established appropriateness criteria for the evaluation of low back pain and has defined several variants of low back pain. The ACR states that an MRI is not warranted in the acute setting. In the setting of low back pain in which the patient is a candidate for surgery or other intervention, then the ACR considers an MRI to be the most appropriate study, with no stipulation about delaying the MRI. In this case, the submitted records do not indicate that he is a potential candidate for surgery or that he is a candidate for intervention. Current research supports that prior to an intervention, it is recommended to attempt a trial of conservative treatment such as physical therapy, a targeted exercise program, or methodical use of anti-inflammatory drugs. All told, given the current guidelines and submitted records, the requested MRI of the back is not indicated for this patient.  Final Result: The reviewer determined that the requested services are 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 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: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested Orthovisc injections for treatment of her medical condition.   Findings:  The physician reviewer found that per the evidence-based guidelines, the requested Orthovisc injections are not medically necessary in this patients case. The American Academy of Orthopedic Surgeons in Treatment of Osteoarthritis of the Knee Evidence-based guidelines, recommendation #9 states: We cannot recommend using hyaluronic acid for patients with symptomatic osteoarthritis of the knee. The strength of this recommendation is strong. The evidence is based on two or more high strength studies with consistent findings for recommending for or against the intervention.  A strong recommendation means that the quality of the supporting evidence is high. The implication is that practitioners should follow a strong recommendation unless clear and compelling rationale for an alternate approach is present. Based upon recent literature, evidence-based guidelines no longer support viscosupplementation (Orthovisc injections) for osteoarthritis of the knees.  Final Result: The reviewer determined that the requested services are not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.  Credentials/Qualifications:  The reviewer is board certified in orthopedic surgery and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested authorization and coverage for custom orthotics. The sesamoid bones are part of the big toe metatarsophalangeal joint and are contained within the tendons of the flexor halluces brevis. They form a portion of the plantar plate. There are two sesamoids on each foot, and they articulate with the plantar facets of the metatarsal head. The function of the sesamoids is to distribute weight. Sesamoiditis is a painful condition that may or may not be associated with trauma. Conservative treatment includes decrease in activity, and custom insoles are often beneficial. Injections followed by excision are utilized for those that fail more conservative management strategies. Surgical management should only be used in cases refractory to all other therapies. This patient has tried conservative therapies, with little relief. She has used shoes inserts, but not custom orthotics, without significant benefit. As a last resort prior to recommending surgical intervention, custom orthotics have been prescribed. Based on the current standard of care as well as her failure to respond to all other conservative measures, the requested custom orthotics are medically necessary.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 pediatrics 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 28-year-old female enrollee requested authorization and coverage of biofeedback therapy. The Health Plan denied the request indicating that the requested therapy is considered investigational for treatment of the enrollees rectal incontinence. Three physician reviewers performed an experimental/investigational Independent Medical Review. Two of the three physician reviewers concluded that the requested therapy is likely to be more beneficial for treatment of the enrollee's medical condition than any available standard therapy. One of the three physician reviewers concluded that the requested therapy is not likely to be more beneficial for treatment of the enrollee's medical condition than any available standard therapy. Because two of the three physician reviewers concluded that the requested therapy is likely to be more beneficial for treatment of the enrollee's medical condition than any available standard therapy, the Health Plans denial has been overturned.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary:  An enrollee has requested authorization and coverage for the requested anesthesia during colonoscopy (CPT 00812).According to Jensen and colleagues, class II obesity is categorized as BMI of 35 kg/m2 to 39.9 kg/m2. Patients with obesity, BMI over 30 kg/m2, are at a significantly higher risk for desaturation during endoscopy. In a study by Wani and colleagues, patients with BMI over 30 kg/m2 were found to be at higher risk for sedation-related complications during endoscopic procedures, with even higher risk for patients with BMI over 35 kg/m2. Per the most recent American Society for Gastrointestinal Endoscopy (ASGE) guideline for sedation and anesthesia in endoscopy, elevated BMI is an independent risk factor for hypoxemia during endoscopic procedures. In this case, the patient had a BMI of 36.5 kg/m2. Based on current medical literature, the patient is at increased risk for sedation-related complications. Thus, the requested anesthesia during colonoscopy (CPT 00812) is medically necessary for treatment of the patients medical condition.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 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

