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 foot orthotics.Plantar fasciitis is one of the most common causes of heel pain seen by foot and ankle surgeons. Approximately 10% to 16% of the population suffer from plantar fasciitis. Plantar fasciitis can be caused by numerous conditions, but most common is a biomechanical change in the subtalar joint placing excessive pressure to the medial column and the plantar fascia. This condition may cause inflammatory or degenerative changes of the fascia and periostitis of the medial calcaneal tubercle.Custom orthotics have been long considered a standard of care for plantar fasciitis. Orthotics are utilized to control the abnormal biomechanics of the foot. The use of custom foot orthotics has been shown to improve short and long-term pain in patients suffering from plantar heel pain. In this case, the patient has been diagnosed with plantar fasciitis which is painful when weight-bearing on the right side. The patients current orthotics do not appear to be sufficient to control the patients abnormal calcaneal eversion. Thus, the provider recommended that the patient receive a new pair of foot orthotics to control the foot and help alleviate the painful plantar fasciitis. The new orthotics would control the abnormal resting calcaneal stance position, alleviating pressure from the plantar fascia. Under these circumstances, the requested foot orthotics are medically necessary to treat the patients medical condition.Final Result: The reviewer determined that the requested medical equipment 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 podiatry and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for an Orthovisc (hyaluronic acid) injection, once weekly for four weeks, in the left knee. 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 is unable to take NSAIDs or corticosteroid injections due to a cardiovascular condition and has failed treatment with acetaminophen. Given the patients limited options, with the alternative being a total knee arthroplasty, and based on the current medical literature, the requested services are medically indicated. Therefore, an Orthovisc (hyaluronic acid) injection, once weekly for four weeks, in the left knee, 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 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

The enrollees parent requested reimbursement for lab work. The enrollee has neuro-immune syndrome, emotional dysregulation, mood lability, acute onset of cognitive dysfunctions and memory lapses. There is also concern for seizures as she had a previously abnormal electroencephalogram. The enrollees pediatric neurologist ordered laboratory tests and a prolonged, ambulatory video electroencephalogram to evaluate for seizures and encephalopathy. Research shows there is no evidence to support the usefulness of the requested tests for the evaluation of new seizures or behavioral changes. The medical records do not provide any clinical indication for these tests. The appropriate and evidence-based recommendations for evaluating possible immune encephalopathy do not include these laboratory studies. There is no literature to support these tests in the evaluation of children with suspected auto-immune encephalitis. In addition, researchers noted that while antibody positive and negative enrollees had similar clinical features, the response to treatment was unrelated to antibody status.Final Result: Two of the three reviewers determined that the requested services were not likely to have been more beneficial than any available standard therapy for treatment of the enrollees medical condition. Credentials/Qualifications: Three reviewers are board certified in neurology 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: Upheld

A 57-year-old male enrollee has requested outpatient mental health sessions provided twice per week (rather than the approved frequency of once per week) for treatment of his behavioral health issues. Findings:  The physician reviewer found that according to the American Psychiatric Association (APA) criteria for outpatient therapy, this patient did not present with a need for a higher frequency of sessions necessary to stabilize a crisis. In addition, there was no expectation of progress in treatment given that this patient has been in therapy for a prolonged time period at the same frequency. Further, the providers goals were described as primarily for providing support and were focused on addressing chronic symptoms and behaviors. All told, the therapy services provided twice per week for this patient have not been established as medically necessary for the management of his OCD, anxiety, and depression.
Appeal type: Medical Necessity
Decision: Upheld

A 57-year-old female enrollee, with a body mass index of 40.1, has requested authorization for the medication Xenical. Findings:  The physician reviewer found that Pharmacotherapy for weight reduction should be used as an adjunct to significant diet therapy and participation in a weight loss program. The patient should be enrolled in a structured diet program a six-month period prior to consideration of Xenical.
Appeal type: Medical Necessity
Decision: Upheld

