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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Prolia (denosumab). Findings:  The physician reviewer found that The records indicate that this patient is unable to tolerate oral bisphosphonates due to gastrointestinal upset and pain. However, given this patients medical history, the current guidelines recommends class IV bisphosphonates (zolendronic acid) as the preferred agent when oral bisphosphonates are not tolerated. Prolia is a recommended alternative for women at high risk for fracture, or who have difficulty with the dosing requirements of oral bisphosphonates. Prolia is also preferred for those patients who wish to avoid intravenous bisphosphonates due to side effects, or those who have chronic kidney disease. In this patients case, the records do not indicate she has a history of chronic kidney disease or a contraindication to Reclast. While this patient has a reported family history of allergy to Reclast, the records do not document a personal history of allergy with Reclast.  Moreover, there are no long term safety data for Prolia, at this time. Bisphosphonates, on the other hand, have been used for many years and are considered standard or the preferred therapy.  Therefore, Reclast would be considered the preferred therapy in this case given the patients normal renal function, and the medications efficacy, based on long term safety profile. For these reasons, Prolia is not medically indicated 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 internal medicine with sub-specialty certification in rheumatology 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 transcranial magnetic stimulation (TMS) therapy for treatment of his behavioral health condition.  Findings:  The physician reviewer found that TMS is endorsed by the American Psychiatric Association (APA) for the treatment of acute phase depression in the adult population. TMS is a non-invasive brain stimulating procedure utilized in the treatment of major depressive disorder. TMS tends to be very well tolerated with fewer barriers than electroconvulsive therapy. In this case, the patient has chronic recurrent affective illness. He has history of poor tolerability to psychotropic medication. Considering the medical records, endorsement from the APA and the support in the peer-reviewed literature, TMS represents a safe, appropriate treatment consistent with good medical practice in this clinical setting. TMS therapy would reasonably be expected to improve the patients condition and prevent a more serious episode of illness. As such, TMS therapy is medically necessary for 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 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 authorization and coverage for Euflexxa injection for the left knee. The Health Plan has denied this request indicating that the requested medication is not medically necessary for treatment of the enrollees left knee osteoarthritis. Findings:  The physician reviewer found that evidence based medical peer-reviewed literature supports the use of viscosupplementation injections for the treatment of pain in patients with osteoarthritis of the knee. The American Medical Society for Sports Medicine (AMSSM) recommends hyaluronan acid for appropriate knee osteoarthritis patients, based on a large network meta-analysis. Viscosupplementation has been found to be safe and effective and more effective than corticosteroid injections. In this case, the patient presents with chronic left knee pain and a diagnosis of primary unilateral osteoarthritis of the left knee. She has failed other conservative treatments, including corticosteroid injection. She was treated with a series of Euflexxa injections with significant pain relief and ability to reduce her use of anti-inflammatory medications. Repeat viscosupplementation injections have been found to be safe and effective and allow for delay of knee replacement surgery. Therefore, the request for Euflexxa injections for the left knee are 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 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 patient is a 34-year-old male who is status post gastric bypass surgery and loss of over 150 pounds. As a result of the weight loss the patient has developed excess thigh tissue, which he would like surgically removed. The patients Health Plan has denied authorization for the requested procedure. The Health Plans denial should be upheld. There is no evidence the patient has chronic or recurrent skin infections that have not responded to medical therapy. Neither the patients medical records nor photograph provide objective evidence that the patient has a condition requiring surgery. In the absence of such evidence I have determined the requested procedure is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary:  An enrollee has requested Harvoni for treatment of his hepatitis C virus.  Findings:  The physician reviewer found that per the 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. According to the guidelines, patients with cirrhosis are considered highest priority for treatment. In patients with decompensated cirrhosis, guidelines recommend treatment with Harvoni with ribavirin for 12 weeks. The only alternatives are Sovaldi/Daklinza/ribavirin and Sovaldi/Daklinza (in ribavirin-intolerant patients). The Harvoni recommendation is based on the SOLAR-2 trial, which demonstrated efficacy in this population. The AASLD/IDSA guidelines specifically recommend against treatment of decompensated patients with Viekira Pak in a Red Box warning, and the United States Food and Drug Administration has warned that Viekira Pak can induce serious liver injury in patients with advanced liver disease.  For these reasons, the requested treatment with Harvoni (to be used with ribavirin) is supported as medically necessary for the treatment of this 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 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