A 62-year-old male enrollee has requested morphine sulfate immediate release (MSIR) and MS Contin for treatment of his paraplegia with neuropathic pain syndrome.  Findings:  The physician reviewer found that the requested opioid treatment regimen is not supported as medically necessary for treatment of this patients medical condition. The records indicate the patient has neuropathic pain. However, there is no documentation that the patient has tried and failed a comprehensive trial of neuropathic pain medication. The current treatment guidelines do not recommend opioid medications for treatment of chronic neuropathic pain. Further, the patients quality of life has not improved with use of opioid medications given his request for hospice treatment. An interdisciplinary pain management evaluation would address the neurological, neuropathic, and mental health aspects of this patients pain. Thus, the recommendation by the provider for an integrated or interdisciplinary pain management program is appropriate and the requested continued opioid treatment outside of this setting is not medically necessary.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested minimally invasive cervical spine surgery for treatment of his medical condition. Findings: The reviewer found that the requested minimally invasive cervical spine surgery has not been established as medically necessary in this clinical setting. The patient presents with multiple medical comorbidities and multi-factorial cervical and lumbosacral anatomical changes. The requested surgery would not likely provide benefit to the patients medical condition.  The use of minimally invasive techniques is not a substitute for overall considerations of patient care. And the outcomes of any surgical intervention will be limited by difficulties in localizing the relationship between specific anatomical changes and current symptoms. Cervical myelopathy, such as changes within the spinal cord, have not been established due to patient motion. The overall efficacy of minimally invasive posterior cervical techniques is controversial. In view of the complexity and limitations in diagnoses and the presence of multiple significant organ system disorders, the requested services are not clinically indicated for the treatment of the patients medical condition. Final Result: The reviewer determined that the requested services are not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.  Credentials/Qualifications: The reviewer is board certified in 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 is a 57-year-old male who has been diagnosed with osteoarthritis. In addition, the patient has a history of gastroesophageal reflux disease. The patient is unable to tolerate Alleve and ibuprofen. Further, trials of Relafen and Naprosyn were unsuccessful. The patient has requested authorization and coverage for Vioxx. The Health Plan has denied the patients request on the basis that Vioxx is not medically necessary for treatment of the patients osteoarthritis.The Health Plans denial should be overturned. The patient is under age 65 and carries a diagnosis of osteoarthritis. Alleve and ibuprofen caused the patient to experience gastrointestinal upset and cramping. Additionally, the patient has failed a trial of Relafen, a low-gastrointestinal risk NSAID. As such, the medical necessity of Vioxx has been established. 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: Experimental/Investigational
Decision: Upheld

A 51-year-old female enrollee, who underwent foot surgery, has requested authorization for a continuous passive motion (CPM) machine.  Findings:  Two physician reviewers found that the medical literature does not demonstrate any specific references regarding the use of a CPM machine for orthopedic rehabilitation following ankle surgery. Although there is a possible reduction in the risk of deep vein thrombosis, there are no studies concerning the speed of recovery, improvement in the ultimate range of motion or other objective orthopedic parameters. While there is data supporting the efficacy of a CPM machine following shoulder or knee surgery, there is no evidence to support its use in this clinical context.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for mental health and substance abuse residential treatment center level of care services for treatment of the enrollees behavioral health conditions. Findings:  The physician reviewer found that the submitted documentation supports the medical necessity of a portion of the services at issue.  This patients use of opiates, benzodiazepines and cannabinoids was impairing his daily routine and contributing to significant impairment across multiple domains of functionality.  He had strained family relations. The patient was prescribed psychotropic medication for his psychiatric comorbidities of panic disorder and major depressive disorder. Based on the records, the patient was clinically unstable and had not consolidated the treatment gains necessary to succeed in the outpatient setting, after just three days of residential programming. The patient was experiencing sequelae from a medication, quetiapine, and treatment ambivalence. The patients poor motivation and disruptiveness prompted a behavior contract.  The patient was addressing family dynamics and boundaries in therapy, and looking for a sponsor. The patient was experiencing post-acute withdrawal symptoms and cravings to use. Thereafter, the patient showed steady signs of improvement.  He had a sponsor and was medication adherent. The records noted that he was making significant progress and developing better insight.  He was sleeping through the night and he realized that he needed to stay connected to the 12 steps.  He was considering a sober living environment. His family was not participating in family week, and he did not attend his second process group that day. Based on the medical documentation, discharge earlier would have been reasonable. Substance abuse residential treatment center level of care services provided a total of four weeks of residential treatment, which would be a duration of care consistent with community standards. Final Result: The reviewer determined that a portion of the services at issue was medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be partially overturned. Credentials/Qualifications: The 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 a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary:  An enrollee has requested growth hormone (GH) therapy with Genotropin for treatment of her medical condition.   