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

An enrollee has requested reimbursement for intravenous immune globulin (IVIG) and prospective authorization and coverage for intravenous immune globulin (IVIG) to be received monthly going forward.Findings:  Three physician reviewers found that there is limited high-quality data on the management of recurrent pregnancy loss. Currently, therapeutic recommendations are largely based upon clinical experience and data from observational studies. In this patients case, the records document recurrent pregnancy loss, and her provider has recommended intravenous immune globulin (IVIG) therapy. Systematic reviews have not demonstrated a beneficial effect of immunotherapy for the treatment of recurrent pregnancy loss.  Colleagues performed a systematic review of 20 trials, and the authors noted that immunotherapy did not result in a statistically significant improvement in live births compared to untreated controls. Treatment with intravenous immune globulin was included in this study. Therefore, IVIG was not likely to have been superior over other available treatment options. Additionally, the superior efficacy of future IVIG to be received monthly going forward has not been established.Final Result: The reviewers determined that the services at issue were not and 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: Physician reviewers 1, 2 and 3 are board certified in obstetrics and gynecology 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: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for MAKOplasty knee surgery for treatment of the enrollees knee pain status post left knee arthroplasty.  Findings:  The physician reviewer found that MAKOplasty is a robotic assisted system to help the surgeon improve the alignment of unicompartmental and total knee arthroplasties. A review of the literature indicates no superiority with regard to the functional outcome with MAKOplasty compared to a standard unicompartmental or total knee arthroplasty. Although the robotic systems can help improve lower leg alignment, component positioning and soft tissue balancing, studies have shown no functional superiority in outcomes compared to conventional unicompartmental or total knee arthroplasties. The study by Blyth and colleagues concluded that robotic arm-assisted surgery results in improved early pain scores and early function scores in some patient reported outcomes measures, but no difference was observed at one year post-operatively between the robotic arm-assisted and conventional procedures. Similarly, the review by van der List and colleagues also does not indicate any superiority with regard to functional outcome with the robotic arm-assisted arthroplasty. In light of the foregoing, MAKOplasty has not been established as superior to conventional unicompartmental or total knee arthroplasty in the peer-reviewed literature. Concerning the bicompartmental knee replacement, the literature recommends a total knee arthroplasty instead due to inconsistent pain relief with the bicompartmental arthroplasty and a significantly higher complication rate. As such, the request for MAKOplasty knee surgery is not likely be more beneficial for the treatment of the patients medical condition than standard cold packs. Final Result: Two of three reviewers determined that the requested surgery is 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: Physician reviewer number one 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.Physician reviewer number two 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.Physician reviewer number three 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 is requesting for speech therapy services for their medical condition of autism. Findings:  The physician reviewer found that She has received speech therapy since at least 2014. In 2014, the patients score on the Expressive One-Word Picture Vocabulary Test (EOWPVT) was 89, with a test age equivalent of eight years 11 months. In 2016, the patients EOWPVT score was 130, with a test age equivalent 14 years eight months. Also in 2016, a Receptive One Word Picture Vocabulary Test (ROWPVT) score was 105, with a test age equivalent of 11 years two months. In 2018, the patients EOWPVT score was 78, with a test age equivalent of seven years one month and a ROWPVT score of 105, with a test age equivalent of 11 years two months. The patient received eight sessions of adult speech therapy in 2018. On 8/6/18, the patient could correctly identify opposites six of 10 times and identify the remaining four opposites with maximal prompting. She correctly answered seven out of 10 picture memory questions and three of six general information questions. The patients speech therapist recommended discharge from speech therapy and implementation of a home-based program. At issue in this case is whether the requested speech therapy services are medically necessary for treatment of the patients medical condition. The influence of pragmatic language abilities on social function and in resolving interpersonal conflicts with peers needs to be considered in children with autism, and further development of therapy plans and interventions targeting pragmatics is strongly needed. Most cases of specific language impairment are diagnosed in childhood. The patient has received speech therapy since at least 2014. She has not made consistent progress according to her scores on the EOWPVT and ROWPVT, and had a deterioration in her scores from 2016 to 2018, despite receiving speech therapy. Based on the current guidelines, home-based speech therapy is appropriate for this patient. Therefore, the requested speech therapy services are not medically necessary for this patient. 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 pediatrics, neurology with special qualification child neurology, and 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: Upheld

