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

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Euflexxa injections in the left knee. The current evidence on viscosupplementation is limited and the guidelines from organizations such as the American Academy of Orthopaedic Surgeons (AAOS) indicate that the data remains inconclusive. As such, the AAOS does not support viscosupplementation as standard treatment for all patients with osteoarthritis of the knees. A review of the 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 patients with osteoarthritis, it has not been established which patients will benefit. However, there is adequate support for viscosupplementation for patients with a history of lasting benefit from prior injections and in carefully selected cases where the treatment options are limited. In this case, the records document the patient has experienced moderate pain relief with prior viscosupplementation. Moreover, prior surgery did not substantially improve his condition and further treatment options are limited to relieve pain and postpone a total knee arthroplasty. As such, the requested Euflexxa injections of the left knee are 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: Medical Necessity
Decision: Overturned

The patients parent has requested authorization and coverage for speech therapy two times per week for 60 minutes. This patient has autism and the records indicate that he has made considerable progress using an adaptive communication program known as language acquisition through motor planning (LAMP) on his tablet. Young patients with autism can experience a differential response to standard approaches with speech therapy and exhibit considerable progress using augmentative or assisted approaches to speech and language. Given this patients progress, noted by his caregivers and provider, continued speech therapy services are appropriate. Given this support, the requested speech therapy two times per week for 60 minutes is medically necessary for treatment of this patient.Final Result: The reviewer determined that the requested services are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in neurology with special qualification in child neurology 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 father of a 17-year-old female enrollee requested authorization of continued residential treatment services. The Health Plan denied the request indicating that the requested services are not medically necessary for treatment of the enrollees behavioral health problems.One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer upheld the Health Plans denial on the basis that the requested services are not medically necessary.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for surgery.Findings:  Two of the three physician reviewers found that the medical records fail to demonstrate the superior effectiveness of the services at issue. The first-line treatment for intermittent claudication due to femoropopliteal occlusive disease is a supervised exercise training program along with established guideline directed medical therapy. Based upon the documentation provided, this patient underwent percutaneous revascularization without a trial of exercise training. There was no critical limb ischemia to necessitate revascularization prior to a trial of exercise. Thus, surgery was not likely to have been more efficacious than other available treatment options.  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 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.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: A patient has requested authorization and coverage for Ingrezza 40 mg capsule, (quantity of 60 per 30 days). The Health Plan has denied this request indicating that the requested medication regimen is not medically necessary for treatment of the patients tardive dyskinesia. The submitted documentation does not support the medical necessity of the requested services. Tardive dyskinesia (TD) is a hyperkinetic movement disorder that presents usually as the result of extended use of dopamine blocking agents. The clinical elements of TD include chorea, athetosis, akathesia, dystonia, and in rare cases tremor. American Psychiatric Association guidelines include significant effort in maintaining drug regimens in schizophrenia at the lowest effective dose. There is evidence to suggest that second generation antipsychotics clozapine and quetiapine have beneficial effects on TD severity. Additionally, there are several treatments that have shown efficacy for the treatment of TD, which include clonazepam, tetrabenazine, botulinum toxin, amantadine, and levetiracetam. While Valbenazine (Ingrezza) has also demonstrated efficacy in a six-week study, long-term effectiveness and safety is unclear at this time. Given that the advantages of Ingrezza over other medications are unclear at this time, the medical necessity of Ingrezza has not been established in this case. Therefore, Ingrezza 40 mg capsule (quantity of 60 per 30 days is not medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested medication regimen 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 neurology 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 49-year-old female has requested coverage for a Chemo FX Assay previously performed for evaluation of her ovarian cancer.  Findings:  Three physician reviewers found that the patient was diagnosed with stage IIIc papillary serous carcinoma of the ovary.  She was initially treated with debulking surgery, followed by chemotherapy with carboplatin and Taxotere.  The patient was found to have recurrent cancer the following year, and she again received carboplatin and Taxotere.  A year later, she underwent exploratory laparotomy and liver resection.   Her tissue was sent for Chemo FX analysis.  Chemo FX Assay is used to attempt to determine the likelihood of effectiveness of a specific therapeutic agent for the treatment of a patient.  There have been many assays developed over the years.  At this time, there is a lack of evidence demonstrating that the use of these assays results in significantly better survival when compared to selecting a regimen based on known clinical studies and standards.  For patients with ovarian cancer, the National Comprehensive Cancer Network guidelines state that there is insufficient evidence to support the use of these assays to supplement standard of care chemotherapy.  The American Society of Clinical Oncology does not recommend the use of such assays to select chemotherapeutic agents in this clinical situation.  All told, the Chemo FX Assay performed was not likely to have been more efficacious for evaluation of the patient than other available modalities.
Appeal type: Medical Necessity
Decision: Overturned

