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 Mohs procedures for the right upper arm basal cell lesion and upper back basal cell lesion (CPT codes 17313, 17314, Q4131, and 15271). The Health Plan has denied this request indicating that the requested procedures are not medically necessary for treatment of the enrollees basal cell carcinoma lesions. Per the American Academy of Dermatology, Mohs micrographic surgery is considered appropriate for aggressive, infiltrating basal cell carcinoma (BCC) to prevent recurrence. Mohs micrographic surgery for superficial BCC is considered indeterminate or insufficient evidence to recommend as appropriate. In this case, the patient has infiltrative basal cell carcinoma on the right upper forearm and superficial basal cell carcinoma on the left upper back. Therefore, the Mohs procedures for treatment of the right upper forearm (CPT codes 17313, 17314, Q4131, and 15271) are medically necessary. The Mohs procedures for treatment of the left upper back (CPT codes 17313, 17314, Q4131, and 15271) are not medically necessary.Final Result: The reviewer determined that some 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 dermatology 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 a home birth. The American College of Obstetricians and Gynecologists (ACOG) Committee on Obstetric Practice note that while each woman has the right to make a medically informed decision about delivery, the ACOG supports the hospital setting for delivery over planned home birth due to the availability of physicians, blood transfusions, antibiotics, anesthesia, and other resources for intensive and emergency maternal and newborn care. While acknowledging that many patients are concerned about leaving their home because of the COVID-19 pandemic, the ACOG continues to recommend existing evidence-based guidance regarding hospitals and accredited birth centers as the safest setting for delivery. In this case, the patient has chosen to receive care from a midwife and is planning a home birth. Based on current medical literature, planned home birth is not medically indicated. Therefore, a home birth is not medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested service is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is board certified in obstetrics and gynecology 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 Norco. The Centers for Disease Control and Prevention (CDC) guidelines state that, clinicians should evaluate benefits and harms of continued therapy with patients every three months or more frequently. If benefits do not outweigh harms of continued opioid therapy, clinicians should optimize other therapies and work with patients to taper opioids to lower dosages or to taper and discontinue opioids. The Federation of State Medical Boards guidelines report that, continuation, modification or termination of opioid therapy for pain is contingent on the clinicians evaluation of (1) evidence of the patients progress toward treatment objectives and (2) the absence of substantial risks or adverse events, such as signs of substance use disorder and/or diversion. The records provided for review document that this patient sustained a non-displaced left tibial fracture. The provider advised that the patient does not need to be evaluated for acute or subacute pain. The provider also reported that the patient is not a good candidate for opioid therapy since the benefits of treatment do not outweigh the potential risks. The records reviewed do not include a current Controlled Substance Utilization Review and Evaluation and System (CURES) report demonstrating continued compliance with her opioid regimen. The CDC guidelines recommend providers to discontinue opioid therapy in patients where the risks outweigh the benefits. Accordingly, the requested Norco is not medically necessary for treatment of this patient. Final Result: The reviewer determined that the requested medication is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The 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: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Otezla. The Health Plan has denied this request indicating that the requested medication is not medically necessary for treatment of the enrollees psoriasis vulgaris.  The submitted documentation supports the medical necessity of the requested medication. Otezla was approved by the U.S. Food and Drug Administration in 2014 and became standard of care around that time.  National guidelines in the United States are not up to date on the treatment of psoriasis, especially given the new discoveries and treatments over the last few years. There are more recently published guidelines in Canada that recommend use of Otezla as first line treatment. This is based on trials which have shown safety and efficacy of Otezla in treating chronic plaque psoriasis. Thus, the medication is currently FDA approved and is safe and effective. There are no step therapy guidelines in existence in the United States, and the choice regarding which systemic treatment a patient is prescribed is based on comorbidities and individual response at this time. The requested medication is medically appropriate in this clinical setting. Therefore, Otezla is 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 dermatology 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 breast tomosynthesis for evaluation of her medical condition.  Findings:  Three physician reviewers found that breast tomosynthesis was likely to be more beneficial for this patient than any available standard modalities. Medical studies have shown that the addition of three dimensional (3D) digital breast tomosynthesis (DBT) reduces false positives and increases cancer detection when compared to two dimensional full field digital mammography (FFDM, 2D) alone. Recall rates are reduced by 15-17%: 3D allows for separation of structures to differentiate architectural distortion from masses and overlapping fibroglandular tissue (asymmetries). Studies have also shown that there has been an increase in cancer detection by 33-53%: cancer detection increased from 6 cancers/1000 women screened with 2D to 8 cancers/1000 women screened with 3D. Three dimensional DBT allows better characterization of possible masses, spiculation, and architectural distortion. In sum, there is sufficient evidence supporting the use of tomosynthesis for this patients routine breast cancer screening. Final Result: Three reviewers determined that the services at issue were 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 reviewers are board certified in diagnostic radiology 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