A 50-year-old female enrollee has requested authorization and coverage of the medication Miacalcin. The Health Plan denied the request indicating that the requested medication is not medically necessary for treatment of the enrollees osteopenia.One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer upheld the Health Plans denial on the basis that the requested medication is not medically necessary.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Euflexxa injection series (J7323) in both knees. Evidence from systematic reviews and randomized controlled trials support 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 patient reportedly experienced substantial relief from prior Euflexxa injections on multiple occasions. Furthermore, the patients remaining treatment options are limited. The patient has tried and failed other conservative treatments including non-steroidal anti-inflammatory drugs (NSAIDs) and physical therapy, with the alternative being surgery. For these reasons, the requested Euflexxa injection series (J7323) in both knees 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

Standard Review Fulfills requirements of (1374.33) (h)(1)(D)A transgender male enrollee has requested authorization and coverage for phalloplasty surgery. The Health Plan has denied this request indicating that the requested services are not medically necessary and are not reconstructive in nature for treatment of the enrollees gender dysphoria.  Credentials/Qualifications: The reviewer is board certified in plastic 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. Nature of Statutory Criteria/Case Summary: The submitted documentation demonstrates the medical necessity for the requested services in this clinical setting. The patient is well-documented to have gender dysphoria. Thus, his external anatomy should be more consistent with a male than a female. The patient has undergone bilateral mastectomy as part of his surgical transition to a male.  He is noted to have begun hormonal therapy with testosterone treatment. Although he may have had some gaps in his testosterone therapy, he has been evaluated by mental health providers who have assessed him to be a good candidate for phalloplasty.  In this patients case, the medical necessity for the requested services has been adequately supported in the documentation provided. This patient began hormonal therapy in 2009 and has taken irreversible steps towards his transition. Therefore, the requested phalloplasty is medically necessary for the treatment of this patients gender dysphoria.With regard to whether the requested services are considered reconstructive in nature, the submitted documentation demonstrates that the patients condition constitutes an abnormal body structure. Based on the patient's diagnosis of gender dysphoria, lack of male genitalia should be considered abnormal. Is the abnormal structure of the body caused by any of the following: congenital defects, developmental abnormalities, trauma, infection, tumors or disease? Yes, the abnormal structure is due to the fact that the patient has a diagnosis of gender dysphoria and has not had adequate development of male genitalia. Is the requested surgery being performed to do either of the following: improve function or create a normal appearance to the extent possible? Yes, phalloplasty would help to create a more normal appearance. Does the surgery provide more than a minimal improvement in the appearance of the patient? Yes, the proposed phalloplasty would be expected to provide significant improvement in the patients appearance. Final Result: The reviewer determined that the requested services are medically necessary and are reconstructive in nature for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.
Appeal type: Experimental/Investigational
Decision: Overturned

A 58-year-old female enrollee has requested intravenous immunoglobulin (IVIG) for the treatment of her Behcets disease. Findings:  Three physician reviewers found that at this point in the patients illness, the use of infliximab would certainly have to be considered, but as noted in the patients providers letter, the previous trial of etanercept was associated with recurrent major infections, and was further complicated by the patients allergies to various antibiotics. The reference to the patients reported mouse allergy also raises a novel concern with specific regard to the mouse-derived component of infliximab. As a result, the use of any other TNF inhibitor could pose major risks to this patient, and the decision to recommend IVIG instead of another TNF inhibitor is appropriate.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for L5 and S1 decompression and fusion treatment of the enrollees lumbar spondylosis with bilateral foraminal stenosis at L5-S1 with bilateral radiculopathy. Findings:  The physician reviewer found that in the peer-reviewed medical literature, researchers noted that lumbar fusion is a commonly performed procedure for the treatment of painful instability of the spine, usually manifest as chronic low back pain. This patients medical records do not include evidence of instability, fracture, or tumor. In addition, there is no significant neurologic deficit on physical examination to support an indication for lumbar fusion or lumbar decompression. Final Result: The reviewer determined that the requested surgery 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 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: An enrollee has requested authorization and coverage for Saxenda for treatment of the enrollees obesity. Findings:  The physician reviewer found that pharmacotherapy can be added to lifestyle interventions in patients with a BMI of 30 kg/m2 or greater regardless of health history or patients with a BMI of greater 27 kg/m2 and one additional cardiovascular risk factor, such as diabetes, hypertension, or hyperlipidemia. The U.S. Food and Drug Administration (FDA) approval of Saxenda followed several randomized controlled trials demonstrating its safety and efficacy in obese or overweight patients. This patient meets the criteria for the addition of an anti-obesity pharmacological agent as his BMI is over 30 kg/m2, he has comorbidities including hyperlipidemia, metabolic syndrome, and sleep apnea, and has not lost weight with diet. His provider has prescribed Saxenda. He already has responded to Saxenda with a weight loss of 10 pounds. Since treatment should be made available early in the disease to prevent irreparable complications, the requested Saxenda is supported as medically necessary for treatment of this patients obesity. 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: Experimental/Investigational
Decision: Upheld

