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 Euflexxa injections in the left knee.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 options are limited. The patient has tried and failed other conservative treatments. Intraarticular corticosteroid injections are contraindicated because of diabetes mellitus and the chronic right foot ulcer, with the alternative being a total knee arthroplasty. Thus, Euflexxa injections in the left knee 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: Medical Necessity
Decision: Upheld

The parents of a 13-year-old male enrollee have requested growth hormone therapy for treatment of the enrollees growth hormone deficiency.  Findings:  The physician reviewer found that the patients workup was initiated when he was at the 10th percentile. His IGF-1 level was borderline low, and the GH stimulation testing was incomplete. Therefore, there is limited evidence to support a diagnosis of GH deficiency, especially because the patients bone age was reported as normal to advanced. Although the patients possible adult height prediction is borderline low there is no evidence of a falling growth rate prior to therapy.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the genomic sequencing analysis for evaluation of the enrollees metastatic invasive ductal adenocarcinoma. Findings:  Two physician reviewers found that there are currently a variety of assays evaluating genomic and molecular abnormalities which explore an individual patients cancer cells for a specific alteration that could be the target of a specific therapy. However, there is a paucity of evidence that such assays bring benefit to the patient in addition to clinical judgment. There are a variety of non-randomized studies that do not suggest benefit of the use of these assays. Given the lack of evidence to indicate that this assay would be of benefit to this patient, the genomic sequencing analysis provided was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Final Result: The reviewers determined that the testing at issue was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: All physician reviewers are board certified in internal medicine with sub-specialty certification in medical oncology 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: Overturned

A 56-year-old female enrollee has requested Celebrex 200 mg capsules for treatment of her rheumatoid arthritis, fibromyalgia and osteoarthritis. Findings: The physician reviewer found that the relevant medical studies on Celebrex in the treatment of patients with osteoarthritis and rheumatoid arthritis patients have demonstrated positive results. Celebrex is also FDA approved for use in osteoarthritis related and inflammatory pain. In addition, this patient has experienced severe adverse reactions to other NSAIDs including GI bleeding. Also, she has been on this medication, well monitored and with good results for at least six years. Thus, the requested Celebrex should be approved for this patient, due to significant contraindication to taking non-selective COX inhibitors, other adverse events noted in the medical record, and her reported relief with Celebrex.
Appeal type: Medical Necessity
Decision: Overturned

A 52-year-old female enrollee has requested a mandibular advancement splint for the treatment of her sleep apnea. Findings:  The physician reviewer found that it is generally accepted that CPAP is the most effective method to manage OSA. If tolerated, it improves the subjective and objective measures of sleepiness by acting as a pneumatic splint to elevate and maintain constant pressure along the upper airway during inspiration and expiration. If CPAP is not tolerated, one alternative is an oral appliance that increases the posterior oropharyngeal airway space, therefore reducing upper airway collapsibility during sleep. The devices are more commonly used for patients with mild and moderate OSA who are not compliant with or poorly compliant to nasal CPAP. Most of the medical literature recommends using appliances for mild to moderate OSA among patients who are not compliant or fail treatment with CPAP. Thus, although CPAP is more effective than appliance therapy, given this patients intolerance to CPAP, treatment with an oral appliance was medically appropriate and adheres to generally accepted practices among providers who treat patients with OSA.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary:The patient has requested reimbursement for the immune cell function assay blood test provided. Findings:  The physician reviewer found that in the peer-reviewed medical literature, a study noted that inherited thrombophilias do not appear to be related to unexplained infertility. The authors reported that a large retrospective study showed no significant association with common thrombophilias, including factor V Leiden and lupus anticoagulant, and diminished in vitro fertilization success. Thus, neither screening for thrombophilias nor treating them is advised in cases of repeated infertility treatment failure. Similarly, the authors discussed the immunologic testing of infertile women and stated that, an increased frequency of abnormal immune test results in women with early reproductive failure has been reported repeatedly; however, the most rigorous studies have not proven a cause and effect between these phenomena. Thus, the immune cell function assay blood test was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Final Result: All three  reviewers determined that the testing at issue was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: Physician reviewers are  board certified in obstetrics and gynecology 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: The patient has requested authorization and coverage for clonazepam (Klonopin) 0.5 mg tablets (120 tablets per 30 days). There is a lack of evidence in the medical literature to support the use of benzodiazepines for the treatment of chronic anxiety. Darker and colleagues noted, Long-term use of benzodiazepines is not generally recommended and can lead to physical and psychological dependence and withdrawal symptoms. Researchers further outlined the long-term risks of benzodiazepines. This patient has a history of bipolar disorder, generalized anxiety disorder, post-traumatic stress disorder, attention-deficit/hyperactivity disorder, and cannabis use disorder. Per chart review, there were no vital signs to support that the patient is experiencing benzodiazepine withdrawal. Given the lack of evidence-based data on the use benzodiazepines for the long-term treatment of generalized anxiety disorder, the requested clonazepam (Klonopin) 0.5 mg tablets (120 tablets per 30 days) is not medically necessary for 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 psychiatry with subspecialty certification in addiction 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

