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

Nature of Statutory Criteria/Case Summary: The patient is a male diagnosed with osteoarthritis of both knees.  He has failed treatments, which has included anti-inflammatory medication, bracing, and corticosteroid injections. The patient prefers to delay surgical treatment and has benefitted from viscosupplementation in the past. The most recent Orthovisc injections were administered to both knees and provided pain relief. The patient has requested coverage for a Monovisc injection. The Health Plan denied the request and reported that the requested treatment was not medically necessary for the treatment of this patient. At issue in this case is whether a Monovisc injection is medically necessary for the treatment of the patients medical condition. Intra-articular hyaluronic acid injections provide a symptomatic benefit for patients with knee osteoarthritis without major safety concerns.  Viscosupplementation increases functional scores in patients with osteoarthritis of the knee, especially within three months of injection (Campos, et al.). Viscosupplementation is recommended for patients with a history of lasting benefit from prior injections. The patient has reported benefit with previous viscosupplementation injections to the knees. In this case, the medical evidence supports the requested treatment in this clinical setting. Therefore, a Monovisc injection is medically necessary for the treatment of this patient.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. Findings:  The physician reviewer found that
Appeal type: Experimental/Investigational
Decision: Overturned

A 61-year-old female has requested hyperbaric oxygen therapy in advance of a tooth extraction.  Findings:  Two physician reviewers found that HBO for osteoradionecrosis (ORN) prophylaxis is still considered standard of care in the radiation oncology and maxillofacial communities. It is the only treatment option for prophylaxis and active management of ORN. Surgery is an option, but related to high morbidity. Antibiotics are not superior.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Erleada (apalutamide) 60 mg tablets. Findings:  The physician reviewer found that Current medical literature does not support the safety and efficacy of Erleada in patients with metastatic castration-resistant prostate cancer. Randomized placebo-controlled clinical trials of apalutamide (TITAN and SPARTAN trials) only included patients with non-metastatic castration-resistant and metastatic castration-sensitive prostate cancer. They did not include patients with metastatic castration-resistant prostate cancer. In addition, current medical literature supporting the efficacy of apalutamide in patients with failed similar drug Xtandi, abiraterone and Taxotere is largely unknown, and as such not considered a generally accepted and clinically appropriate standard. NCCN guidelines mention multiple options for patients who have had prior failure to first-line abiraterone or enzalutamide. These include docetaxel, Sipuleucel-T, olaparib, pembrolizumab, radium223, cabazitaxel, fine particles abiraterone or other secondary hormone therapy (ketoconazole, ketoconazole plus hydrocortisone, plus generation antiandrogen, corticosteroids, DES, antiandrogen withdrawal). In this case, the patient has metastatic castration-resistant prostate cancer and has failed Xtandi, abiraterone and Taxotere. Accordingly, the requested medication, Erleada (apalutamide) 60 mg tablets, is not medically necessary for the patients medical condition.Final Result: The reviewer determined that the requested medication is not medically necessary for the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is board certified in urology 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 63-year-old male enrollee has requested proton beam therapy treatments for treatment of his prostate cancer. Findings:  The physician reviewer found that although there is an increased risk of stricture after radiation post transurethral resection of the prostate, this is a manageable toxicity.  It is not clear from the literature that dose to the transurethral resection of the prostate deficit impacts this risk, and there is a lack of evidence indicating that proton therapy can reduce this risk.  Due to the dosimetric uncertainties with proton therapy, particularly if image-guided radiation therapy is not being used for this patient, it is possible that toxicity could be worse with proton therapy versus intensity modulated radiation therapy/image-guided radiation therapy.  All told, proton beam therapy treatments were not and are not medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Overturned

