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

A 57-year-old male enrollee has requested further testing of the cataract in his right eye for treatment of his right eye cataract.  Findings:  The physician reviewer found that the submitted records indicate that the patient has seen three in-plan ophthalmologists. All of these providers have strongly recommended against cataract surgery in the patients right eye, due to an extremely poor prognosis, as well as concerns over risk. A review of the medical records reveals no indication that further testing is likely to yield any clinical information that would alter this patients management. In the absence of any data demonstrating that the patient is a viable candidate for cataract surgery, further testing/evaluation is not warranted. Therefore, I agree with the Health Plans denial of this patients request for coverage for further testing.
Appeal type: Experimental/Investigational
Decision: Overturned

A 46-year-old female enrollee has requested bronchial thermoplasty for treatment of her asthma. Findings:  Two physician reviewers found that the requested services are likely to be more effective than other available treatment options.  Bronchial thermoplasty may be indicated for patients with severe persistent asthma.  Based upon the medical records, this patient is an appropriate candidate for this procedure based upon her recurrent exacerbations and lack of control on maximal therapy.  This procedure is likely to lead to reduced exacerbations.  All told, bronchial thermoplasty is likely to be more efficacious than other available alternatives in this clinical setting.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for 4Kscore blood test (CPT 81539). The 4Kscore test incorporates four prostate-specific kallikrein assay results and clinical information to calculate an individual patients percent risk for aggressive prostate cancer on prostate biopsy. The 4Kscore test might be helpful for patients with an abnormal PSA or abnormal digital rectal examination (DRE) prior to initial or repeat prostate biopsy to identify the risk of high-grade prostate cancer. The National Comprehensive Cancer Network (NCCN) guidelines recommend considering a 4Kscore test prior to biopsy for patients with an elevated PSA and risk factors. However, the NCCN guidelines do not consider the test as the standard of care for all patients with elevated PSA. Furthermore, current data have not demonstrated that the 4Kscore improves patient health outcomes in randomized studies when compared to standard risk assessment. Hence, use of 4K score is not considered a clinically appropriate standard of care in the routine screening for prostate cancer in this patient with an elevated PSA, who has not undergone a prostate biopsy. All told, the 4Kscore blood test (CPT 81539) was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Findings:  Three of the three physician reviewers found the 4Kscore blood test (CPT 81539) was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the services at issue were not likely to be more beneficial for evaluation 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 urology 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

The parent of a 12-year-old male has requested approval for NordiFlex  for treatment of his diagnoses of short stature and small for gestational age.   Findings:  The physician reviewer found that although this patients length at birth was more than two standard deviations below normal for gestational age, review of his growth chart indicates that his height caught up to the normal curve by the age of three years; thus, he does not meet criteria for GH treatment on the basis of SGA with failure to catch up in growth. Based on the patients bone age assessment and height measurement in July 2011, his estimated final adult height prediction is approximately sixty-four inches, which is on target for his genetic potential and not short enough to warrant GH treatment on the basis of the FDA-approved idiopathic short stature indication. In sum, the patient has a normal IGF-1 level, his bone age is not delayed more than two standard deviations from chronological age, and he has no known morphological abnormality of his pituitary gland; thus, he does not meet medical necessity criteria for GH therapy.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Orthovisc injections for both knees. Per the medical literature, although viscosupplementation may relieve knee pain in some individuals with osteoarthritis, it is not known as to which individuals will benefit. 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 patient has a history of bilateral osteoarthritis. He has tried and failed other conservative treatments with the alternative being bilateral total knee arthroplasties in the presence of morbid obesity with associated increased cardiovascular risk. Given the patients limited options and based on the current medical literature, the requested services are medically indicated. Therefore, Orthovisc injections for 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: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for monitored anesthesia care (MAC) services provided during upper and lower gastrointestinal endoscopic procedures. The current American Society of Anesthesiologists (ASA) guidelines for sedation and anesthesia in gastrointestinal endoscopy recommend that the combination of an opioid and benzodiazepine is a safe and effective regimen for achieving minimal to moderate sedation for upper endoscopy and colonoscopy in patients without risk factors for sedation-related adverse events. The ASA states that, Minimal and/or moderate sedation can be delivered safely by endoscopists to patients who are ASA Class I, II, or III. A review by Wernli and colleagues concluded that, Use of anesthesia service was associated with a 13% increase in the risk of any complication within 30 days. In this case, the patient presented for upper and lower endoscopy. The patient does not have any documentation of significant heart, lung, kidney, or liver disease. There is a lack of detailed description of previous history of difficulties with anesthesia or sedation with past colonoscopies. The patient was given an ASA classification score of 2 and airway score of 1 without evidence that they presented with a difficult airway. The ASA guidelines for sedation and anesthesia in gastrointestinal endoscopy do not support the use of MAC services in this patient in the absence of significant health conditions or airway concerns. The ASA guidelines state that there is high quality evidence to support the use of mild to moderate sedation in uncomplicated endoscopy procedures, such as in this patients clinical setting. All told, the MAC services provided during upper and lower gastrointestinal endoscopic procedures were not medically necessary for this patient. Final Result: The reviewer determined that the services at issue were not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in anesthesiology with subspecialty certification in pain management 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

