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 Synvisc One injection in both knees.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 and desires to delay total knee arthroplasties. There is sufficient support for the requested services in this clinical setting. Therefore, Synvisc One injection in both knees are medically necessary for the 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: Urgent Care
Decision: Upheld

Nature of Statutory Criteria/Case Summary:  The parent of an enrollee requested air ambulance services on an emergent basis.  The physician reviewer found that an air ambulance is considered medically indicated under certain circumstances such as when the point of pickup is inaccessible by land or there is a great distance or obstacle involved in land transport, when the time needed to transport the patient by land poses a threat to a patients survival, or when the proper equipment needed for the patient is not available on a land ambulance. A patient might also require air ambulance services in order to be transferred from one facility to another in order to receive specialized services such as trauma care or a burn unit. This patient was transported to a facility for non-emergent treatment of her eating disorder, not for emergency complications of her condition. Thus, a prudent layperson would not have believed her health was in serious jeopardy in the absence of immediate medical attention. Accordingly, air ambulance services were not required on an emergent basis for treatment of this patients medical condition. Final Result:  The reviewer determined that the patients symptoms did not meet prudent layperson criteria for emergency care. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications:  The reviewer is board certified in emergency medicine and is actively practicing.  The reviewer is knowledgeable in the treatment of the enrollees medical condition and the proposed treatment, and familiar with guidelines and protocols in the area of the treatment under review.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary:  An enrollee has requested Repatha for treatment of his medical condition. Findings:  The physician reviewer found that based on the records provided, the patient has hyperlipidemia. However, there is a lack of documentation submitted for review demonstrating obstructive coronary disease (no angina and no ischemia on stress testing). In this clinical setting, incremental addition of a PCSK9 inhibitor such as Repatha is not medically necessary and not considered the standard of care in the medical community. There is no documentation that the patient has heterozygous familial hypercholesterolemia. Heterozygous familial hypercholesterolemia usually manifests by a combination of physical exam findings (arcus cornealis below the age of 45, tendon xanthomatas) and LDL- cholesterol levels that are at minimum above 150 mg/dl. None of the above is documented in the medical records provided. In addition, there is no evidence the patient has obstructive coronary vascular disease. PCSK9 inhibitors have been studied in and approved for patients with heterozygous familial hypercholesterolemia or for patients with documented obstructive coronary heart disease who require additional lowering of LDL-cholesterol. This patient does not fit any of those criteria. Also, current guidelines endorsed by several national organizations do not recommend the use of PCSK9 inhibitors in this setting. 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 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: Overturned

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested intensive outpatient psychiatric (IOP) level of service for treatment of the enrollees behavioral health condition. Findings: The physician reviewer found that the review of the submitted documentation demonstrates the medical necessity of IOP services. The patient requires IOP to prevent an exacerbation of symptoms. A letter from the patients therapist demonstrates that the patient regressed and relapsed when treatment was not continued at the IOP level. As the patients provider indicates, the patient needs the structure of an intensive outpatient program as he is not able to comply with treatment recommendations at home. Additionally, the patients family also requires the structure of IOP level of care to maintain compliance with instructions and provide adequate support to the patient. All told, the medical necessity of the IOP level of care has been established in this case.  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 physician reviewer is board certified in psychiatry with sub-specialty certification in child and adolescent 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

This case involves a 13.5-year-old female with idiopathic/familial short stature who is being followed by a pediatric endocrinologist. She was 4 9.5 tall in October 2005 and had a bone age read at 13 years in July 2005.  Her predicted adult height was 410.5. Her parents were 56 (father) and 55 (mother) giving her a potential height of 53. Her workup information included a normal in-utero karotype of XX, normal IGF-I (284), normal IGFBP-3 (4.2), normal thyroid testing and robust growth hormone (GH) responses to arginine-clonidine stimulation testing. The Health Plan denied authorization for GH therapy on the grounds that it is not medically necessary.Although the patient does not have a growth hormone deficiency, she does meet the FDA criteria of July 2003 for the use of growth hormone therapy in the treatment of idiopathic short stature. It is predicted she will not achieve an adult height of 411 and is unlikely to reach her mid-parental height prediction. Since GH therapy was begun relatively late in her adolescent, the endocrinologist intends to use Lupron along with GH therapy to delay the closure of the epiphyses and extend the growth period. The use of GH therapy in this clinical setting is medically appropriate and indicated.Based upon the information set forth above, I have determined the requested therapy is medically necessary for treatment of the patients medical condition. The Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Upheld