The patient is a 59-year-old female who had a bone mass density scan in December 2004 showing severe osteoporosis. She was placed on calcium and vitamin D as well as Actonel as anti-fracture treatment. A repeat bone scan was performed 12 months later while the patient was being treated with tamoxifen. The repeat test was ordered by her oncologist to see if changing her anti-cancer treatment from tamoxifen to an aromatase inhibitor might be harmful to her bones and increase her risk of fracture. The result showed a statistically significant additional loss of bone in her spine and a statistically significant gain in her hip. Based on these results the patients oncologist decided not to make the treatment change, as one of the potential new medications side effects was increased fracture risk. At issue is whether the repeat bone density scan was medically necessary.It is standard of care to perform a repeat bone density scan after 12 months if the T-score of any measured area is less than 3 SD. As such, the patient met medical necessity criteria for the repeat bone density scan in December 2005. Additionally, the patients oncologist makes it clear that the follow-up study affected his decision regarding the patients cancer treatment since changing the medication could have resulted in a worsening of her bone mass density and may have increased the vertebral fracture risk. Therefore, I have determined the bone scan at issue was medically necessary for evaluation of the patients medical condition. The Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Upheld

A male enrollee requested continued skilled nursing facility services for medical treatment of his medical condition.  Findings:  The physician reviewer found that there was no indication that this patient lacked improvement or could not safely return home to be evaluated for home physical therapy if necessary.  The current medical evidence does not support the requested services in this clinical setting.  All told, the requested continued skilled nursing facility services are not medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Overturned

The patient is a 48-year-old male who is seeking authorization for the medication Celebrex. The Health Plan has denied this request and recommended the patient proceed with trials of formulary alternatives.The Health Plans denial should be overturned. A review of the information submitted demonstrates the patient is a 48-year-old male with a history of arthritis involving his knees and lower back. He is status post left rotator cuff repair, status post lumbar fusion at L5-S1, and status post meniscectomy of the right knee. He has been taking Celebrex since 2002 and reports relief of his arthritis related pain. Prior to treatment with Celebrex he tried and failed therapy with Motrin, Naprosyn, Feldene, and Vioxx. He utilized PPI therapy with his previous trials of NSAID therapy. The information submitted documents the patient has significant degenerative joint disease as well as a chronic pain condition related to his spinal fusion. He has tried traditional NSAID therapy and reported no significant pain relief. He has obtained significant pain relief with Celebrex since 2002. There is no medical indication for him to attempt trials of NSAID therapy. Given his arthritis history and previous surgical interventions, he should be maintained on a medical therapy that has provided documented improvement in his condition. Therefore, I have determined 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: Overturned

 Nature of Statutory Criteria/Case Summary:  An enrollee has requested total cervical disc arthroplasty for treatment of her medical condition. Findings:  Two physician reviewers found that total cervical disc arthroplasty was likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The patient had evidence of chronic right upper extremity radiculopathy with associated MRI findings of stenosis, particularly in the foraminal area. Progressive neurologic deficit was documented. She had exhausted conservative measures including facet rhizotomies and epidural steroid injections.  Surgery was therefore indicated. Based upon the imaging studies, the degenerative changes at other levels were not significant.  As such, the services at issue were likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.  Final Result: Two reviewers determined that the services at issue were likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned.  Credentials/Qualifications: All three reviewers are board certified in orthopedic surgery 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