A 51-year-old male enrollee has requested Rituxan therapy for the treatment of his cerebellar degeneration. Findings:  Two physician reviewers found that there are no large-scale studies documenting the usefulness of Rituxan for a progressive cerebellar process. This being said, there have been some incidental reports speculating about its usefulness in subsets of patients. Given that this patient has autoantibodies by laboratory examination and has responded to Rituxan in the past, continued use of this investigational therapy is medically reasonable and appropriate for his cerebellar dysfunction and related symptoms.
Appeal type: Medical Necessity
Decision: Overturned

The patient has requested authorization and coverage for Orthovisc injections in both knees. Evidence from systematic reviews and randomized controlled trials indicate that although viscosupplementation may relieve knee pain in some patients with osteoarthritis, data has not established which patients will benefit. Guidelines from the American Academy of Orthopedic Surgeons (AAOS) indicate that the data on safety and efficacy of viscosupplementation remain inconclusive. As such, the AAOS does not currently recommend viscosupplementation as standard treatment for osteoarthritis of the knees. Viscosupplementation is reserved for patients with a history of lasting benefit from prior injections and in cases where the remaining options are limited. In this case, the patients treatment options are limited. The patient has tried and failed other conservative treatments with the alternative being total knee arthroplasties. Furthermore, the patient reported excellent results from viscosupplementation provided in the past. All told, the requested Orthovisc injections in both knees are medically necessary for treatment of this patient. Final Result: The reviewer determined that the requested services are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in orthopedic surgery and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for weekly chiropractic services for treatment of severe chronic neck, shoulder, and back pain. Findings:  The physician reviewer found that chiropractic maintenance therapy is defined as a treatment plan that seeks to prevent disease, promote health, and prolong or enhance the quality of life or to maintain or prevent deterioration of a chronic condition. As defined by the Centers for Medicare and Medicaid Services (CMS), when further clinical improvement cannot reasonably be expected from continuous ongoing care, the chiropractic treatment becomes supportive rather than corrective in nature, the treatment is considered maintenance therapy and not considered medically necessary. The records indicate that this patient is receiving chiropractic care but is no longer making active improvement. Given these findings, the requested weekly chiropractic services are not supported as medically necessary for treatment of this patients medical condition. 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 chiropractic 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: Urgent Care
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for emergency medical services.  Findings:  The physician reviewer found that the patient experienced the sudden onset of severe lower back pain radiating to the left leg on the date of dispute On this date the patient was evaluated in the emergency department and discharged. The pain continued to be severe despite taking the prescribed medications. The patient had been instructed to return if symptoms worsened or failed to improve. The patient returned to the emergency department two days later. At that time the patient received imaging studies to rule out a spinal fracture and leg deep vein thrombosis. These entities can be life- or limb-threatening . As such, the services provided on met criteria for emergency medical services. However, the patient did not receive emergency medical services.  The patient returned to the emergency department for additional pain control. The patient had not suffered trauma. The patient denied any symptoms of acute infectious process such as fever. The patient denied any symptoms of spinal cord compression or cauda equina syndrome such as limb numbness or weakness, or bowel or bladder dysfunction. For the reasons provided, the medical services provided on other dates  were not emergency medical services. Final Result: The reviewer determined that the patient received emergency medical services on a portion of the dates of service at issue. Therefore, the Health Plans denial should be partially overturned. 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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for H.P. Acthar Gel 80 units daily for 10 days.The submitted documentation supports that the requested medication is medically necessary. In this case, the patient has relapsing remitting multiple sclerosis. Records reflect that the patient has acute exacerbation of disease with severe fatigue, disabling motion sickness, ataxia, and severe cognitive symptoms. Records indicate that it is difficult for the patient to go an inpatient facility to receive IV steroids. The use of H.P. Acthar Gel is indicated under such conditions where the patient is not able to tolerate steroids or transport to an inpatient facility poses a barrier. Under these circumstances, the requested medication H.P. Acthar Gel 80 units daily for 10 days is medically necessary to treat the patients medical condition.Final Result: The reviewer determined that the requested medication is medically necessary to treat the patient's 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: Overturned