A 36-year-old male enrollee requested magnetic resonance imaging (MRI) of the shoulder for evaluation of his shoulder pain.  Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested services.  The records noted shoulder pain of three weeks duration.  There is no documentation of an orthopedic consultation.  X-rays have been negative for any skeletal lesion.  While MRI is an important adjunct to clinical assessment, there needs to be a clinical examination and patient history prior to MRI.  Although there is documentation of a prescription for an anti-inflammatory, there is a lack of documentation of other aspects of conservative care.  All told, the requested MRI of the shoulder is not medically indicated for the evaluation of this patient.
Appeal type: Experimental/Investigational
Decision: Overturned

A male enrollee requested genetic testing for medical evaluation of his rectal cancer. Findings:  Two physician reviewers found that in patients diagnosed with colon cancer at a young age the odds of carrying a HNPCC mutation are increased, and as such, the revised Bethesda criteria recommend screening for HNPCC, with IHC and/or MSI, in any individual diagnosed with colon cancer younger than age 50. In this regard, the patient is eligible for screening with MSI and/or IHC. In cases where tumor tissue is not available for screening with MSI or IHC, it would be reasonable to proceed directly to genetic screening of the HNPCC-related genes. Screening for other non-HNPCC related genes included in the ColoNext panel has no proven clinical role, and are not clinically indicated. Testing for epithelial cell adhesion molecule (EPCAM) gene mutations, which are implicated in HNPCC, are not relevant in this case given that the IHC screen was intact. In sum, testing for HNPCC-related deleterious gene mutations of MLH1, PMS2, MSH2, and MSH6 were clinically indicated and likely to be more beneficial than other modalities. However, the other non-HNPCC related genes in the panel do not demonstrate a clinically proven role and were not likely to be more beneficial for evaluation of the patients medical condition than other modalities.
Appeal type: Experimental/Investigational
Decision: Overturned

An enrollee has requested authorization and coverage for Acthar 80 unit/mL gel. Adrenocorticotropic hormone, such as repository corticotropin injection (HP Acthar gel), is currently indicated for the treatment of patients with multiple sclerosis relapses. This patient has profoundly demyelinating multiple sclerosis. Timely and effective resolution of multiple sclerosis relapse is critical to minimizing residual deficits, which can result in neurologic disability. Alternatives to oral and intravenous corticosteroids include HP Acthar gel, plasmapheresis, and intravenous immunoglobulin. Acthar gel is a viable choice for patients who are unable to tolerate traditional therapies. Both methylprednisolone and HP Acthar gel have demonstrated efficacy in reducing short-term disability after exacerbations of multiple sclerosis. The rate of neuropsychiatric side effects observed in Acthar gel patients is low. The data support Acthar gel as a viable alternative for the treatment of acute exacerbations of multiple sclerosis, particularly in patients who have a history of neuropsychiatric disorders. All told, Acthar 80 unit/mL gel is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Findings:  Three of the three physician reviewers found the requested Acthar 80 unit/mL gel is 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 medication is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: Physician reviewers 1, 2, and 3 are board certified in neurology 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: Urgent Care
Decision: Overturned

A 29-year-old female enrollee has requested for emergency services on an emergent basis. Findings:  The physician reviewer found that the prudent layperson standard applies to distress that reasonably requires urgent medical therapy or diagnosis. The patient in this case, who was pregnant, was in sufficient distress to seek medical attention. Given the lack of alternative options, it was reasonable for her to seek treatment at a local hospital. Pruritis, as with pain, is a subjective matter and cannot be readily quantified. As such, its severity, as interpreted by the patient cannot be discounted as non-urgent just because no life threat was indentified. Additionally, there are a number of potentially severe medical conditions that can present with itch  with or without apparent rash. Pregnancy can also complicate matters by broadening the diagnostic considerations (e.g., cholestasis of pregnancy). Likewise, pregnancy can complicate therapy.
Appeal type: Experimental/Investigational
Decision: Upheld