A fifty year-old female is status post anterior cruciate ligament transplant and now has loss of cartilage and arthritic changes resulting in left knee pain is requesting authorization of Synvisc injections.  Reviewers Findings:  The reviewing physician found that although the patient will eventually require knee replacement, a series of Synvisc injections is the best treatment alternative at this time.  The reviewing physician found that the Health Plan denial should be overturned.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for magnetic resonance imaging (MRI)  of the thoracic spine. The American College of Radiology appropriateness criteria for the evaluation of back pain reports that in a patient with subacute or chronic back pain who is a surgical candidate with persistent symptoms after four to six weeks of conservative management, MRI is considered usually appropriate. Imaging after conservative treatment could affect patient management if intervention is pursued, and may demonstrate disc disease and central canal stenosis among other findings, which may be the cause of the patients symptoms and may prompt intervention. First-line conservative treatment of back pain may include the use of nonsteroidal anti-inflammatory drugs (NSAIDs), physical therapy, or activity modification. If the patient is a candidate for intervention, and the pain persists despite four to six weeks of conservative measures, then MRI imaging may be appropriate. In this case, the submitted records do not document trial and failure of conservative management, specifically the physical therapy for at least four to six weeks. A previous MRI of the thoracic spine demonstrated minimal degenerative changes. There is no indication of trauma since the prior MRI or significant symptoms to suggest a substantial change would be detected on imaging. While the provider has requested an MRI for evaluation of possible arteriovenous malformation (AVM), there is no indication from the prior MRI report of an AVM. Given the lack of documentation regarding the trial and failure of physical therapy, the requested service is not medically indicated. Therefore, MRI of the thoracic spine is not medically necessary for the evaluation of this patient.Final Result: The reviewer determined that the requested service is 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.
Appeal type: Medical Necessity
Decision: Overturned

A 64-year-old female enrollee has requested Hyalgan injections for treatment of her osteoarthritis and severe degeneration of both shoulders.  Findings:  The physician reviewer found that although the use of Hyalgan would be an off-label indication for use in this patient, she has documented severe degeneration in both shoulders. In addition, she has already undergone surgical intervention but continues to experience pain with limitation of function. As there is scientific data supporting the safety and efficacy of Hyalgan for knee osteoarthritis and promise as a modality for the shoulder, it is a clinically reasonable approach to provide the requested treatment to the patient. For the reasons discussed above, I have determined that the requested therapy is medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld

A 38-year-old female enrollee requested a pain management consultation for treatment of her sciatica.  Findings:  The physician reviewer found that the requested pain management consultation is not medically necessary for evaluation and treatment of this patients medical condition. There is lack of documentation of the patients response to conservative therapy, which may be appropriately ordered and assessed by the primary care physician. Conservative therapy includes physical therapy and non-steroidal anti-inflammatory medications. Additionally, the results of the MRI do not demonstrate any pathology requiring a pain management consultation prior to failed conservative therapy.  All told, the requested pain management consultation is not medically necessary for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld

