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

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested authorization and coverage for in-home private duty nursing. Findings:  The physician reviewer found that the records document that this patient has multiple medical problems due to his CHARGE syndrome and intellectual disability. The documentation provided indicates that he is not medically stable as he is immunosuppressed, and has had at least one inpatient hospitalization for pneumonia and streptococcal pharyngitis. He requires constant adult supervision due to his intellectual disability, as he can become agitated during interventions. The patient has obstructive sleep apnea, asthma and congenital airway abnormalities requiring him to wear CPAP. He also requires gastrostomy bolus feeds and diaper changes. These treatments require 24-hour monitoring to prevent him from removing the device. His two primary caregivers are in poor health, and it is unrealistic for them to provide constant 24-hour nursing care for the patient. In the medical literature, the complexities and difficulties faced by families caring for chronically ill children, and describe the importance of the provision of in-home nursing care. Recommendations for in-home nursing care for chronically ill children are also outlined in the position statement issued by the American Academy of Pediatrics. Although the providers recommendation for 16 hours per day of in-home private duty nursing is not medically necessary, the medical records support 10 hours per day of in-home private duty nursing seven days per week. Final Result: The reviewer determined that a portion of the requested services are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be partially overturned. Credentials/Qualifications: The reviewer is board certified in pediatrics and neurology with special qualification in child neurology and sub-specialty certification in hospice and palliative 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

A male enrollee requested embolization of hepatic artery and surgical removal of cancerous pancreatic tumor (possible Whipple procedure for medical treatment of his pancreatic cancer.  Findings:  The physician reviewer found that surgical resection of all local/regional disease with negative margins is the only potential treatment to offer a modest chance at long-term survival.   Surgical resection and reconstruction of the common hepatic artery is an option for those rare patients with localized pancreatic cancer of the head/neck of the pancreas to provide a modest chance at long-term survival that would otherwise not be achieved with chemotherapy alone In sum, the request for embolization of hepatic artery and surgical removal of cancerous pancreatic tumor (possible Whipple procedure) is medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Euflexxa injections of the right knee. 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 routine 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, there is no history of prior viscosupplementation. However, the patients remaining treatment options are limited, and a corticosteroid injection was only effective for a few days. Furthermore, the patient does not wish to undergo total knee arthroplasty for the treatment of mild osteoarthritis. Given this support, the requested Euflexxa injections of the right knee 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: Overturned