A 56-year-old female enrollee has requested for Electron Beam Computed Tomography (EBCT) for evaluation of her coronary condition. Findings:  Three physician reviewers found that cardiac CT scan is able to detect coronary artery calcification present in artherosclerotic plaque but not in the wall of normal arteries.  Studies have demonstrated only a moderate increased risk for hard cardiac events associated with calcification detected in high-risk asymptomatic patient populations. Additionally, even large amounts of calcium do not necessarily imply the presence of significant stenosis.  There is a lack of outcome data showing calcium scoring impacts the quality or quantity of life.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for tofacitinib citrate (Xeljanz XR) 11 mg TB24 for treatment of the enrollees rheumatoid arthritis. Findings:  The physician reviewer found that the available medical records do not adequately document failure of treatment with methotrexate nor do they document any trial and failure of at least two biologic agents such as Humira, Enbrel, Remicade, or Simponi. The current medical literature supports first-line therapy with these biologic agents as effective for most patients with rheumatoid arthritis. On the basis of this lack of documentation, the request for treatment with tofacitinib citrate (Xeljanz XR) 11 mg TB24 is not supported as medically necessary for treatment of this patients rheumatoid arthritis. 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: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for Botox injection. There is sufficient support for the services at issue in this clinical setting. This patient has spasmodic torticollis and cervical dystonia. She has had pain which has persisted for more than six months. Cervical dystonia is a U.S. Food and Drug Administration (FDA) approved indication for Botox injections. Randomized controlled trials have supported its use in cervical dystonia. Therefore, Botox injection was likely to have been of greater benefit than other treatment options. Findings:  Two of the three physician reviewers found the services at issue were likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned.Final Result: The reviewers determined that the services at issue were likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: Physician reviewers 1, 2 and 3 are board certified in anesthesiology with sub-specialty certification in pain medicine 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 53-year-old female requested authorization and coverage for a DEXA scan.  The health plan has denied this request indicating that the requested scan is not medically necessary for treatment of the enrollees osteoarthritis.One physician reviewer performed a medical necessity Independent Medical Review.  The physician reviewer upheld the health plans denial on the basis that the requested treatment is not medically necessary.
Appeal type: Experimental/Investigational
Decision: Overturned

The parent of a 16-year-old male enrollee has requested Remicade for treatment of the enrollees idiopathic immunological disorder. Findings:  Three physician reviewers found that the patient suffers from a very rare disorder which is not well understood or well controlled at the present time. It is not surprising that Remicade has not been specifically approved for the treatment of such a rare condition. The patients provider is appropriately concerned about the consequences of long-term treatment with oral steroids for this young patient. The proposed trial of Remicade to treat the patients acute exacerbation is theoretically sound and likely to be helpful in the management of his symptoms.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary:   An enrollee has requested Viekira Pak and ribavirin for treatment of her hepatitis C.  Findings:  The physician reviewer found that according to the most recent guidelines, all patients with chronic hepatitis C, regardless of fibrosis, should be treated except those with limited life expectancy due to non-liver-related comorbid conditions.  Per the guidelines, treatment-naive genotype 1a patients should be treated with Viekira Pak and ribavirin.  The current guidelines cite data showing increased survival with earlier treatment.  For these reasons, the requested treatment with Viekira Pak and ribavirin is supported as medically necessary for the treatment of this patients hepatitis C infection.  Final Result: The reviewer determined that the requested medications 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 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 authorization and coverage for magnetic resonance imaging (MRI) of the lumbar spine (CPT code 72148 MRI, spinal canal and contents, lumbar, without contrast). Findings:  The physician reviewer found that medical literature supports obtaining an imaging study when it will change the course of therapy.  The correlation between magnetic resonance findings and clinical symptoms require strict clinical correlation. The American College of Radiology (ACR) has established appropriateness criteria to evaluate various clinical presentations, including low back pain.  The guidelines indicate that imaging patients with acute low back pain of less than six weeks duration and no red flag symptoms provide no clinical benefit (ACR Appropriateness Criteria). The ACR also notes, [I]nterestingly, the size and type of disc herniation and location and presence of nerve root compression were not related to patient outcome. A recent study found no statistically significant difference in primary outcome after 1 year for older adults who had spine imaging within 6 weeks after an initial visit for care for LBP versus similar patients who did not undergo early imaging. It is well documented that imaging patients with chronic LBP is often not beneficial and similar imaging findings are often present in asymptomatic individuals. Additionally, patients with new episodes of LBP and previous MRI scans are unlikely to detect changes in disc protrusion, annular fissures, high-intensity zones, or end-plate signal changes with repeated MRI. In this clinical setting, routine radiographs, while generally obtained, are not helpful.   Moreover, conservative management for this patient has not been documented. Final Result: The reviewer determined that the requested services are not medically necessary for evaluation of 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.