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 Orthovisc injections for treatment of the enrollees osteoarthritis. Findings:  The physician reviewer found that the requested service is medically necessary for treatment of the patients medical condition. The peer-reviewed literature supports the use of viscosupplementation injections for the treatment of pain in patients with severe osteoarthritis of the knee. Viscosupplementation has been found to be safe and effective and allow for delay of total knee replacement, and more effective than corticosteroid injections. Colleagues concluded that hyaluronic acid was the best pharmacologic intervention for knee osteoarthritis. The authors noted that hyaluronic acid has been found to be better than injected placebo or injected corticosteroids. Colleagues conducted a systematic review of overlapping meta-analyses comparing intra-articular hyaluronic acid with other non-operative treatment modalities for knee osteoarthritis. The authors reported that the current highest level of evidence suggests that intra-articular hyaluronic acid is a viable option for knee osteoarthritis. In this case, the patient has been diagnosed with severe end-stage osteoarthritis of the left knee. She has severe left knee pain that interferes with activities of daily living and work activities. She has failed to respond to conservative treatment, including physical therapy, medications, and activity modification. Given the patients young age, a trial of Orthovisc injections is medically reasonable and supported by evidence based medical literature. Therefore, the requested Orthovisc injections 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 parent of a 13-year-old male enrollee requested Saizen growth hormone therapy for medical treatment of the enrollees medical condition.  Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested therapy.  This patient has normal results on provocative growth hormone testing, normal growth factors, and no known morphological abnormality of his pituitary gland.  Thus, he does not have classic growth hormone deficiency.  The most likely explanation for his fall-off in growth between 10 and 12 years of age and delayed bone age is constitutional delay.  This may have been compounded by concurrent malabsorption from celiac sprue, as well as attention deficit/hyperactivity disorder treated with simulant medication.  Once sex steroid secretion is increased with progression in pubertal development, growth velocity is expected to accelerate.  All told, the requested Saizen growth hormone therapy is not medically necessary for the treatment of this patient.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary:  An enrollee has requested a positron emission tomography (PET) scan for evaluation of her medical condition.   Findings:  Two physician reviewers found that the current medical evidence supports the services at issue in this clinical setting.  Groheux and colleagues noted when a recurrence is depicted or a patient is suspected of having a recurrence by using conventional imaging, PET/CT is useful to determine whether this recurrence is isolated or not, and such a determination may have a potential effect on the patients treatment.  There is sufficient support in the literature for the use of PET to follow-up in this case.  In sum, the PET scan performed was likely to have been of greater benefit than other options for evaluating this patient. 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 diagnostic radiology and are actively practicing. All three reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested reimbursement and prospective authorization and coverage for home health therapy services for treatment of her feeding difficulties with tracheostomy.  Findings:  The physician reviewer found that per the U.S. Department of Health and Human Services/National Institutes of Health (NIH), a child with Down syndrome likely will receive care from a team of health professionals, including, but not limited to, physicians, special educators, speech therapists, occupational therapists, physical therapists, and social workers. The guidelines note that physical therapy includes activities and exercises that help build motor skills, increase muscle strength, and improve posture and balance. Further, occupational therapy helps find ways to adjust everyday tasks and conditions to match a persons needs and abilities. This patients multiple medical issues include emesis due to stress, which would interfere with therapy and prolong the timing of therapy outside of the home. While the patient does not meet the Centers for Medicare and Medicaid Services (CMS) definition of homebound, when the patient is not at home and does not receive the services at home, she has episodes of emesis due to stress. Thus, the patient is in need of occupational therapy and physical therapy within the home and requires the assistance of another person and an assistive device in order to leave her residence. In order for the patient to leave her home to attend therapy, the parents would have a considerable and taxing effort to leave the home. The parents may need to bring tracheostomy supplies and feeding supplies dependent upon the length of therapy and timing of therapy outside of the home. The patient has received therapy in her home for five years. She is legally deaf, blind and non-verbal. The patient has additional complex issues including Downs syndrome and a tracheostomy. Final Result: The reviewer determined that the services at issue were and 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 physical medicine and rehabilitation with sub-specialty certification in pediatric rehabilitation 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: Medical Necessity
Decision: Upheld