The patient is a 44-year-old female with a body mass index (BMI) of 41. She has comorbid conditions of hyperlipidemia and sleep disturbance. She has requested authorization for gastric bypass surgery. The Health Plan has denied the patients request. She has undergone a psychological evaluation and is considered an appropriate candidate for weight loss surgery.With a BMI of 41 the patient meets nationally accepted medical necessity criteria for consideration of weight loss surgery. In addition, the patient has undergone a psychological evaluation and is considered an appropriate candidate for weight loss surgery. Furthermore, scientific evidence does not show that structured weight management plans consisting of diet and exercise have been successful in the treatment of the morbidly obese. The study referenced above demonstrates that surgery has the best long-term outcome for the morbidly obese. Therefore, I have determined that the requested procedure is medically necessary for treatment of the patients medical condition. The Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for brand name timolol maleate preservative-free ophthalmic solution 0.5% (Timoptic Ocudose).Many patients develop adverse reactions to glaucoma medications. According to medical literature, the preservative benzalkonium chloride (BAK) is one of the main culprits for these reactions. Further, medical literature state that the use of BAK can lead to ocular discomfort, poor intraocular pressure control, glaucoma surgery failure, and decreased patient compliance. Medical literature state that preservative-free treatment, like timolol, reduced dry eye symptoms and improved compliance. In this case, the use of preservative-free timolol has been shown to be tolerated by the patient and effectively lowered ocular pressure. Records also indicate that the patient has had adverse reactions to the timolol preparation with preservative in the past. Therefore, brand name timolol maleate preservative-free ophthalmic solution 0.5% (Timoptic Ocudose) is medically necessary for the treatment of the 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 ophthalmology 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 Synvisc-One injection for both knees.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 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. As such, the Academy does not currently support viscosupplementation as standard treatment for osteoarthritis of the knees. 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 patients options are limited. The patient has tried and failed other conservative treatments, including corticosteroid injections, with the alternative being total knee arthroplasties for `moderate` degenerative changes. Under these circumstances, the requested Synvisc-One injection for both knees is medically necessary to treat the patients medical condition.Final Result: The reviewer determined that the requested services are 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 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 a continuous passive motion (CPM) machine. There is a lack of evidence in current medical literature supporting the use of a CPM machine following total knee replacement. Chen and colleagues note that while total knee arthroplasty can alleviate pain and improve range of motion, aggressive CPM does not provide additional benefits. Harvey and colleagues explain that CPM is applied by a machine that passively and repeatedly moves the knee through a specified range of motion and may be included in rehabilitation following knee arthroplasty. However, based on data from 24 randomized controlled trials including 1,445 total study subjects, the authors concluded that CPM does not have clinically important effects on active knee flexion range of motion, pain, function or quality of life to justify its routine use. Trzeciak and colleagues note that while there may be a beneficial effect from CPM on subjective assessment of pain level, joint stiffness and functional ability, CPM has no significant advantage in terms of improving clinical measurements. Given the lack of support for the use of CPM following a total knee replacement in influencing clinical outcomes, the equipment at issue was not medically indicated. Therefore, the CPM machine was not medically necessary for the treatment of this patient.Final Result: The reviewer determined that the equipment at issue was 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: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary:  An enrollee has requested a lab test (infectious disease HCV 6 assays) for evaluation of her medical condition.  Findings:  Two physician reviewers found that hepatitis C recurrence in this case had already been excluded, and liver-related blood studies proved normal. Prior liver biopsy showed no fibrosis, and no contemporary imaging testing was provided to support concern for either fatty liver or for occult fibrosis to warrant FibroTest. The use of FibroTest is generally reserved for assessment, by non-invasive means, to measure the degree of liver fibrosis in patients with active viral hepatitis C, or in those with biopsy-proven non-alcohol steatohepatitis (NASH) and neither condition of which is supported by the patients available record. As such, the lab test (infectious disease HCV 6 assays) was not likely to be more beneficial for evaluation of the patients medical condition than already performed standard assessments. Final Result: Two 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:  All three reviewers are board certified in internal medicine with sub-specialty certification in gastroenterology and are actively practicing. All three reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a one-year-old male enrollee has requested for physical therapy for treatment of the enrollees hypotonic cerebral palsy and partial complex epilepsy.  Findings:  The physician reviewer found that in the study by Hielkema and colleagues, the authors combined a family centered approach with a motor approach. Blauw-Hospers and Hadders-Algra concluded that the type of intervention that might be beneficial for infants at preterm age differs from the type that is effective in infants who have reached at least term age. Preterm infants seem to benefit most from intervention that aims at mimicking the intrauterine environment, such as newborn individualized developmental care and assessment program (NIDCAP) intervention. After term age, intervention by means of specific or general developmental program has a positive effect on motor development. In a related article by the same authors, they noted that coping with and caring for infants with special needs (COPCA) was more beneficial for the development of sitting behavior and cognition than traditional pediatric physiotherapy. In addition, Anttila and colleagues concluded that due to limitations in methodological quality and variations in population, interventions and outcomes, mostly limited evidence on the effectiveness of PT interventions is available through randomized controlled trials. Overall, moderate evidence was reported as showing the effectiveness of upper extremity training. Since PT is supported as improving patient outcomes in the rehabilitation of patients with cerebral palsy, the requested physical therapy is medically necessary.
Appeal type: Experimental/Investigational
Decision: Upheld

A 40-year-old male has requested approval for physical movement therapy (electrical muscle treatment) for treatment of his medical condition status post stroke.   Findings:  Three physician reviewers found that the patient is status post right middle cerebral artery cerebrovascular accident (CVA) a little over one year ago secondary to a traumatic carotid artery dissection with residual left-sided spastic hemiparesis. The patients upper extremity has dense spastic plegia and lower extremity strength is antigravity. A physical movement therapy device (PMTD) by Flexiciser has been prescribed as a home therapeutic device to improve the patients functional mobility and activities of daily living (ADLs).  Although there is some preliminary evidence suggesting that passive motion exercise may result in improved cardiovascular fitness, there is a lack of scientific evidence supporting its efficacy to promote motor or functional recovery following stroke (Wee). As noted by Lum and colleagues, Robotic devices for movement therapy are moving closer to becoming commercially available tools for aiding in stroke rehabilitation. However, the clinical value of stroke therapy systems are still being studied and any improvement in patient outcomes has not been established. Therefore, based on the current medical literature, it is unlikely that the requested device is likely to be more beneficial for the patients condition than standard therapy.
Appeal type: Medical Necessity
Decision: Upheld