Nature of Statutory Criteria/Case Summary:   An enrollee has requested the Zoster vaccine for treatment of his medical condition.  The physician reviewer found that based on the clinical documentation submitted for review, the medical necessity for the Zoster vaccine has not been established. There is a lack of support in the medical literature for the services at issue in this clinical setting. In this case, the patient has a diagnosis of perioral dermatitis/acne rosacea. There is no known connection between this type of cutaneous problem and Herpes zoster infection. Therefore, the shingles vaccination is not indicated for this patient. All told, the Zoster vaccine was not medically necessary for treatment of the patients medical condition. Final Result: The reviewer determined that the services at issue were not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.   Credentials/Qualifications: The reviewer is board certified in dermatology 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 has requested authorization and coverage for Euflexxa injections in the right knee. Evidence from systematic reviews and randomized controlled trials indicate that although viscosupplementation may relieve knee pain in some patients with osteoarthritis, data has not established which patients will benefit. Guidelines from the American Academy of Orthopedic Surgeons (AAOS) indicate that the data on safety and efficacy of viscosupplementation remain inconclusive. As such, the AAOS does not currently recommend viscosupplementation as standard treatment for osteoarthritis of the knees. Viscosupplementation is reserved for patients with a history of lasting benefit from prior injections and in cases where the remaining options are limited. In this case, there is a history of lasting benefit from prior injections over a period of three years. Each series of injections lasted six months or more. The patient has tried and failed other conservative treatments. Furthermore, the remaining treatment options are limited to total knee arthroplasty at a young age in the absence of imaging evidence of severe osteoarthritis. Therefore, the requested Euflexxa injections in the right knee are 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 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: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the digital breast tomosynthesis. Findings:  Three physician reviewer found that tomosynthesis is a technique that was developed as a problem solving adjunct to routine mammography. Applying the same basic concept as computed tomography scanning, the logic is that by separating the various layers of breast tissue, one can better detect abnormalities. In this case, tomosynthesis was indicated due to the presence of a breast lump, in the clinical setting of nipple discharge. It is important to be as sure as possible that an occult mass is not being missed. Tomosynthesis is a valuable tool in separating overlapping breast tissue and delineating any masses that may be palpable. Final Result: Three reviewers determined that the diagnostic procedure at issue was 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 physician reviewers are board certified in diagnostic radiology 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

A 55-year-old female enrollee has requested Aranesp injections for the treatment of her unspecified anemia. Findings:  The physician reviewer found that the submitted documentation does not support the need for Aranesp for this patient.  She had a liver transplant. Although transplant medications may have caused the anemia, it is not known whether careful observation would have resolved the issue.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested total knee arthroplasty for treatment of her medical condition. Findings: The physician reviewer found that the requested total knee arthroplasty has been established as medically necessary in this clinical setting. The patient has had appropriate conservative treatment including an arthroscopic debridement which was undertaken after informing the patient that it is not likely to have been successful. Based on the medical records, there is a lack of options available for this patient, other than total knee arthroplasty. Moreover, the proposed surgery is consistent with the standard of care for this patients medical condition (Cannada). Given the lack of alternative treatments available and that conservative care has been ineffective, the proposed total knee arthroplasty is medically necessary to improve the patients function of her knee. Based on the peer-reviewed literature and clinical documentation the requested total knee arthroplasty is clinically indicated 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 authorization and coverage for a MvoPro Motion G mvoelectric orthosis for left arm device. There is a lack of evidence in current medical literature supporting the use of the requested device following a cerebral event, such as stroke, in assisting a patient regain neurological or muscular strength or function, such as the innate ability to use the arm for functional tasks when the orthosis is removed. The available medical literature regarding the potential of the device is limited and does not establish proven health outcomes, such as reduction in the incidence of overuse injury of the sound, unaffected limb. Harrison and Field note that following stroke, there is a risk of musculoskeletal pain including shoulder subluxation. Arya and colleagues note that rehabilitation efforts to reduce shoulder subluxation in post-stroke hemiparesis should aim to support and suspend the shoulder and