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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Monovisc injection in both knees and Monovisc injection in both knees every six (6) months.An exhaustive review of the current medical literature pertaining to viscosupplementation reveals mixed results. Evidence from eight systematic reviews and six randomized controlled trials indicates that although viscosupplementation may relieve knee pain in some individuals with osteoarthritis, it is not known as to which individuals will benefit. Different studies have tried mixing hyaluronic acid with corticosteroids, platelet rich plasma, and other agents to make it more effective. The current evidence is limited, and guidelines from organizations such as the American Academy of Orthopedic Surgeons indicate that the evidence is not conclusive. In light of the foregoing, viscosupplementation can only be recommended in individuals with a history of lasting benefit from prior injections, and in carefully selected cases where everything else has been tried, and the options are limited. In this case, the patient has a history of lasting response to prior viscosupplementation. Furthermore, physical therapy was not effective Additionally, the patient is not a candidate for total knee arthroplasties because she only has mild osteoarthritis. Therefore, Monovisc injection in both knees and Monovisc injection in both knees every six (6) months are medically necessary for the treatment of the 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 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: Upheld

Nature of Statutory Criteria/Case Summary:  An enrollee has requested Valcyte for treatment of her medical condition.  Findings:  Two physician reviewers found that the requested medication is not likely to be more beneficial for evaluation of the patients medical condition than available standard modalities. Chronic fatigue syndrome (CFS) has not been confirmed to be the result of an infection. There have been associations with infections but the causal nature has not been established in chronic fatigue syndrome. Pathogens such as mycoplasma and other bacteria have also been associated with CFS. The treatment plan indicated that the provider could not rule out an infectious trigger. CFS has been associated with viruses such as EBV and HHV-6 but not reliably reproducibly with any infectious pathogen. A recent review of research focusing on the various treatment strategies for chronic fatigue syndrome evaluated 35 treatment trials with regard to the benefit and harm of the various interventions. The authors concluded that counseling, behavior therapies, and graded exercise therapy improved measures of fatigue, function, global improvement, and work impairment; counseling and behavior therapies also improved quality of life. All other therapies including valganciclovir provided insufficient strength of evidence. In addition valganciclovir is not U.S. Food and Drug Administration (FDA) approved for the treatment of HHV-6. For these reasons, Valcyte is not likely to be more beneficial for treatment of the patients medical condition compared to standard therapy.  Final Result: Two reviewers determined that the requested medication 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:   All three reviewers are board certified in internal medicine with sub-specialty certification in infectious disease 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: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested residential treatment services for treatment of her behavioral health condition.  Findings:  The physician reviewer found that the submitted documentation fails to establish the medical necessity of the services at issue. The patient was medically stable. She was actively participating and highly engaged in her treatment plan. She demonstrated motivation and willingness. She showed a high degree of insight into her functioning. She no longer required the 24-hour restricted setting of a residential treatment program. Her medication management did not require a residential setting. She could have safely and effectively continued her recovery at a lower level of care such as intensive outpatient program services. Thus, the residential treatment services at issue were not and are not medically necessary for treatment of the patients behavioral health condition.  Final Result: The reviewer determined that the services at issue were not and 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 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: Upheld

A 31-year-old female enrollee requested authorization and coverage of a level III obstetrical ultrasound. The Health Plan denied the request indicating that the requested ultrasound is not medically necessary to evaluate the enrollees medical condition.One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer upheld the Health Plans denial on the basis that the requested ultrasound is not medically necessary.
Appeal type: Experimental/Investigational
Decision: Upheld

A 58-year-old male enrollee has requested authorization and coverage for cryosurgical ablation for treatment of the enrollees solid mass within the right kidney. Findings:  Two physician reviewers found that the patient has a history of dermatomyositis, lupus, deep vein thrombosis and bilateral total knee replacements. He was found to have a right renal mass and he underwent a CT guided biopsy of the mass. The biopsy revealed the mass to be consistent with oncocytoma, however, renal cell cancer was not able to be excluded as a diagnosis. The patients provider recommended cryoablation surgery to remove the renal mass, given the patients medical history and current medication regimen. The Health Plan denied the requested procedure, indicating that the procedure is not likely to be more beneficial for treatment of the patients medical condition than other available standard therapies. In cases such as this patients, open or laparoscopic surgical resection is the first line treatment typically utilized. This patient does not have a solitary kidney or known renal insufficiency that support the use of an alternative to standard surgical treatment, such as cryosurgical ablation. Additionally, the available peer-reviewed medical literature has not established the long-term efficacy of cryosurgical ablation in the treatment of renal masses. All told, the patient has no contraindications to standard surgical treatment for his renal mass. Therefore, the requested cryosurgical ablation is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.
Appeal type: Medical Necessity
Decision: Upheld