A 57-year-old female enrollee has requested repeat bilateral viscosupplementation (Hyalgan) every 6 months for treatment of her bilateral osteoarthritis of the knees. Findings: The physician reviewer found that the efficacy of Hyalgan as a method of treatment has been supported for several years by level III and level IV studies. Specifically, one study demonstrating the efficacy of viscosupplementation was controlled for selection bias and placebo effect (Jrgensen and colleagues). The researchers randomized 337 patients to a double-blind administration of Hyalgan or saline. The patients were carefully selected to meet the American College of Rheumatology criteria for knee osteoarthritis with a Lequesne algofunctional index score of 10 or greater. The authors concluded that 5 intra-articular injections of hyaluronan did not improve pain or function at 3-, 6-, 9- and 12-month follow-up when compared to the saline cohort. A level I study published by Jubb and colleagues was designed to compare Hyalgan to saline in terms of effect on medial joint space. Of 408 patients randomized in this placebo-controlled trial, no overall treatment effect was observed in the width of the medial joint space. This patient presents with a documented tear of the lateral meniscus. The patient may achieve benefit from an arthroscopic debridement of the torn meniscal fragment preserving as much of the meniscus as possible in an effort to delay further degenerative change. In summary, the requested Hyalgan injections are not medically necessary in this patients care.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary:   An enrollee has requested Otezla therapy for the treatment of his medical condition.  Findings:  The physician reviewer found that there is a lack of support for the requested medication in this clinical setting.  This patient has tried and failed therapy with multiple topical steroids and a topical Vitamin D analogues.  However, he has not been treated with other first-line agents and there are no documented contraindications to any of these therapies.  The Health Plans requirement of a trial and failure of two preferred formulary medications is medically appropriate.  All told, the requested Otezla therapy is not medically necessary for the treatment of this patient.  Final Result: The reviewer determined that the requested medication is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.  Credentials/Qualifications: The reviewer is board certified in dermatology 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 gastric bypass for treatment of the enrollees obesity. Findings:  The physician reviewer found that this patient meets all of the standard nationally accepted criteria for bariatric surgery including the guidelines from the American Society for Metabolic and Bariatric Surgery. The records document morbid obesity with a BMI of 39 and at least one serious obesity co-morbid condition with obstructive sleep apnea. In addition, the patient completed a thorough multidisciplinary evaluation that did not reveal any obvious dietary or behavioral barriers to surgery and also documented completion of supervised dietary efforts for over six months. Final Result: The reviewer determined that the requested surgery 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 surgery with sub-specialty certification in bariatric 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 was diagnosed with left knee osteoarthritis. In December of 2018, the provider noted a left knee x-ray revealed narrowing of the left knee medial joint space that had progressed compared to previous x-rays. The patient received Orthovisc injections to the left knee in June and July 2018. The provider noted prior Orthovisc injections provided significant pain relief. Physical examination findings included tenderness to palpation over the left knee lateral joint line and lateral patella. A left knee steroid injection was administered in July of 2019. The patient has requested authorization and coverage for Orthovisc injections in the left knee. The Health Plan denied the request and reported the requested services are not medically necessary for the treatment of this patient. At issue in this case is whether Orthovisc injections in the left knee are medically necessary for the treatment of the patients medical condition. Review of current medical literature pertaining to viscosupplementation reveals mixed results.  Although viscosupplementation may relieve knee pain in some patients with osteoarthritis, it is not known which individuals will benefit. Viscosupplementation can only be recommended in patients with a history of lasting benefit from prior injections and in carefully selected cases where the options are limited. A clinical trial by a study  found that viscosupplementation increased functional scores in patients with severe osteoarthritis of the knee, especially within three months of injection. In this case, the patient has a history benefit from prior left knee viscosupplementation injections. Furthermore, the options are limited, with the alternative being a total knee arthroplasty. Medical evidence supports the requested services in this clinical setting. Therefore, Orthovisc injections in the left knee 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

The patient is a 32-year-old male who was diagnosed with adenocarcinoma of the esophagus, arising from Barretts esophagus in May 2004. At that time he was noted to have hilar adenopathy. The patient was started on neoadjuvant chemoradiation, receiving 5040 cGy of radiation and two cycles of cisplatin-5FU. An attempt at surgical resection was performed in October 2004, but the patient was found to have military spread of tumor throughout his lungs; therefore, no resection could be performed.The patient was seen at USC and started on chemotherapy consisting of CPT-11 with Taxotere on 11/18/04. After six cycles of this treatment a CT scan revealed progressive disease. At this time, USC has recommended continuing the patients chemotherapy with a new combination to include Gemzar, Xeloda and C225 (Erbitux). Authorization for this treatment has been denied as it is out-of-network and the Health Plan indicates appropriate services can be provided by in-network oncologists.In cases such as this case, there are different opinions as to which chemotherapy drugs should be tried. Many oncologists would favor the choice of Xeloda with Gemzar as both drugs have activity in GI adenocarcinoma. These drugs are readily available in the community setting.The regimen proposed by USC includes the addition of Erbitux. This is a drug approved for use in metastatic colon cancer, either when used along with CPT-11 or as a single agent in those patients who are intolerant of CPT-11. Its use with Gemzar and Xeloda in this patient with esophageal cancer is considered investigational and unproven. There is no medical necessity for treatment with the protocol proposed by USC. The patient can be treated equally effectively by an in-network oncologist. Therefore, I have determined that the requested therapy is not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Experimental/Investigational
Decision: Upheld

A female enrollee requested hyaluronan (Orthovisc) injections for medical treatment of her hip pain.  Findings:  Three physician reviewers found that viscosupplementation is safe and effective for treatment of pain due to osteoarthritis of the knee and temporomandibular joints. However, it is not U.S. Food and Drug Administration (FDA) labeled for osteoarthritis of joints other than knees and temporomandibular joints. Currently, there is a paucity of randomized controlled clinical trials that demonstrate the safety and effectiveness of viscosupplementation of the hip. Based on the literature and American Academy of Orthopaedic Surgeons (AAOS) clinical guidelines, viscosupplementation cannot be recommended as standard treatment in hip osteoarthritis. For these reasons, the requested hyaluronan (Orthovisc) injections are not likely to be more beneficial for treatment of this patients medical condition than any available standard therapy.
Appeal type: Medical Necessity
Decision: Upheld

A 55-year-old male enrollee requested authorization and coverage of a power-operated vehicle (POV). The Health Plan denied the request indicating that the requested equipment is not medically necessary for treatment of the enrollees paraplegia. One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer upheld the Health Plans denial on the basis that the requested equipment is not medically necessary.