Findings:  The physician reviewer found that growth hormone deficiency is a medical condition in which the body does not produce enough GH. Recognized effects include reduced muscle mass and strength, reduced bone strength and osteoporosis, decreased energy levels, impaired concentration and loss of memory, increased body fat, lipid abnormalities, and insulin resistance. GH replacement therapy can provide a number of measurable benefits to GH-deficient adults. These include improved bone density, increased muscle mass, decrease of adipose tissue, faster hair and nail growth, strengthened immune system, increased circulatory system, and improved blood lipid levels. In this case, based on the clinical documentation submitted, the patient will likely benefit from growth hormone replacement therapy. As such, growth hormone replacement therapy with Genotropin is medically necessary in this clinical setting. 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-certification 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: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary:  An enrollee has requested customized acoustic stimulation for treatment of his medical condition.   Findings:  Three physician reviewers found that tinnitus is a mostly subjective phenomenon in the non-vibratory type.  For the patient with this complaint, the symptoms of hearing constant or intermittent noise in one or both ears is difficult to evaluate.  All patients with these symptoms should undergo hearing testing and potential intracranial scanning to differentiate tinnitus that is idiopathic from tinnitus with an observable cause.  The medical literature has not established the superior efficacy of the requested customized acoustic stimulation.  Because of the lack of case controls and long-term benefits, this type of therapy has not been found to offer statistically significant success.  Thus, the requested customized acoustic stimulation is not likely to be of greater benefit than other treatment options.  Final Result: Three reviewers determined that the requested services are not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld.  Credentials/Qualifications:  All three reviewers are board certified in otolaryngology and are 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: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Dexcom G6 continuous glucose monitor (CGM) with alerts. Based on the records provided for review, this patient has brittle insulin dependent diabetes due to her lack of pancreas as noted by the provider. Specifically, the patient has no beta cells to produce insulin or alpha cells to produce glucagon. Her glucose levels fluctuate widely, especially due to chemotherapy every two weeks for pancreatic cancer. In addition, she has neuropathy. Risk of hypoglycemia would place the patient at risk for neuroglycopenic symptoms, confusion, and loss of consciousness. Moreover, the patient is extremely insulin sensitive, such that small doses of insulin can make large changes in her glucose levels. For these reasons, the provider recommended the Tandem T-slim pump, which requires the patient to make decisions based on glucose levels, and self-adjust her insulin doses. The Tandem T-slim device works with the Dexcom G6 CGM, which communicates wirelessly with the Tandem T-slim insulin pump, in order to act with a predictive suspension of insulin delivery when the patients glucose levels are starting to drop fast into hypoglycemia range. 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 internal medicine with subspecialty certification in diabetes, 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: An enrollee has requested Harvoni for treatment of the enrollees hepatitis C virus.  Findings: The physician reviewer found that the current American Association for the Study of Liver Diseases/Infectious Diseases Society of America (AASLD/IDSA) recommendations support the medical necessity and medical appropriateness of HCV treatment. Also per the guidelines, all patients with chronic hepatitis C should be treated except those with limited life expectancy due to non-liver-related conditions. This applies regardless of fibrosis stage or viral load. Afdhal and colleagues state, once-daily ledipasvir-sofosbuvir with or without ribavirin  was highly effective in previously untreated patients with HCV genotype 1 infection. Given that the patients viral load exceeds 6 million IU/mL, a 12 week course of Harvoni is clinically indicated. While the Health Plans clinical criteria recommends Viekira Pak plus ribavirin, Harvoni would be the preferred regimen for treatment of this patients hepatitis C infection. Harvoni is a single pill regimen whereas Viekira Pak plus ribavirin requires use of multiple drugs and pills, up to 10 pills a day. The potential for drug-drug interactions is significant with Viekira Pak plus ribavirin. Moreover, Viekira Pak can have significant side effects that are not anticipated with Harvoni monotherapy. Finally, Harvoni is the least complicated drug regimen, one pill, once a day versus ten pills throughout the day. For all these reasons, the requested Harvoni for 12 weeks is medically necessary for treatment of the patients hepatitis C infection.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 physician is board certified in internal medicine with sub-certification in gastroenterology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld

A 52-year-old male enrollee has requested for artificial intervertebral disc replacement for treatment of her progressive degeneration of the L3-4 disc with stenosis. Findings:  Three physician reviewers found that short-term results are encouraging, long-term results of lumbar disc replacement are lacking. There are insufficient long-term, well-controlled studies showing lumbar disc replacement to be superior to lumbar fusion. In addition, the patient had a previous lumbar fusion and has multiple-level degenerative disease, which makes artificial disc replacement even less appropriate for this patient.