Persius/imr-appeals huggingface dataset:
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for spinal distraction device procedure. Interspinous process decompression offers an intermediate step in the continuum of care for patients with neurogenic intermittent claudication associated with lumbar spinal stenosis. The Coflex device is a titanium alloy interlaminar device designed to fit between two adjacent spinous processes in the lumbar spine. The U.S. Food and Drug Administration (FDA) approved indications for Coflex is one- or two-level lumbar stenosis from L1 to L5 producing at least moderate impairment in skeletally mature patients. The FDA specified that patients should have failed at least six months of non-operative treatment. One randomized controlled trial conducted in patients with grade I or lower spondylolisthesis showed that stabilization of a decompression with a Coflex implant was non-inferior to decompression with spinal fusion. However, the health benefit of fusion in this patient population remains unconfirmed. Until the results of higher quality trials become available, the use of a Coflex implant cannot be recommended over laminectomy, which is considered the gold standard for lumbar spinal stenosis. All told, the requested spinal distraction device procedure is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.One reviewer found that the requested spinal distraction device procedure is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: Two of the three 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:  One reviewer is board certified in orthopedic surgery and is actively practicing. One Reviewer is board certified in orthopedic surgery and is actively practicing.  One Reviewer is board certified in orthopedic surgery and is 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: Experimental/Investigational
Decision: Upheld

A 54-year-old female enrollee has requested prolotherapy for treatment of her low back pain. Findings:  Two physician reviewers found that the review of the record shows that the patient sustained a sports injury which resulted in chronic low back pain. She has undergone treatment with multiple modalities of treatments, including lumbosacral stabilization exercises, oral analgesics, sacroiliac joint bracing and activity modifications. She also has undergone multiple diagnostic and therapeutic procedures including sacroiliac joint and facet joint injections and medial branch blocks which have only provided her with minimal relief. The evidence-based use of dextrose prolotherapy for musculoskeletal pain was investigated by Hauser and colleagues who determined that there is Level I and II evidence to support the use of dextrose prolotherapy for osteoarthritic pain and function, tendinopathies, myofascial pain syndrome, and sacroiliac pain. They also concluded that there was Level III evidence in support of the use of dextrose prolotherapy for diffuse musculoskeletal pain involving the spine, pelvis, and peripheral joints. However, the evidence in this article was not assessed systematically and the methodologic quality assessment of the studies was not carried out. Additionally, studies performed by Chou, et al. and Cusi, et al. found that prolotherapy was not effective in the treatment of sacroiliac joint pain. Overall, the evidence in the peer reviewed medical literature demonstrating the efficacy of prolotherapy is limited, in terms of large, multicenter, double-blind studies. Further, the studies that have shown prolotherapy to be effective have a patient population that differs from this patients case
Appeal type: Experimental/Investigational
Decision: Overturned

A 64-year-old female enrollee has requested authorization and coverage for radiofrequency neurolysis of the thoracic spine. The Health Plan has denied this request indicating that the requested services are considered investigational for treatment of the enrollees lumbosacral spondylosis with neck and back pain with radiation down the upper and lower extremities.   Findings:  Two physician reviewers found that given the documentation of facet arthropathy shown as the pathological cause through the physical exam, MRI and the patients positive response to the cervical facet blocks, the requested radiofrequency neurolysis of the thoracic spine is likely to provide this patient with a greater health benefit than treatment with any available therapy.
Appeal type: Medical Necessity
Decision: Upheld