A 67-year-old male enrollee has requested Plavix, 150 mg daily (60 doses of 75 mg tablets) for treatment of his medical condition. Findings:  The physician reviewer found that it is becoming standard clinical practice to test for Plavix responsiveness in individual patients by genotyping for cytopchrome P-450 enzymatic activity. The current clinical approach to those patients shown to exhibit resistance to the drug is to increase the daily dose of Plavix, with most recommendations being for a 150 mg dose for some period of time.This patient was unable to tolerate other anti-platelet agents. Therefore, it is medically necessary to treat him with a higher dose of Plavix in view of his documented genetic resistance. There is no indication in the medical records to suggest that he had adverse side effects from this drug.
Appeal type: Experimental/Investigational
Decision: Overturned

A female enrollee requested authorization and coverage of Botox injections. The Health Plan denied the request indicating that the requested therapy is considered experimental for treatment of the enrollees hyperhidrosis.Three physician reviewers performed an experimental/investigational Independent Medical Review. All 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. Because all 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

A 55-year-old female enrollee has requested weekly outpatient therapy for treatment of her depression, anxiety, and post-traumatic stress disorder.  Findings:  The physician reviewer found that based on review of the available records, her providers have documented that she is disabled as a result of her CFID. This disorder triggers psychological problems such as depression and anxiety, and is itself triggered by stress. This is a chronic condition so the patient requires ongoing supportive psychotherapy. Thus, weekly therapy is medically indicated in this patient. During acute exacerbations, the patient may need more intensive treatment. For these reasons, the weekly outpatient therapy treatments from the said date and forward are supported as medically necessary for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld

A 55-year-old male enrollee has requested for skilled nursing facility (SNF) services for treatment of his Guillain-Barre Syndrome. Findings:  The physician reviewer found that physical and occupational therapy do not promote nerve recovery. The pace of nerve recovery is such that patients cannot benefit from daily skilled physical and occupational therapy. The patient required daily range of motion, but this could have been done via a home exercise program. He required only intermittent physical and occupational therapy, supervision and review of his status.
Appeal type: Medical Necessity
Decision: Overturned

A 46-year-old female enrollee has requested for Synvisc injections for treatment of her bilateral knee osteoarthritis. Findings:  The physician reviewer found that it is reasonable for this patient to repeat these series of injections on a yearly basis, providing that there is documented improvement over this time interval. Given the patients young age, the importance of exhausting conservative modalities prior to undergoing any surgical treatment, and the patients previous benefit from the injections, she is a good candidate for repeat Synvisc injections and the request is both reasonable and appropriate.
Appeal type: Medical Necessity
Decision: Upheld