arm weight. Due to its weight, the requested device may cause the shoulder to sublux and result in greater instability for a patient with hemiparetic gait by displacing the center of gravity. In this case, the patient is noted to have a chronically weak left arm following a stroke. In this clinical setting, the weight of the requested device would make it difficult for the patient to position her upper extremity for purposeful use of the device. The requested device is not proven to enhance or replace the role of conventional orthoses and is not expected to provide clinically or functionally significant marginal benefits over conventional orthotic therapy. Therefore, a MvoPro Motion G mvoelectric orthosis for left arm device is not likely to be more beneficial for the treatment of the patients medical condition than any available standard therapy.Findings:  Three of the three physician reviewers found the requested MvoPro Motion G mvoelectric orthosis for left arm device is 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 requested device 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: Physician reviewers 1 and 3 are board certified in physical medicine and rehabilitation and are actively practicing. Physician reviewer 2 is board certified in physical medicine and rehabilitation with sub-specialty certification in pain medicine 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: Upheld

A 59-year-old female enrollee has requested continued care, four visits per year, with a pain management physician for treatment of her medical condition. Findings: The physician reviewer found that the medical literature shows that PCPs have a primary role in the treatment of common conditions such as migraine, and that with appropriate education and support, they can be effective in that role. In general, the use of Fiorocet or opiates by migraine patients is discouraged due to the risk of the development of medication overuse and headache transformation, while triptans are considered a first choice for most migraine patients. If this patient requires the renewal of her ongoing medications, this service does not require the expertise of a pain specialist, and can be appropriately done by the patients PCP. All told, ongoing treatment by a pain medicine specialist is not medically necessary to treat this patients condition as the patients diagnoses can be appropriately managed by her PCP.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested Xanax for treatment of her behavioral health condition. Findings:  The physician reviewer found that in this clinical setting, treatment with Xanax is medically necessary. It is appropriate for the treatment team to eventually transition this patient from Xanax to non-addictive treatments for her symptoms, and it appears that they have been somewhat successful to date; the patient had reduced her Xanax usage. Given that her dosage of Xanax is fairly low, she should be at a lowered risk of complications from Xanax such as dementia and dependence. All told, the requested medication is indicated for the treatment of the patients behavioral health condition.  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 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

The parent of a 16-year-old male enrollee has requested reimbursement for residential treatment services provided on consecutive days and prospective authorization and coverage for resumption of residential treatment. Findings:  The physician reviewer found that based on review of the available records, the RTC level of care services provided on the dates in question were medically necessary. There is a family therapy note dated the day before that describes the patient as being very negative. He was noted to still exhibit impulsive behaviors and would run away when triggered. When his mother entered the session, he appeared to jump into his emotions and needed prompting to take some deep breaths. The records indicate the patient was still very labile at this session and not stable enough to ensure he would not relapse if discharged to a lower level of care. He expressed considerable hostility toward his father. The patient was not stable enough to maintain himself absent the structure of the RTC setting through the second date in question. Therefore, RTC services on the dates in question were medically necessary. Subsequently, the patient received services for approximately two weeks and was discharged in an improved condition. Based on the records provided for review, there is inadequate documentation to support re-referral to the RTC level of care. All told, the RTC services provided on the first two days were medically necessary but readmission to RTC is not medically necessary for treatment of the patients behavioral health issues.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/ Case Summary:  The enrollee is requesting reimbursement for a vitamin D test. The enrollee has complaints of brain fog and an inability to focus. The enrollees past medical history includes high cholesterol and testicular cancer. As part of the enrollees health care maintenance, the provider ordered lab testing; including vitamin D. According to the medical exam and lab results, there was no clear medical need for vitamin D supplementation to treat a vitamin D-deficiency medical illness.  Therefore, there was no need for a vitamin D screening lab test.  There was no documentation of any prior issues related to vitamin D deficiencies; therefore, testing for vitamin D deficiency without a clear reason was not needed.Final Result: The reviewer determined that the requested service is not medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The physician reviewer is board certified in internal 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 similar medical condition.