A 50-year-old male enrollee has requested a power wheelchair for treatment of his foot pain, neuralgia, and difficulty ambulating.  Findings:  The physician reviewer found the documentation provided for review does not support the medical necessity of a power operated vehicle (POV) for this patient. Applying the Centers for Medicare and Medicaid Services (CMS) guidelines, the determination of medical necessity for a POV is based on the following criteria: 1) the patient is unable to ambulate independently with use of an assistive device; 2) the patient does not have sufficient upper extremity function to propel a manual wheelchair; 3) the patient has demonstrated the ability and willingness to safely operate a POV; 4) a POV is needed to perform in-home MRADLs; and 5) the patients residence will accommodate such a device. In the case under review, records indicate that the patient is ambulatory and able to perform his mobility-related activities of daily living (ADLs) without the use of a power wheelchair. Therefore, the patient does not meet these criteria for the medical necessity of a power wheelchair.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Doptelet (20 mg once daily). In a phase III randomized study, Jurczak and colleagues report that avatrombopag (brand name Doptelet) was well tolerated and efficacious for the treatment of chronic immune thrombocytopenia (ITP). In this case, the patient has a diagnosis of ITP and experienced significant rectal bleeding despite treatment with intravenous immunoglobulin (IVIG). In this clinical setting, given that the patients ITP is associated with significant bleeding symptoms, the requested medication is medically indicated. Therefore, Doptelet (20 mg once daily) is medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested medication is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in internal medicine and in allergy and immunology 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 the 3D x-ray breast tomosynthesis for evaluation of her palpable finding and heaviness in the right upper quadrant.  Three physician reviewers found that while there is a lack of long-term studies demonstrating increased survival rates correlated with the use of digital breast tomosynthesis as a part of screening mammography, recent data have shown great promise of the technique due to a decrease in repeated imaging and an increase in the detection of small cancers. The technique has been particularly useful in cases of very dense breast tissue where the utility of standard mammography alone is limited due to breast density. For these reasons, the use of digital breast tomosynthesis in this patient was likely to have been more beneficial than standard screening mammography alone. 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