The patient's parent is requesting Nutropin AQ Nuspin (a growth hormone) for idiopathic (unknown cause) short stature ISS. The patient is below the percentile for age and height prediction of 5% and there is a family history of short stature with mid-parental height. The patient has normal growth and maturity factors and no known underlying disease. His growth factor (IGF-1) is normal. Growth hormone in the treatment of ISS is supported by randomized controlled trials and consensus guidelines. Federal Drug Administration approval for this indication is for non-growth hormone-deficient short stature, defined by height less than or equal to -2.25 standard deviations, and associated with growth rates unlikely to permit attainment of adult height in the normal range, in pediatric patients whose epiphyses are not closed and for whom diagnostic evaluation excludes other causes associated with short stature that should be observed or treated by other means. The patients pretreatment height is not less than or equal to -2.25 standard deviations. The IGF-1 is normal.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 pediatric endocrinology 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: Experimental/Investigational
Decision: Overturned

A 64-year-old male enrollee requested a positron emission tomography (PET) scan for medical evaluation of his memory disturbance.  Findings:  Three physician reviewers found that this patient has documented cognitive impairment and conventional imaging showing atrophy. The use of PET scan in this scenario has proven to be a beneficial functional imaging tool in establishing the diagnosis of Alzheimer disease differentiating the disease from frontotemporal dysplasia.  Therefore, the requested PET scan is likely to be more beneficial for evaluation of this patients medical condition than any available standard therapy.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/ Case Summary:  The enrollee is requesting reimbursement for lumbar spine disc replacement surgery and in-patient hospital services. The enrollee has a long-standing history of low back pain. He has a history of a L4-L5 left micro discectomy. He underwent micro-discectomy for a herniation of the nucleus pulposus. The enrollee had a reduction of low back pain after the procedure, but it returned and it was worse. He has had physical therapy, nerve blocks, epidural injections, acupuncture, and radiofrequency facet denervation. These treatments were ineffective. The enrollee underwent an anterior lumbar approach discectomy at L3-L4-L5; followed by placement of the M6 lumbar artificial discs at both levels. There is no evidence that disc replacement reliably, reproducibly, and over long periods of time fulfills the three primary aims of clinical efficacy, continued motion, and fewer adjacent segment degenerative problems. Total disc replacement has been associated with a high rate of re-operations, and the potential problems that may occur with longer follow-up have not been fully documented. Total disc arthroplasty has been associated with substantial morbidity and even mortality. Literature shows that, while there is a large amount of data to support the short-term outcomes of total disc replacement surgery, it is important to note that most of the data concern single-level studies. Data on multilevel disc replacement are more limited.  The alternate approaches described in studies involve hybrid approaches with one level disc replacement and one level fusion. This highlights the uncertainty surrounding multilevel disc replacement. Lumbar total disc replacement was developed with the goal of preserving motion and avoiding fusion-related complications, but the relative merits of single versus multiple level procedures remain unclear. Final Result: The reviewer determined that the requested services were not medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The physician reviewer is board certified in neurosurgery 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

The patient is a 27-year-old male who had an 18-month history of low back pain. He underwent an MRI scan which revealed a small disc bulge at L5-S1, and a technetium-99 bone scan which was essentially normal. The patient was referred for facet injections which provided no relief and subsequently he was treated with a sacroiliac (SI) joint injection under fluoroscopy which provided pain relief. The patients request for reimbursement for the SI joint injection was denied by the Health Plan based upon a determination that the procedure was not medically necessary.Based upon a review of the records, is does not appear that the patient had significant radiculopathy or that he underwent a course of conservative therapy prior to the SI joint injection. In situations such as this one, a trial if anti-inflammatory medications, analgesics, physical therapy or chiropractic manipulation is generally appropriate. Conservative measures should have been exhausted prior to any course of interventional injection therapy being performed. Therefore, I have determined the procedure at issue was not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Experimental/Investigational
Decision: Upheld

A 67-year-old female enrollee has requested for an Oncotype DX tumor assay for evaluation of her history of breast cancer. Findings:  Three physician reviewers found that Oncotype DX assay is a 21-gene assay that has been shown to predict the risk of recurrence of a patients breast cancer if treated systemically with hormonal therapy alone, without chemotherapy. In the appropriate patient the test is no longer considered investigational and is an accepted standard of care in the oncology community. However, there is no data as to its usefulness in answering the clinical question being asked in this situation, i.e., whether an aromatase inhibitor after tamoxifen would be useful.