The parent of an eight-year-old male enrollee has requested speech therapy for the treatment of the enrollees Aspergers disorder. Findings:  The physician reviewer found that the medical documentation indicates that the patients language development appears normal. A formal assessment noted that the patient had a normal voice, good fluency and articulation with low average to borderline expressive and receptive language skills. The submitted clinical documentation does not demonstrate that the patient had deficits in speech and language which necessitated speech therapy.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested authorization and coverage for myofunctional therapy.The submitted documentation does not support that the requested services are medically necessary. In this case, records reflect that the patient is suffering from nasal obstruction adenoid hypertrophy causing 90% obstruction of the nasopharynx and resultant obstructive sleep apnea and speech issues. Records indicate that the patient's problem is due to near complete nasal obstruction caused by adenoid hypertrophy and allergic rhinitis. Orofacial myofunctional therapy cannot improve an obstructive lesion in the nose, as the therapy is concentrated on the mouth and pharynx. Studies of myofunctional therapy have not shown significant benefit in sleep apnea especially in children (Rueda, et al.; Hsu, et al.). Under these circumstances, the requested myofunctional therapy 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 otolaryngology  head and neck 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: An enrollee has requested authorization and coverage for Zepatier 50-100 mg for 12 weeks for treatment of the enrollees hepatitis C. Findings:  The physician reviewer found that The physician reviewer found 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 1a patients should be treated with regimens including Zepatier for 12 weeks when NS5A resistance is not found. These guideline recommendations are based on clinical trial results showing a 99% cure rate when NS5A resistance is absent. AASLD/IDSA guidelines cite data showing reduced survival with delayed treatment. For these reasons, Zepatier 50-100 mg for 12 weeks 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: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary:  An enrollee has requested reimbursement for laboratory lipoprotein testing (CPT 83704) provided 3/09/21. Findings:  The physician reviewer found that According to published guidelines by the American Heart Association and American College of Cardiology (AHA/ACC), advanced lipoprotein testing may be indicated in patients at intermediate or borderline ten-year risk to further refine their risk when statin medication is being considered or intensified. In this case, the patient has multiple risk factors for atherosclerotic coronary artery disease and is already being appropriately treated with moderate dose statin therapy for risk reduction per AHA/ACC guidelines. Given her underlying diabetes and other risk factors, treatment with moderate to high intensity statin therapy is appropriate. Additionally, for patients treated with moderate to high dose statin medication, the nuclear magnetic resonance lipoprotein LDL particle testing is not recommended as a risk enhancer according to the AHA/ACC guideline approach. Therefore, laboratory lipoprotein testing provided 3/09/21 was not likely to have been more beneficial than any available standard method of evaluation for the patients medical condition.Findings: Three out of three physician reviewers found that laboratory lipoprotein testing (CPT 83704) provided 3/09/21 was not likely to be more beneficial for you than any available standard therapyFinal Result: The reviewer determined that the service at issue was not likely to have been more beneficial than any available standard method of evaluation for the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewers 1, 2, and 3 are board certified in internal medicine with sub-specialty certification in cardiovascular disease 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: Overturned

A 55-year-old female enrollee has requested for services for treatment of her back pain and right leg symptoms. Findings:  The physician reviewer found that there were pathological findings on her lumbar MRI that were consistent with her symptoms.  When removal of the cyst is not possible, steroid injection of the facet joint housing the cyst can serve as therapeutic.  Bureau and colleagues performed an observational study to determine the imaging characteristics of lumbar facet joint synovial cysts after percutaneous treatment with steroid injections and distention of the cyst.  The authors concluded that image-guided percutaneous steroid injections are often effective in the treatment of lumbar facet joint synovial cysts and may result in complete regression of the cyst.  Sabers and colleagues performed a retrospective study to evaluate the success of fluoroscopically-guided, contrast-enhanced lumbar zygapophyseal joint aspiration and steroid injection combined with transforaminal epidural steroid injection for treatment of lumbar zygapophyseal joint cyst-induced radicular pain. Following the study, the authors concluded that fluoroscopically-guided, contrast-enhanced spinal procedures as part of an aggressive nonsurgical treatment program are a safe and effective alternative to surgical intervention for lumbar zygapophyseal joint cyst-induced radicular pain.  All told, the services provided were medically indicated in this patients case.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The spouse of an enrollee has requested authorization and coverage for immediate cataract surgery.The American Academy of Ophthalmology (AAO) has issued interim guidelines on resuming elective ophthalmic care during the COVID-19 pandemic. The AAO states that cataract surgery is considered semi-urgent, not elective, when the affected person cannot drive, work or see to take their medications properly, or has an increased risk of falling, phacomorphic glaucoma or intolerable anisometropia. The AAO states that such cases warrant surgery within days to weeks. In this case, because the patient has a history of dementia and decreased mobility, the typical considerations of encumbered working or risk of falling are not applicable. However, the patients bilateral visual acuity measurements of 20/400 demonstrate a visual decline that would correlate with marked decrease in functioning in most cases. The potential harm resulting in delayed treatment of 20/400 vision related to cataracts would likely be related to increased difficulty with mobility, eating, or taking medications. Under these circumstances, immediate cataract surgery is medically necessary for the patients medical condition.Final Result: The reviewer determined that the requested services are medically necessary for the patient's medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in ophthalmology 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.