The parent of a four-year-old male enrollee has requested reimbursement and continued authorization and coverage for care with an out-of-network provider. The Health Plan has denied this request indicating that the services at issue were not and are not medically necessary for treatment of the enrollees autistic disorder.  Findings:  The physician reviewer found that the patient underwent a specialty evaluation which noted the patient was receiving appropriate conventional therapies and management for autism. A gluten-free-casein-free diet, avoidance of food allergens and the addition of vitamin and mineral supplements was subsequently implemented. Such treatment measures do not require ongoing monitoring by a specialist. At this time, there is insufficient evidence for assessing outcomes of such biologic therapies and thus, they have not been found to be a validated treatment for autism (Warren, et al.). Appropriate vitamin and mineral supplements were added to minimize the restrictive effect of the gluten-free-casein-free diet with this patient. This type of diet is similar to the gluten free diet in Celiacs disease and does not require the assistance of another physician to monitor. All told, the efficacy of biologic therapies for the treatment of autism remains unproven. Patients who pursue this course of therapy can be adequately followed by  a primary care physician who can monitor their diet and assist with fortified foods and/or supplements to avoid nutritional deficiencies. (Meyers, et al.) Therefore, the medical necessity of the disputed services has not been established.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for 30-day supply of Nexlizet 180-10 mg tablets. Based on the available documentation, this patient presents with several risk factors for cardiovascular disease including diabetes, with a high 10-year risk of developing symptomatic cardiovascular disease. The patient is on maximally tolerated statin therapy and his low density lipoprotein (LDL) cholesterol remains elevated at 252 mg/dL. These factors suggest that the patient has heterozygous familial hypercholesterolemia. In a situation where a patients LDL is close to the goal of 70 mg/dL, ezetimibe alone is a reasonable treatment approach. However, based on the known lipid lowering efficacy of ezetimibe when added to statin therapy, it is unlikely that this patient would reach goal with this regimen. Treatment with Nexlizet is likely to provide a 40% or greater reduction in the patients LDL and get him closer to his treatment goal. Oral therapy is preferred in this patients clinical setting, and Nexlizet is supported as an appropriate alternative to the addition of a proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitor. Given this patients elevated cardiovascular risk and elevated LDL levels while on high-dose statin therapy, the addition of Nexlizet is within the standard of care. Therefore, the requested 30-day supply of Nexlizet 180-10 mg tablets is 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. Credentials/Qualifications: The reviewer is board certified in internal medicine with subspecialty certification in cardiovascular disease 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

Physician 1: The patient is a 42-year-old male who sustained an injury to his back six months ago and has since been on restricted work duty since. He has degenerative disc disease and is requesting coverage for an intradiscal electrothermal therapy (IDET) procedure for his disc herniation.There is no information available to warrant and support the use of IDET. No long-term prospective study has shown significant long-term benefits, and the risks of the therapy are still unclear. At this time, there is no class I data to support the use of IDET for the treatment of lumbar degenerative disc disease. In fact, the recent article by Freeman, et al. in Spine 2005 utilizes class I data to refute the effectiveness of the procedure. IDET cannot be recommended until the efficacy of the procedure has been established. Therefore, I have determined that the requested procedure is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Plans denial should be upheld.Physician 2: This patient is a 42-year-old male with low back pain, which radiates down both legs and has not responded to conservative treatment. Imaging studies confirm disc pathology. Percutaneous discectomy and IDET has been recommended. The Health Plan has denied authorization for the IDET procedure on the grounds that it is considered investigational for treatment of the patients condition. IDET remains a controversial treatment for degenerative disc disease. Review of the medical literature reveals that several studies showed little to no efficacy of the IDET procedure. IDET is not the standard of care and it is not in the mainstream of lumbar degenerative disc disease treatment. Therefore, I have determined that the requested procedure is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Plans denial should be upheld.Physician 3: The patient is a 42-year-old man with a history of degenerative disc disease. He has undergone conservative treatments with no long-term benefit. The patients provider has recommended that the patient undergo an IDET procedure. The Health Plan has denied coverage for the requested procedure on the basis it is considered investigational.IDET remains an unproven procedure without clearly defined efficacy. There is no substantial proof of its effectiveness for the treatment of chronic back pain. Multiple studies have demonstrated that it is not beneficial or has limited effect. Therefore, I have determined that the requested procedure is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for an increased dosage of buprenorphine/naloxone to three tablets per day for treatment of the enrollee, who has a history of chronic lumbar spine. Findings: The physician reviewer found that the medical literature does not support the requested increased medication dosage in this clinical setting. Chronic pain that is unable to be cured can be considered palliative in nature and treatment. The stepwise World Health Organization (WHO) ladder for pain relief is considered the reasonable approach to pain control in the palliative setting. However, in the documentation available for review, there are no clear objective functional goals for the requested dose escalation. Moreover, multiple minimal requirements to justify a dose escalation have not been performed.  For these reasons, an increased dosage of buprenorphine/naloxone to three tablets per day is not medically necessary for the treatment of this patients medical condition.Final Result: The reviewer determined that the requested medication dosage 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 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: Experimental/Investigational
Decision: Upheld