A 56-year-old male enrollee requested authorization and coverage of cataract surgery. The Health Plan denied the request indicating that the requested surgery is not medically necessary for treatment of the enrollees visual acuity.One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer overturned the Health Plans denial on the basis that the requested procedure is medically necessary.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for Optune Tumor Treatment Fields Therapy and prospective authorization and coverage for future Optune treatment.Findings:  Three physician reviewers found that the services in issue were and are likely to be more beneficial for treatment of the patients medical condition than any other available standard therapy. In 2011, the U.S. Food and Drug Administration (the FDA) approved the Optune portable medical device for the treatment of recurrent glioblastoma. The Optune device generates low-intensity alternating electric fields, or tumor treatment fields (TTF). Approval was based on results of a clinical trial that randomly assigned 237 patients to either TTF therapy or chemotherapy. Similar survival was observed in the two groups, and TTF therapy was associated with lower toxicity and improved quality of life. A subsequent open-label randomized trial in patients with newly diagnosed glioblastoma showed prolonged progression-free and overall survival in the group assigned to TTF therapy when used in combination with post-radiation temozolomide. Consensus-based guidelines published by the National Comprehensive Cancer Network (NCCN) include alternating electric field therapy as a treatment option for patients as adjuvant therapy in combination with temozolomide or with recurrent glioblastoma. It has been used alone as well as with other standard therapies such as Avastin, where it is felt to enhance efficacy. Therefore, under the present circumstances, Optune Tumor Treatment Fields Therapy was and 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 services in issue were and are likely to be more beneficial for treatment of the patients medical condition than any other available standard therapy. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: All three physician reviewers are board certified in internal medicine with subspecialty certification in medical oncology, and they 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

Nature of Statutory Criteria/Case Summary: An enrollee has requested residential treatment center (RTC) services for treatment of the his alcohol abuse. Findings:  The physician reviewer found that the records provided for review document that this patient had minimal post-acute withdrawals. He was not a danger to himself or others and he was medically and psychiatrically stable. His medication management did not require RTC level of care. There were no emotional, behavioral, cognitive, impulsive, psychotic, or manic concerns which would have precluded stepping him down to a lower level of care. He has been motivated and engaged in treatment. He is future oriented, becoming increasingly aware of his triggers and the behavior patterns that drive his addiction. He has been utilizing coping skills. His family is supportive and his living environment is conducive to recovery. He has improved and there is a lack of evidence that he would deteriorate if stepped down to a less restrictive level of care. Although he had issues of shame, guilt, and self-identity due to retirement, these could have been addressed in psychotherapy at intensive outpatient program (IOP) level of care, in conjunction with additional community based Alcoholics Anonymous, along with help from his sponsor. Final Result: The reviewer determined that the services at issue were not and 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 psychiatry with sub-specialty certification in addiction 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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Sovaldi and Daklinza for 12 weeks for treatment of the enrollees hepatitis C virus. Findings:  The physician reviewer found that according to joint guidelines issued by the American Association for the Study of Liver Diseases and the Infectious Diseases Society of America, all patients with chronic hepatitis C should be treated except those with life expectancy less than 12 months due to non-liver-related conditions. In treatment naive genotype 3 patients, therapy is recommended with Sovaldi and Daklinza for 12 weeks. This is based on the ALLY-3 study for Sovaldi and Daklinza which showed a cure rate of 97%. Delay in treatment may result in decreased survival. For these reasons, Sovaldi and Daklinza for 12 weeks is supported as medically necessary for the treatment of this patients hepatitis C infection. Final Result: The reviewer determined that the requested medication regimen is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in internal medicine with sub-specialty certification in gastroenterology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.