The parent of the enrollee is requesting reimbursement for anesthesia services. The patient had cavities, which required treatment, extraction and spacers. The patient required surgery to fix the cavities. Because of his age, this could not be done in a dental office setting. Instead, the treatment was provided with general anesthesia. For young patients, treatment under general anesthesia in a hospital setting is the best way to treat this condition.  The medical records show the patient was extremely shy, fearful and anxious. General anesthesia is often used with young patients to fix multiple cavities; especially if the child is anxious and unable to cooperate, like this patient was.           Final Result: The reviewer determined that the requested services were medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The physician reviewer is board certified in anesthesiology 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.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Percocet 10 mg/325 mg, #120 necessary for treatment of the enrollees chronic pain. Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested medication.  In this patients case, non-opioid treatment options have not been exhausted.  The records do not document behavior therapy despite significant research to support its use.  Given the documentation of a history of drug abuse, continuation of such medication should be under the direct guidance of a mental health professional.  It is medically appropriate to consider alternatives to opioids and to wean the patient off opioids.  The clinical notes indicate that tolerance has taken place since the start of the narcotics.  The current medical evidence does not support the requested medication in this clinical setting.  All told, Percocet 10 mg/325 mg, #120 is not medically indicated for the 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 physician reviewer is board certified in anesthesiology with sub-specialty certification in pain medicine and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for a cortisone shot for treatment of the enrollee who has a history of sacroiliac joint pain. Findings:  The physician reviewer found that the current peer reviewed medical literature indicates that the evidence is limited and insufficient to support short and long term relief from intraarticular SI joint corticosteroid injections. Additionally, evidence based medical guidelines state that therapeutic SI joint injections are not recommended (neither therapeutic SI intra-articular nor periarticular injections) for non-inflammatory SI pathology based on insufficient evidence in the literature. SI joint injections are recommended on a case by case basis as injections for inflammatory spondyloarthropathy (sacroiliitis). In this patients case, there is limited evidence on clinical examination relative to SI joint provocative testing and no documentation of imaging evidence suggestive of sacroiliitis. Current evidence based medical guidelines and peer-reviewed literature does not support the use of SI joint corticosteroid injection for this patients left SI joint dysfunction. Therefore, a cortisone shot is not medically necessary for treatment of this patients medical condition. Final Result: The reviewer determined that the requested service 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 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 parents of a 21-month-old male enrollee have requested a Dynamic Orthotic Cranioplasty for the treatment of the enrollees positional plagiocephaly. Findings:  The physician reviewer found that although a Dynamic Orthotic Cranioplasty was recommended, there is no hard, scientific data to support its use. The patient had normal facial features and milestones. The use of this device is only for cosmetic purposes.
Appeal type: Medical Necessity
Decision: Upheld

The enrollee is requesting authorization and coverage for a power scooter. The enrollee has chronic low back pain with lumbar radiculopathy, osteoarthritis of the hips, and high body mass index. The physician reported the enrollees pain seemed to be affecting her ability to walk and stand for long durations, and a power scooter was reasonable. The occupational therapist notes the enrollee does not require a mobility device inside the home, but the enrollee stated she needed it for stores that do not provide mobility devices and for vacation. The enrollee reports she can only walk very short distances. Literature shows significant health and safety issues with the use of motorized mobility scooters, including the potential for deconditioning with the exacerbation of underlying chronic conditions, and the potential for operator and pedestrian injuries due to unintended collisions. Studies also demonstrated long-term use of these devices resulted in detrimental effects on cardiovascular performance and insulin resistance, with a resultant increased risk of diabetes prevalence. The requested power scooter is not considered medically necessary for the members medical condition and intended utility. Her home is not power scooter accessible, nor does she intend to use the power scooter at home. Use within the community is considered a convenience, and not for medical needs. Furthermore, the medical records do not support why a manual wheelchair is contraindicated.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 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 similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for transcranial magnetic stimulation (TMS) for treatment of the enrollees behavioral health condition. Findings:  The physician reviewer found that the submitted documentation and medical literature support the services at issue in this clinical setting. TMS is a noninvasive brain stimulating procedure utilized in the treatment of major depressive disorder.  The medical literature supports that TMS tends to be well tolerated with fewer barriers than electroconvulsive therapy. Further, the American Psychiatric Association (APA) investigated this treatment option and the available literature. The outcome of the investigation in 2010 was an APA endorsement of TMS for the acute phase treatment of major depressive disorder after failure of at least one antidepressant trial. In this particular case, the patients affective illness was not disputed. The patient had pursued, but not exhausted, other standard therapies used to combat depression. Thus, common alternatives may have also been considered medically necessary as defined by the Health Plan. However, considering the medical records, endorsement from the APA and the expanding peer reviewed literature base, TMS represented a safe and appropriate treatment consistent with standard medical practice. TMS was reasonably expected to improve the patients condition and prevent a more serious episode of illness at the time of service delivery.  As such, TMS received was medically necessary for treatment of the patients medical condition. Final Result: The reviewer determined that the services at issue were 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: Upheld