A 38-year-old female enrollee has requested for Botox injections for treatment of her headache.   Findings:  Two physician reviewers found that there is no indication about previous use of beta blockers, Depakote or antidepressants. While Botox has been shown to be effective in chronic migraine, it is not clear that this patient currently meets the criteria for this diagnosis.
Appeal type: Urgent Care
Decision: Overturned

The parent of a then eight-year-old female enrollee has requested coverage for emergency services.  Findings:  The physician reviewer found that the patient was seen in the emergency department with a history of right ear pain for a couple of days associated with a fever, cough, vomiting, and a discharge from the right ear. At the time of the emergency department visit, the pain was rated as moderate. The physical examination revealed a temperature of 100.4 degrees, petechial lesions on the palate, and erythema of both tympanic membranes with blisters on the right tympanic membrane. No perforation of the tympanic membrane or discharge was noted in the medical records. The patient was treated with ibuprofen orally and Auralgan ear drops in the ear canal for pain. The diagnoses were otitis media and bullous otitis.  The patient was given prescriptions for ibuprofen for pain and Zithromax (an antibacterial antibiotic) for a presumed bacterial infection of the ears. The patient was discharged to follow-up with her primary care physician. Subsequent to the emergency department visit, the patients father reported that his daughter had mild pain prior to the day of the emergency department visit but developed severe pain associated with a bloody discharge from the right ear on the date in question which prompted the emergency department visit. At issue in this case is whether a prudent layperson in the patients circumstances would have sought immediate medical attention on the date in question. California law defines an emergency medical condition as a medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain) such that the absence of immediate medical attention could reasonably be expected to result in any of the following: (1) Placing the patients health in serious jeopardy; (2) Serious impairment to bodily functions; (3) Serious dysfunction of any bodily organ or part.  Review of the submitted documentation demonstrates the patient had pain that was described by her father as severe, although in the emergency department it was rated as moderate. If, in fact, the tympanic membrane had perforated at home, that would account for the patients transient severe pain and also account for the bloody discharge from the ear as reported by her father and which was noted in the emergency department record as discharge. Although the severe pain and discharge might not have been present by the time the patient arrived at the emergency department, the patient did have a fever and physical evidence of a bacterial infection of the right tympanic membrane. The blisters were diagnostic of bullous otitis which is caused by a bacterium and warranted treatment with an appropriate antibiotic. All told, a prudent layperson would have thought the patient to be experiencing an emergency medical condition on the date in question and would have sought immediate medical attention.
Appeal type: Urgent Care
Decision: Overturned

Nature of Statutory Criteria/Case Summary:  An enrollee has requested dental services on an emergent basis.  The physician reviewer found that review of the submitted clinical documentation demonstrates that a prudent layperson would have sought immediate medical attention. In this case, the patient presented with luxation of the anterior teeth, alveolar fracture, and pulpal necrosis. A failure to stabilize these conditions would reasonably be expected to cause serious dysfunction of a body part, the anterior dentition. The pulpal necrosis treatment is an integral part of stabilization of the patients acute injury. The review by Ritwick found that there was an association between pulp extirpation performed within 10 to 14 days after tooth replantation and a reduced incidence of inflammatory resorption. Moreover the dental literature supports the endodontic treatment at issue to address necrotic tissue as neglect of this condition may lead to a potential lead-in to acute infection. Initial stabilization of the patients injury included endodontic treatment. Treatment beyond that period would not be a part of stabilization of the patients immediate injury. Based on the documentation provided for review the patients symptoms did meet prudent layperson criteria for initial emergency care.  Final Result: The reviewer determined that the patients symptoms did meet prudent layperson criteria for initial emergency care. Therefore, the Health Plans denial should be partially overturned.  Credentials/Qualifications: The reviewer is board certified in dentistry 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 52-year-old female enrollee has requested for the Flexitouch pneumatic compression system for treatment of her postmastectomy lymphedema.  Findings:  The physician reviewer found that Warren and colleagues, lymphedema management should be highly individualized and designed to meet the needs of each patient. Mayrovitz and colleagues indicated that treatment selection is critical to the success of home-based lymphedema therapy and should consider the mechanism of action and functionality of the device. The authors further stated that programmable devices providing truncal and proximal clearance, such as the Flexitouch, are highly desirable for an effective home program.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for platelet rich plasma (CPT 0232T) to the left foot. A meta-analysis of nine randomized controlled trials comparing the efficacy of platelet-rich plasma and corticosteroids for the treatment of plantar fasciitis found that significant differences were not observed between short and intermediate effects. Vannini and colleagues reported that, Considering the literature currently available, no clear indications for using platelet-rich plasma in the foot and ankle district emerged. In this case, the patient is being treated for chronic plantar fasciitis. Overall, there is a lack of quality evidence to support the use of platelet-rich plasma for the treatment of this patients plantar fasciitis. Accordingly, the platelet rich plasma (CPT 0232T) to the left foot that was 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 the platelet rich plasma (CPT 0232T) to the left foot that was 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 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: Physician reviewers 1, 2, and 3 are board certified in orthopedic surgery and are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.