The parent of a 5-year-old male enrollee has requested multi-model applied behavioral analysis (ABA) therapy for treatment of the enrollees autism.  Findings:  The physician reviewer found the medical literature strongly supports applied behavioral analysis (ABA) therapy for the treatment of children with autism. However, around the age of school placement, autistic children tend to be gradually transitioned from individual ABA therapy to a combined school, ABA therapy, and group therapy program (Reichow et al). The 15 hours of ABA therapy is therapeutically adequate for a patient such as this patient who presents with normal/borderline intellect, is attending kindergarten and is also receiving speech and occupational therapies. The medical necessity of the requested 25 hours per week of ABA therapy is not established based upon the submitted clinical documentation.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested facet nerve  block injections treatment of the enrollees low back pain.  Findings: The physician reviewer found that based on the current medical literature and the presented clinical records, facet nerve block injections are medically necessary for treatment of the patients medical condition. Criteria for the use of diagnostic blocks for facet mediated pain include patients with low back pain that is non-radicular and documentation of failure of conservative treatments. In this case, the patient has low back pain with pain to the buttocks consistent with facet mediated pain. She does not have radicular pain symptoms and she had a normal neurological examination. Physical examination findings and the imaging results as well as the mechanism of injury are consistent with facet mediated pain. In addition, her pain is moderate to severe despite extensive conservative treatments. Therefore, the requested services are 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 physical medicine and rehabilitation 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 female enrollee requested an oral appliance for medical treatment of her obstructive sleep apnea (OSA).  Findings:  The physician reviewer found that in the medical literature, Epstein and colleagues concluded that treatment strategies for obstructive sleep apnea may include positive airway pressure devices, oral appliances, behavioral treatments, surgery, and/or adjunctive treatments. The records document that this patient has contraindication to CPAP use due to the perforation of the nasal septum. Given these findings, the requested oral appliance is a reasonable treatment alternative and is therefore supported as medically necessary for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary:   An enrollee has requested magnetic resonance imaging (MRI) for the evaluation of his medical condition.  Findings:  The physician reviewer found that there is sufficient support for the requested services in this clinical setting.  There are several treatment options for prostate cancer.  These include active surveillance, radiotherapy, and surgery.  In addition to the risk of tumor recurrence, each of these treatment options carries significant risk of morbidity.  The risks of continuing urinary incontinence and erectile dysfunction are potential complications that are experienced by many patients.  It is not unreasonable to have as much information as possible to help guide a treatment choice, and avoid unnecessary surgery.  In this patients case, based on his Gleason score, active surveillance would likely be excluded as a possibility.  There are instances of both false positive and false negative findings with MRI.  The issue is further complicated by the large number of MRI options.  MRI can be performed simply for anatomic delineation.  However, it can also be performed with diffusion weighting, with dynamic contrast enhancement, with spectroscopy, and with multiparametric imaging.  There are several articles published which note the increased accuracy with multiparametric MRI.  All told, the requested MRI is medically indicated for the evaluation of this patient.  Final Result: The reviewer determined that the requested services are medically necessary for evaluation of the patients medical condition. Therefore, the Health Plans denial should be overturned.  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: Experimental/Investigational
Decision: Upheld

A 55-year-old female enrollee has requested reimbursement for right eye canaloplasty for treatment of the enrollees open angle glaucoma.  Findings:  Two physician reviewers found that the patient underwent canaloplasty for treatment of her open angle glaucoma. She had previously undergone a trabeculectomy in her other eye. The patients glaucoma specialist noted that a canaloplasty was a better option in the second eye. The Health Plan denied the patients request for reimbursement on the basis that canaloplasty is considered investigational. While canaloplasty has been utilized by some glaucoma specialists in select patients, it is not universally accepted as superior to trabeculectomy (Ayyala, et al). In this case, there is inadequate documentation supporting canaloplasty over standard care with trabeculectomy. Therefore, the procedure at issue was not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.
Appeal type: Medical Necessity
Decision: Upheld

A 48-year-old female enrollee requested breast augmentation revision surgery (removal of capsular scar tissue and bilateral implants for treatment of her partially deflated bilateral saline breast implants.  Findings:  The physician reviewer found that the patient is noted to have possible bilateral saline implant rupture following augmentation mastopexy. Based on the submitted documentation, there is no evidence that the breast augmentation mastopexy was done for reconstructive reasons. This is a common cosmetic procedure and the patient has already undergone a revision. Without a defined functional deficit in this clinical setting, the requested breast augmentation revision surgery (removal of capsular scar tissue and bilateral implants) is not reconstructive in nature or medically necessary for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld

A 51-year-old male enrollee has requested for participation in a Level 3 Chronic Pain Management Program for treatment of his chronic pain.  Findings:  The physician reviewer found that it is currently reasonable for him to enter a Level 2 Pain Program first, since he has not attended such program. His need for additional treatment, including a Level 3 Pain Program, should be assessed upon completion of such treatment.
Appeal type: Medical Necessity
Decision: Upheld