enrollee has requested authorization and coverage for a referral to a nephrologist. Per the Kidney Disease Improving Global Outcomes (KDIGO) Guidelines, referral to a nephrology specialist is indicated when:1. There is acute renal insufficiency (stage 4/5) or abrupt fall in GFR (GFR < 30);2. There is consistent finding of significant albuminuria;3. Progression of chronic kidney disease (CKD)  GFR decline > 25% from baseline;4. Blood in urine not easily explained;5. CKD and refractory hypertension- refractory to 4 or more antihypertensive agents6. Persistent abnormalities of serum potassium;7. Recurrent or extensive nephrolithiasis; or8. Hereditary kidney diseaseHere, the patient does not have acute renal failure or stage 4/5 renal insufficiency. There is no evidence of significant albuminuria, recurrent or extensive nephrolithiasis or hereditary kidney disease. The patients GFR and potassium were both recently tested and found to be within normal ranges. The patient also has no history of refractory hypertension. While the patient does have a history of blood in urine, this can be attributed to the removal of a bladder stone. KDIGO criteria for a nephrology referral have not been met. Therefore, a referral to a nephrologist is not medically necessary for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a one-year-old female enrollee has requested for physical therapy for treatment of the enrollees developmental delay.  Findings:  The physician reviewer found that Effgen and McEwen advocate in favor of the positive effects of PT for patients with delays greater than 33%. The authors recommend PT for continued improvement in gross-motor skills acquisition, prevention of secondary disability, and to improve fine motor control and overall muscle strength. In addition, Strubhar and colleagues found that the long-term benefits of PT help to minimize impairments in motor coordination and learning (Strubhar, et al).  The requested PT services have been established as medically necessary in the management of her hypotonia and related gross motor delays.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for left shoulder surgery (CPT codes 29826, 29824, and 29806). Researchers found subacromial decompression to be safe effective for patients with impingement syndrome. Studies concluded that limited distal clavicle excision of patients with acromioclavicular (AC) joint osteoarthritis resistant to conservative treatment reduced the pain and improved the shoulder function in this patient population. This patient presents with persistent left shoulder pain following an initial traumatic shoulder dislocation injury. She has reported two additional dislocation events while dressing as well as ongoing limited function and range of motion. Clinical examination findings are consistent with imaging evidence of an anterior inferior labral tear, small Hill-Sachs lesion, moderate AC joint osteoarthritis, and impingement morphology. She has failed to improve despite reasonable conservative treatment, including activity modification and medications. Current evidence-based medical literature supports surgical intervention for this patient given the recurrent dislocations, marked loss of range of motion, positive apprehension sign, imaging findings, and failure to improve over at least three months with conservative therapy. All told, the requested left shoulder surgery (CPT codes 29826, 29824, and 29806) is 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: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Jardiance 25 mg tablets. Findings:  The physician reviewer found that Jardiance is SGLT-2 agonist agent that has been U.S. Food and Drug Administration (FDA) approved for management of type 2 diabetes. Starting SGLT-2 inhibitor is helpful to improve glycemic control in patients with established type 2 diabetes. SGLT-2 agent therapy can also be started at any stage of the disease as long as the patient does not have significant renal disease. Dual therapy with metformin and SGLT-2 inhibitor is recommended by the American Association of Clinical Endocrinologists (AACE) for management of type 2 diabetes. Per the clinical documentation provided, this patient was recently started on metformin therapy without substantial improvement in his type 2 diabetes. His renal function is adequate to support Jardiance therapy. For these reasons, the requested Jardiance 25 mg tablets is medically necessary for treatment of this patients medical 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 internal medicine with sub-specialty certification in endocrinology, diabetes and metabolism 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 patient has requested authorization and coverage for ZTLido. The Health Plan denied the request and reported the requested medication is not medically necessary for the treatment of this patient. At issue in this case is whether ZTLido is medically necessary for the treatment of the patients medical condition. Reviewers reported that topical lidocaine plasters have been approved as first or second- line therapy for the treatment of post-herpetic neuralgia in the United States. Other reviewers reported in two uncontrolled, open label studies that included patients with moderate-to-severe low back pain, treatment with the lidocaine 5% plaster for six weeks significantly reduced both the intensity of the pain and its impact on the patients quality of life. These topical approaches are generally well tolerated. Per the authors, pharmacokinetic interactions with concomitant oral medications are minimal due to low systemic exposure. Researchers reported topical lidocaine demonstrated excellent risk/benefit ratios, safety, tolerance, and continued efficacy throughout long-term treatment for localized neuropathic pain. In this case, the patient reported neck and back pain and is taking numerous medications for pain relief. Avoiding additional oral systemic agents is appropriate. The medical evidence supports the requested medication in this clinical setting. Therefore, ZTLido is medically necessary for the treatment of this patient. 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 neurology 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 35-year-old male enrollee requested authorization and coverage of sinus surgery. The Health Plan denied the request indicating that the requested procedure is not medically necessary for treatment of the enrollees sinus problems. One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer upheld the Health Plans denial on the basis that the requested procedure is not medically necessary.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested retroactive authorization and coverage for Afirma Gene Expression Classifier for evaluation of the enrollees thyroid nodule.  Findings: Two physician reviewers found that thyroid nodules are commonly managed by diagnostic FNA to evaluate the cytopathology (Hamberger, et al). In this case, the finding by this standard technique was atypia of undetermined significance (Baloch, et al). This diagnostic category creates a dilemma with regards to recommended surgery. This patient was facing total thyroidectomy if malignancy was present and but only subtotal thyroidectomy if the lesion was benign. Hence, the sample was submitted for the Afirma gene expression testing for analysis. In a large study of over 500 patients, 6-14% of patients with atypia of undetermined significance were found to have malignancy on pathology review but no mutation in several known oncogenic pathways (Nikiforov, et al). In contrast, the Afirma gene expression test has demonstrated a very high negative predictive value for malignancy (Alexander, et al; Chudova, et al). Since unnecessary thyroid surgeries may be prevented by implementation of the gene expression test, the use of the Afirma Gene Expression Classifier was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Final Result: Two reviewers determined that the testing 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 internal medicine with sub-specialty certification in medical oncology and are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