A 43-year-old female enrollee requested authorization and coverage of a non-myeloablative allogeneic bone marrow transplant. The Health Plan denied the request indicating that the requested therapy is considered investigational for treatment of the enrollees recurrent metastatic breast cancer.Three physician reviewers performed an experimental/investigational Independent Medical Review. Two of the three physician reviewers concluded that the requested therapy is not likely to be more beneficial for treatment of your medical condition than any available standard therapy. One of the three physician reviewers concluded that the requested therapy is likely to be more beneficial for treatment of your medical condition than any available standard therapy. Because two of the three  physician reviewers concluded that the requested therapy is not likely to be more beneficial for treatment of the enrollee's medical condition, the Health Plans denial has been upheld.
Appeal type: Medical Necessity
Decision: Upheld

A female enrollee requested epidural steroid injections for medical treatment of her degenerative joint disease. Findings:  The physician reviewer found that the records document that this patient has attempted physical therapy in the past with documented aqua therapy. MRI demonstrated degenerative disc disease, with vacuum disc, foraminal narrowing and arthropathy with spondylisthesis. However, the provider noted that the patients pain is mainly into the low back and buttock, and it does not appear that this patient has pain from radiculopathy. Without documented radiculopathy or radiculitis, the use of epidural steroids in this case is not indicated. All told, the requested ESI are not medically necessary for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld

The patient is a 47-year-old woman who underwent gastric bypass surgery for morbid obesity with comorbid diabetes. The patient is seeking surgical treatment of hanging skin and soft tissue resulting from the weight loss. She remains an insulin dependent diabetic but is attempting further control with weight loss and exercise. The patient was examined by a plastic surgeon who recommended a panniculectomy be performed. In addition, the patient wishes to undergo an abdominoplasty and brachioplasty. The Health Plan indicates the requested abdominoplasty and brachioplasty are considered cosmetic in nature and are not medically necessary.The submitted documentation including photographs of the patients trunk reveals findings of a small umbilical hernia and some irritation beneath the pannus. The pannus does not reach the pubis. The trunk and arms demonstrate redundant hanging skin. A panniculectomy has been authorized to treat the patients large pannus. The patient has been examined by a plastic surgeon without findings of medical necessity for abdominoplasty or brachioplasty. Thus, there is no indication that the requested procedures are medically warranted in order to treat clinical symptoms or functional complaints. Therefore, I have determined that the requested procedures are not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The parent of a 14-year-old male enrollee has requested reimbursement for the residential treatment services. Applying the child and adolescent level of care utilization system (CALOCUS), the residential treatment services were not medically necessary for treatment of this patients behavioral health issues. The patient presented with some risk of harm (score 2) due to his history of impulsive actions and running from home which could place the patient at some risk for unintentional self-harm. However, the medical records indicate that the patient was not actively suicidal. The patient demonstrated moderate functional difficulties (score 3) with a history of school disruption due to substance use. The patient had mild co-morbidity (score 2) as he did not have active serious medical problems but had a history of substance use. The patients recovery environment was mildly stressful (score 2) given his positive recovery environment and stable housing situation. The patients recovery environment was supportive (score 2) as the patients father was actively involved in treatment. The patient had limited response to prior treatment (score 3) with minimal history of outpatient treatment consisting of three months of treatment and no community-based intensive forms of treatment. The patient was constructive in treatment (score 2) as he was noted to participate in therapy and used coping skills learned in therapy. The patients parents were constructive (score 2) as they worked actively and constructively with the patients providers. This gives the patients presentation a composite score of 18 which correlates with intensive outpatient services. According to the CALOCUS, the patient would need to have a score of 23-28 in order to require treatment in an RTC. In summary, the patient could have been safely and effectively treated in a less restrictive setting. Thus, the services at issue were not medically necessary. 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 psychiatry with sub-specialty certification in child and adolescent psychiatry and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

The parent of a 14-year-old male enrollee has requested sub-acute residential care for the treatment of the enrollees disorders. Findings:  The physician reviewer found that A review the record indicates that the patient is indeed severely disturbed with a complex set of psychiatric and developmental disturbances. He has been given a great deal of expert care in the recent past. However, his progress throughout the course in the residential setting was minimal or even non-existent. He did not progress in the classroom, his social interactions remained poor, and his misbehaviors continued almost unabated.  He did not respond well to interpersonal therapy, correction or redirection.  I agree with the idea of a therapeutic boarding school. Such a facility may more effectively meet the patients needs.