Nature of Statutory Criteria/Case Summary: A female enrollee has requested authorization and coverage for Harvoni 90/400 mg tablet for the duration of 12 weeks for treatment of the enrollees hepatitis C virus. Findings:  The physician reviewer found that according to the joint guidelines issued by the American Association for the Study of Liver Diseases (AASLD) and the Infectious Diseases Society of America (IDSA), all patients with chronic hepatitis C should be treated except those with limited life expectancy due to non-liver-related conditions. In patients with decompensated cirrhosis, guidelines recommend treatment with Harvoni with ribavirin for 12 weeks. This recommendation is based on the SOLAR-2 trial, which demonstrated efficacy in this population.  Zepatier is not recommended by the AASLD/IDSA guidelines for treatment of genotype 1, hepatitis C in patients with decompensated cirrhosis or severe hepatic impairment. Studies of Zepatier have not included patients with this level of liver disease, except for a series in which a patient with Child Turcotte Pugh Class B cirrhosis died a month after treatment with Zepatier. For these reasons, the requested treatment with Harvoni 90/400 mg tablet for the duration of 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.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Veltassa. Findings:  The physician reviewer found that records provided for review document that this patient presents with a history of hyperkalemia and end-stage renal disease. Treatment has included hemodialysis three times per week as well as recurrent hospitalizations. The patients provider has recommended continued treatment with Veltassa based on the patients positive response since starting therapy in June 2021. The provider also noted that the patient is not a candidate for treatment with Lokelma. In the medical literature, Kovesdy and colleagues found that patients receiving chronic hemodialysis responded well to long-term Veltassa treatment with Veltassa. For these reasons, the requested Veltassa is medically necessary for treatment of this patient.Final Result: The reviewer determined that the requested medication is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in internal medicine with subspecialty certification in nephrology 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 authorization and coverage for right sacroiliac (SI) joint fusion. Findings:  The physician reviewer found that the requested procedure is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The standard of care when evaluating a patient for surgery is obtaining a detailed history and performing a detailed physical, neurologic, orthopedic, and vascular exam to rule out other reasonable causes of pain. In this case, a detailed history and physical examination was not provided for review. The x-rays and CT scans report a fracture of L4, loosening pedicle screws, spondylolisthesis at L4-5, and right hip osteoarthritis. These are potential sources of chronic low back pain that have not been ruled out. Thus, the patients pain generator has not been identified. A single SI joint injection with a positive response does not support the SI joint as the pain generator. Moreover, SI fusion is indicated for tumors, fracture, infection, and correction of spinal deformities. There are no indications for SI fusion for chronic back pain. For the reasons provided, the request for right SI joint fusion is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Final Result: The reviewers determined that the requested procedure 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 reviewers are board certified in neurological surgery and are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Vemlidy 25 mg for treatment of the enrollees chronic hepatitis B virus. Findings:  The physician reviewer found that guidelines for the treatment of hepatitis B from the American Association for the Study of Liver Diseases (AASLD) recommend entecavir and tenofovir compared with alternatives for the treatment of chronic hepatitis B. In comparison with tenofovir disoproxil fumarate (Viread), which the patient is taking, the Vemlidy formulation of tenofovir is effective for hepatitis B, but is associated with lower incidence of side effects such as osteopenia and renal disease. On Viread, this patient with vitamin D deficiency may develop osteopenia in the future. For this reason, the request for Vemlidy 25 mg is medically necessary for the treatment of this patients chronic hepatitis B. 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 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.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for lumbar arthroplasty. Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested services. This patient presents with a longstanding history of low back pain with current left lower extremity symptoms into the calf and dorsum of the foot. Clinical examination documented positive nerve tension signs and sensory deficit consistent with electrodiagnostic evidence of S1 radiculopathy. Imaging documented single level degenerative disc disease at L5-S1 with a left disc herniation abutting the L5 nerve roots and traversing left S1 nerve root. There is no evidence of spondylolisthesis or facet arthropathy. Evidence-based guidelines do not recommend artificial disc replacement for patients with evidence of nerve root compression. The U.S. Food and Drug Administration (FDA) approval document for the ProDisc-L device states that patients with radicular compression syndromes, especially due to disc herniation, are to be excluded from use of this device. This patient presents with clinical examination and imaging and electrodiagnostic evidence of S1 nerve root compression which would be an exclusion from the use of this device. Therefore, the requested lumbar arthroplasty is not medically necessary for the treatment of 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 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 parent of a 14-year-old female enrollee has requested reimbursement and prospective authorization and coverage for residential treatment services provided from a specific date and onward. Findings:  The physician reviewer found that review of the documentation from the patients current treatment team indicates that she comes from a social environment that is not conducive to recovery. Specifically, it has been reported that the patients father continues to abuse substances and encourages the patient to do so. Additionally, the patients past history indicates that she engages in risky behaviors if her depression is not well controlled and she is non-compliant with treatment. Moreover, the patient has refused to attend school. Based upon these factors, the patient meets accepted guidelines for treatment at a residential level of care. Accordingly, the disputed services were and are medically appropriate and necessary for treatment of this patients condition.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested mental health residential treatment program for treatment of the enrollees major depressive disorder.  Findings: The physician reviewer found that the request for a 30-day mental health residential treatment program is not medically necessary for treatment of the patients medical condition. Although episodic placement at higher levels of care is often necessary, modern psychiatric practice aims to place patients in the least restrictive treatment setting to optimize treatment gains and foster autonomous resilience. In this case, the record does not support the medical necessity of placement in a structured and contained residential treatment setting. Despite the diagnoses of depression and anxiety, the patient does not have psychosis, suicidality, or substance use. He is cooperative, engaged in treatment and well-supported by family. He has made modest progress in treatment thus far. The documentation provided for review does not detail prior interventions tried and failed such as a psychiatric/psychological evaluation, serial progress notes, mental status evaluations, clinical rating scales and clinician assessments would be useful in demonstrating the longitudinal illness burden, and its refractoriness. Moreover, it does not appear that standard therapies have been exhausted in this case. The application of cognitive behavioral therapy is an evidence-based intervention for major depressive disorder, however, other therapies such psychodynamic therapy and interpersonal therapy share similar endorsement and may represent reasonable alternatives. Further, the there is no mention of wellness- and community-based interventions, such as exercise, support groups, mindfulness and meditation, which can capitalize on therapeutic gains and meaningfully address at least some impairing symptoms. Although treated with psychotropic medication, there is no report of past trials which introduces the possibility that an alternative standard pharmacologic regimen may be effective. In addition, there is a lack of evidence that specialty services provided in an intermediate setting would be inadequate, inappropriate or unsuccessful based on the patients condition and reported clinical progress with outpatient services. In sum, residential treatment is not medically necessary for the treatment of the 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 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.