The patient is a 58-year-old female said to have Lyme disease for whom extended treatment with IV ceftriaxone (Rocephin) has been prescribed.  The record contains a letter from the patient noting that she was diagnosed with Lyme disease in July 2003 and that she has chronic knee pain.  There is also an October 2005 record of the patient presenting to the emergency department with palpitations. There was no note documenting that the patients knees were painful or other abnormal findings in the extremities. Her laboratory studies at that time (CBC, electrolytes, EKG and chest x-ray) were within normal limits.  Additional labs results from 8/22/05 show reduced CD8/CD7 lymphocytes (normal 60-360; the patients value was 32) and  August 2005 labs indicate that a single Lyme IgG Western Blot was positive (i.e., two bands present). Notes from an office visit with her provider in January 2006 indicate the patient has had (a) some salt and some potassium wasting and that she was somewhat stressed. There is no recorded evidence of cardiac, neurological or joint disease. The patient has requested reimbursement and continued coverage for IV therapy with Rocephin.  The Health Plan does not consider the therapy medically necessary and has denied her request.There is no clinical history supporting a diagnosis of Lyme disease and no evidence of a positive IgM Western Blot in the record. The patient did have a positive IgG Western Blot, but given the lack of clinical indications of acute Lyme disease, this was most likely a false positive result as often occurs. In this case, the diagnosis of Lyme disease has not been substantiated and treatment with IV Rocephin was not necessary.  Even if there is good evidence of Lyme disease, there is no support for treatment with IV antibiotics for a period of over 30 days.  The paper by Krupp cited above is a blinded, randomized trial of 28 days of Rocephin for post Lyme disease fatigue. The group that received the antibiotic did have improvement in fatigue but there was no improvement in measures of cognitive function. Because there are significant adverse effects associated with antibiotic therapy, the authors concluded that there was no indication for Rocephin therapy for patients with Lyme disease who complain of fatigue. Indeed, except for documented cardiac or neurological disease, there is no indication for a months treatment with Rocephin. Based upon the information set forth above, I have determined the therapy at issue was/is not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested a heart computed tomography (CT) scan for evaluation of his medical condition.  Findings: Two physician reviewers found that based on the documentation submitted for review, the patient has significant coronary risk but no evidence of coronary ischemia on recent stress testing. In this circumstance, guidelines to manage coronary risk are available and endorsed by several national organizations. The guidelines currently do not recommend the routine performance of coronary CT scanning to assess coronary risk. Treatment change or addition based on coronary CT scan results in this patient population with high risk has not been demonstrated to improve cardiac outcome incremental to that achievable based on standard clinical profile and basic lipid analysis alone. Therefore, the requested heart CT scan was not likely to be more beneficial for evaluation 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 evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: All three physician reviewers are board certified in internal medicine with sub-specialty certification in cardiovascular disease and are actively practicing. 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 authorization and coverage for Standup Magnetic Resonance Imaging (MRI) scan. Findings:  The physician reviewer found that Symptoms related to the low back are very common, especially in older individuals. The American College of Radiology (ACR) has attempted to provide guidelines for physicians encountering various common patient presentations. Under their guidelines for acute low back pain without red flags, MRI is clearly stated to be, Usually not appropriate. For chronic low back pain, without complications, the ACR characterizes MRI of the spine without contrast material as, Usually not appropriate. In elderly individuals, there is some allowance, but the ACR actually states that CT is preferred. In addition, findings on MRI do not necessarily correlate with symptoms. A patient may have incidental findings on an MRI that are not symptomatic, and, conversely, may have relatively unimpressive findings on MRI but may be experiencing significant symptoms. Regarding the request for Standup Magnetic Resonance Imaging (MRI), as distinguished from routine supine MRI, there is no inherent reason why upright MRI is not justifiable in some situations.As in all cases, the only reason to proceed to imaging studies is if it will change management of the patient. In this case, there is no indication that the patient is being considered for surgery, and there is no indication that the patient has any red flag signs of motor or sensory deficits. Under these circumstances, without additional clinical findings, it is unlikely that a surgical procedure is appropriate, and a conservative approach is typically warranted. Therefore, the requested Standup Magnetic Resonance Imaging (MRI) scan is not medically necessary to treat the patients medical condition.Final Result: The reviewer determined that the requested service is 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 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: Overturned

Nature of Statutory Criteria/Case Summary:  The parent of an enrollee has requested a secondary cranial helmet for treatment of the enrollees deformational plagiocephaly. The physician reviewer found that in this case, the secondary cranial helmet was medically necessary for treatment of the patients plagiocephaly. The use of molding helmets is the standard therapy for children with plagiocephaly. Plagiocephaly, if left untreated, can be associated with significant psychogenic, ocular, and oral occlusion problems. There is support in the medical literature of the effectiveness of the molding helmet for treating children with plagiocephaly. An infants head growth tapers off rapidly from 6 to 12 months of age, and it is preferable to initiate a molding helmet before five months of age. In this case, the patient presented with an initial asymmetry and was provided with a cranial helmet. Two months later the patients head asymmetry had been reduced. A second helmet was recommended due to the tightness of the original helmet as the patient still presented with plagiocephaly. As such, the patients molding helmet therapy was incomplete and a second helmet was medically necessary to complete the molding therapy. Therefore, based on the medical literature cited above and the documentation submitted for review, the secondary cranial helmet was medically necessary for treatment of the patients medical condition. Final Result: The reviewer determined that the device at issue was 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 with sub-specialty certification in neurodevelopmental disabilities 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 59-year-old female enrollee requested authorization and coverage of a power-operated vehicle (POV) for the treatment osteoarthritis. The health plan denied the enrollees request indicating that the requested POV is not medically necessary.One physician reviewer performed a medical necessity Independent Medical Review.  The physician reviewer upheld the health plans denial on the basis that the requested equipment is not medically necessary.