The patient has requested authorization and coverage for total hip arthroplasty. The American College of Rheumatology (ACR) recommends total joint arthroplasty for patients with hip osteoarthritis following failed medical therapy. The ACR therapy recommendations include exercise, weight loss when indicated, medication management, manual therapy, walking aids, and psychosocial interventions. This patient presents with complaints of significant low back pain radiating to the left lower extremity with signs and symptoms of neurogenic claudication, as well as bilateral hip pain. The patients standing tolerance is significantly limited by leg fatigue. Hip examination revealed slightly limited range of motion and positive left provocative test. There is imaging evidence of left hip cam type femoroacetabular impingement and a small tear of the right superior labrum. There is radiographic evidence of cam lesions and mild osteoarthritis. He has been recommended for lumbar decompressive surgery. There is significant evidence of lumbar mediated radicular pain, along with neurogenic claudication that limits functional mobility. There are mild clinical findings, with mild radiographic osteoarthrosis noted at the hips. Lumbar surgery has been recommended and is indicated prior to consideration of hip surgery. All told, the requested total hip arthroplasty is not medically necessary for treatment of this patient. Final Result: The reviewer determined that the requested services are not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.
Appeal type: Experimental/Investigational
Decision: Upheld

A female enrollee requested Nuvigil 150mg for medical treatment of her multiple sclerosis-related fatigue.  Findings:  Two physician reviewers found that multiple sclerosis-related fatigue is very common, and may be a disabling feature of the disease. There is a typical algorithm for treating fatigue which includes ruling out a primary sleep disorder and eliminating medications that may be contributing to fatigue.  Commonly used medications for fatigue include amantadine, modafinil, armodafinil, methylphenidate, pemoline, and amphetamine.  In this patients case, the records do not indicate that amantadine has been tried.  Several recent comparator studies suggest amantadine is more effective than modafinil for the treatment of fatigue.  Armodafinil (Nuvigil) is the enantiomer of modafinil which is more pharmacologically active and requires daily dosing, but otherwise is nearly identical to modafinil as far as its action.  All told, the requested Nuvigil 150mg is not likely to be superior over other treatment options.
Appeal type: Medical Necessity
Decision: Overturned

An 18-year-old female enrollee requested authorization and coverage of a shower chair/commode.  The Health Plan  denied the request indicating that the enrollee does not meet the criteria for authorization of the requested equipment.One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer overturned the Health Plans denial on the basis that the requested equipment is medically necessary.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for laparoscopic sleeve gastrectomy revision (CPT 43848) and hiatal hernia repair (CPT 43281). Sleeve revision has not been documented as a standard treatment for weight regain or enlarged sleeve based on a lack of durable long-term outcomes. Further prospective clinical trials are required to compare the outcomes from revisional sleeve gastrectomy with other standard procedures when primary laparoscopic sleeve gastrectomy has failed. Researchers noted, Further prospective clinical trials are required to compare the outcomes of revisional sleeve gastrectomy with those of laparoscopic Roux-en-Y gastric bypass or duodenal switch for weight loss failure after laparoscopic sleeve gastrectomy. Re-sleeving a dilated sleeve gastrectomy has not been shown in the high-level published literature to result in durable long-term (greater than three-year) weight loss. Although there are some studies with small patient numbers and non-randomized case series with short follow-up, additional research is needed to determine if the requested procedure is a safe, effective and durable treatment for weight regain.   In this patients case, the medical records do not document hiatal hernia. Thus, hiatal hernia repair (CPT 43281) is also not supported. Therefore, laparoscopic sleeve gastrectomy revision (CPT 43848) and hiatal hernia repair (CPT 43281) are not medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested services are not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is board certified in 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 a cervical artificial disc for treatment of her medical condition.   Findings:  Two physician reviewers found that the request for cervical artificial disc replacement is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Per the U.S. Food and Drug Administration (FDA), the ProDisc-C total disc replacement is indicated for the treatment of single-level cervical disc disease following discectomy. In this case, the patient presents with neck pain radiating down the left upper extremity. Clinical exam findings have been consistent with imaging evidence of degenerative disc disease at multiple levels. Given that ProDisc-C total disc replacement is FDA approved and supported by the peer-reviewed literature for single-level cervical degenerative disc disease only, the requested cervical total disc replacement is not likely to be more beneficial for the treatment of the patients medical condition than any available standard therapy. Final Result: Two reviewers determined that the requested services are not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld.  Credentials/Qualifications:  All three reviewers are board certified in 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

A 50-year-old female enrollee has requested eight additional sessions of physical therapy for treatment of her status post right shoulder rotator cuff repair.   Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested therapy in this clinical setting.  The current medical evidence does not support the requested eight additional sessions of physical therapy in this patients case.  The standard of care includes instructing patients regarding self-directed home exercises during their rehabilitation.  In this case, it is medically appropriate to transition this patient to a home exercise program.  The medical records do not document why further rehabilitation cannot take place in a self-directed home exercise program.  All told, the requested eight additional sessions of physical therapy are not medically indicated for the treatment of this patient.