A 45-year-old male enrollee has requested a tertiary multidisciplinary cancer care center for treatment of his metastatic head and neck squamous cell carcinoma.  Findings:  The physician reviewer found that the submitted documentation supports the medical necessity of the requested services at a tertiary multidisciplinary cancer care center that includes a physician specializing in head and neck oncology.  This patient has recurrent metastatic disease.  He has been empirically tried on standard regimens.  In this clinical setting, the standard of care would be to consider a clinical trial and to be managed by a multidisciplinary team that would include a medical oncologist, head and neck surgeon, and palliative care.  This is best accomplished by a National Cancer Institute Designated Cancer Center.  All told, the requested services are medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for a power wheelchair and components. The records indicate that the patient has multiple chronic medical conditions but her primarily mobility-related issue is thoracolumbar scoliosis. This is a condition that can be addressed conservatively, but can also significantly benefit from surgical intervention. The patient has no documented impairments that preclude the use of a manual wheelchair for accomplishing mobility-related activities of daily living. Therefore, a power wheelchair and components are not medically necessary for this patient.Final Result: The reviewer determined that the requested equipment 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 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: Upheld

A 51-year-old female enrollee requested authorization and coverage of gastric bypass surgery with duodenal switch for the treatment of morbid obesity.  The Health Plan denied the enrollees request indicating that the requested treatment is not medically necessary.One physician reviewer performed a medical necessity Independent Medical Review.  The physician reviewer upheld the health plans denial on the basis that the requested procedure is not medically necessary for treatment of the patients medical condition.
Appeal type: Urgent Care
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for ambulance transportation services provided. The Health Plan has denied this request indicating the services at issue were not necessary for treatment of an emergency medical condition.The ambulance transportation services provided were not necessary for treatment of an emergency medical condition. The patient was experiencing abdominal pain. The patient also had been experiencing small amounts of intermittent blood in his stool. The patient had a history of similar symptoms a year ago and suffered from constipation. There was no vomiting or diarrhea. The patient had normal vital signs and was in no distress. The patients airway was patent and lungs were clear. The onset of abdominal pain without other symptoms does not meet criteria for emergency medical services.Final Result: The reviewer determined that the patient did not receive emergency medical services on the date of service at issue. 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 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 is a 42-year-old female with a body mass index (BMI) of 40.4 and significant comorbid conditions.  She has completed a psychological evaluation and was deemed a suitable candidate for weight loss surgery. The Health Plan has denied coverage for gastric bypass surgery on the basis it is not medically necessary for treatment of the patients morbid obesity.With a BMI of 40.4 and comorbid conditions such as sleep apnea, hypertension, arthritis, and gastroesophageal reflux disease (GERD) the patient meets nationally accepted medical necessity criteria for consideration of weight loss surgery. It is highly likely that gastric bypass will be beneficial for this patient. Furthermore, the patient does not require further dietary workup prior to undergoing weight loss surgery. There is no scientific evidence demonstrating that structured diet or exercise plans have been successful in the treatment of the morbidly obese. In fact, the Swedish obesity study identifies that even though there may be reduction or resolution of some symptoms with diet and exercise, surgery has the longest and best long-term outcome for the morbidly obese. Therefore, I have determined the requested surgery is medically necessary for treatment of the patients medical condition. The Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Overturned

A 42-year-old male enrollee has requested a podiatrist consult for treatment of her calcaneal spur.  Findings:  The physician reviewer found that in this patients case, his treating provider has recommended follow-up care with a podiatrist.  X-rays were ordered due to swelling to his posterior heels.  The x-rays confirmed posterior calcaneal spurs, which can cause significant pain.  The Health Plan has indicated that conservative care has not been attempted.  However, this conservative care, including foot inserts, ice or NSAIDs, must be instituted and monitored by a podiatrist.  The requested podiatrist consult is within the accepted standards of medical practice in this clinical situation.  The submitted medical documentation establishes the medical necessity of the requested services.  All told, the requested podiatrist consult is medically indicated in this patients case.
Appeal type: Experimental/Investigational
Decision: Overturned

The parent of a 15-year-old female enrollee has requested DeNovo NT Natural Tissue Graft for treatment of the enrollees osteochondral defect in the medial facet of the patella.  Findings:  Two physician reviewers found that in this patients case, the services at issue were likely to have been of greater benefit than other available treatment alternatives.  This patient had a large osteochondral defect involving the entire medial facet.  There was also deep involvement of the subchondral bone, which the provider addressed through bone graft.  There is a lack of options for the treatment of the combination of full thickness cartilage loss and lack of supporting bone.  There is adequate support in the current medical literature for the services at issue in this clinical setting.  All told, DeNovo NT Natural Tissue Graft was likely to have been more efficacious than other modalities for the treatment of this patient.