A 48-year-old male enrollee has requested for inpatient psychiatric treatment and electroconvulsive therapy (ECT) treatment for treatment of his behavioral health problems. Findings:  The physician reviewer found that the Level Of Care Utilization System (LOCUS) for psychiatric and addiction services is useful in determining the medically necessary level of care for adults to insure the level of care provided meets their individual needs, safely and effectively in the least restrictive setting possible. According to those guidelines, the patient presents as follows: his risk of harm is serious; his functional status is moderate; his medical, addictive and psychiatric co-morbidity is significant, his recovery environment is moderate; his recovery environment, level of support is limited; his treatment and recovery history is noted to have been poor; and, his engagement and recovery status is minimal.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for DecisionDx-Melanoma gene assay.  While gene expression profile (GEP) testing has been shown to accurately identify risk of metastasis for patients with cutaneous melanoma, there is a lack of  consensus on how this affects the treatment plan for patients. GEP testing is not considered routine standard of care and is not currently recommended under National Comprehensive Cancer Network (NCCN) guidelines. There is a lack of medical literature supporting its use for the evaluation of patients with thin melanomas. In this case, the course of treatment for this patient would not change based on the results of the GEP testing, as the recommended course of treatment would still be a wide local excision with follow-up skin surveillance and possible sentinel lymph node biopsy. Therefore, the DecisionDx-Melanoma gene assay was not likely to have been more beneficial than any other available standard therapy for the patients medical condition.Findings:  Three of the three physician reviewers found the DecisionDx-Melanoma gene assay  at issue was not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the service at issue was 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 dermatology 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 49-year-old female enrollee has requested Restasis Emulsion 0.05% for the treatment of her dry eyes. Findings:  The physician reviewer found this patient could continue on covered topical lubricant until she is reevaluated again later this month. The physician has reversed his original recommendation for this medication, at least until further evaluation. Therefore, given the prescribing physicians statement that the patient does not require the medication at this time as well as the absence of any objective evidence documenting the need for Restasis, the Health Plans denial was medically appropriate.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for an implantable cardioverter defibrillator (CPT-33249). Findings:  The physician reviewer found that patients with extensive late-gadolinium enhancement may be at increased risk of sudden death, independent of other high-risk features, with implications on management strategies including consideration for primary prevention implantable cardioverter defibrillator therapy. In this case, the patient has several risk factors for sudden death given her history of hypertrophic cardiomyopathy, recurrent syncopal episodes, inappropriate blood pressure response to exercise, a left ventricular aneurysm, and diffuse delayed gadolinium enhancement on MRI. Given the current medical literature, the requested device is medically indicated. Therefore, an implantable cardioverter defibrillator (CPT-33249) is medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested device 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  cardiovascular disease and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

A 65-year-old male enrollee requested authorization and coverage of additional pulmonary rehabilitation therapy. The Health Plan denied the request indicating that the requested therapy is not medically necessary for treatment of the enrollees pulmonary disease.One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer upheld the Health Plans denial on the basis that the requested therapy is not medically necessary.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Norco 10/325 mg one tablet every six hours at four times per day and morphine sulfate 15 mg twice per day for treatment of the enrollees chronic pain.  Findings:  The physician reviewer found that the records demonstrate that this patient is a poor candidate for long-term opioid use. The provider has not included documentation of continued and improved function as a result of ongoing opioid treatment. In addition, the patient reportedly recently failed random urine toxicology tests. The providers recommendation for opioid tapering and enrollment in a dependency rehabilitation program is therefore appropriate. Final Result: The reviewer determined that the requested medications 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 anesthesiology with sub-specialty certification in pain medicine and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

The wife of a 41-year-old male enrollee requested authorization and coverage for 16 hours of daily shift nursing care. The health plan has denied this request indicating that the requested services are not medically necessary for treatment of the enrollees advanced, severe, end-stage ALS.One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer overturned the health plans denial on the basis that the requested services are medically necessary.
Appeal type: Medical Necessity
Decision: Overturned

A 31-year-old female enrollee has requested Flexitouch Pneumatic Compression System for treatment of her lymphedema of both lower extremities secondary to lipedema surgery.  Findings:  The physician reviewer found that in the medical literature, Todd described the treatment of lipedema as involving external compression and in some cases liposuction. Muluk evaluated various types of external pneumatic compression therapies and noted that the simplest provide non-calibrated, non-gradient static compression to the entire limb. The next category has multiple chambers that provide sequential treatment and may or may not have gradient pressure. The author made a distinction between the latter devices and advanced devices that include new generation technology that provides calibrated, gradient sequential inflation with additional features enabling custom treatment to address individual patient needs. The literature shows that pneumatic compression devices are recognized as standard and effective treatment for this patients condition. The patients medical condition requires the recommended Flexitouch system given the successful trial of the device to establish compatibility and ability to use. All told, the medical records support the medical necessity of the requested Flexitouch system for treatment of this patients medical condition.