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

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for Grafix skin graft procedures. While placental allografts show promise for the treatment of diabetic foot ulcerations, there is a paucity of large prospective randomized controlled clinical trials demonstrating the significant effectiveness of Grafix application in the treatment of surgical incision dehiscence wounds. The current standard of care includes soft tissue and nonviable tissue debridement along with scrupulous cleansing of the wound, antibiotics if needed, and non-weight bearing and/or offloading of the ulcer site. In this patients case, Grafix allograft was used as a supplement to wound debridement for the patients left lower leg surgical incision dehiscence wound. The patient did not have additional risk factors that would have slowed the progression of the wound with standard wound care management. All told, the Grafix skin graft procedures were not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Findings: Two of the three reviewers determined that the services at issue were 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.Final Result: The services at issue were 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:  One reviewer is board certified in podiatry and is actively practicing. One Reviewer is board certified in podiatry and is actively practicing.  One Reviewer is board certified in podiatry and is 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 twenty-three year-old morbidly obese female with multiple comorbid conditions is requesting authorization for laparoscopic Roux-en-Y gastric bypass with cholecystectomy.  Reviewers Findings:The reviewing physician found that laparoscopic Roux-en-Y gastric bypass with cholecystectomy is medically indicated and necessary, the patient will not be able to lose weight and maintain the weight loss through non-surgical means.  The reviewing physician found that the Health Plan denial should be overturned.
Appeal type: Medical Necessity
Decision: Upheld

A 41-year-old male enrollee has requested intensive outpatient program (IOP) level of care services for treatment of his alcohol dependence and cannabis abuse.  Findings:  The physician reviewer found that the records provided for review indicate this patient demonstrated progress in IOP treatment. Specifically, he attended and actively participated in groups, he was involved in Alcoholics Anonymous (AA) and had secured a sponsor. Urine toxicology screenings were negative for illicit substances. In addition, he does not show any impairment in functioning, and there are no comorbid medical or psychiatric conditions. He shows good self care and impulse control. He has remained sober since the said date. He has expressed motivation to change and is a willing participant in this process. While there is the potential for relapse, he has an understanding of issues surrounding relapse. He is in a relationship with his girlfriend who is supportive of his recovery. Based on the American Society of Addiction Medicine (ASAM), this patient does not meet the criteria for IOP services from the date in question and forward. Thus, the patient is a candidate for treatment in the outpatient setting and the services at issue are not supported as medically necessary.
Appeal type: Medical Necessity
Decision: Upheld

A 37-year-old female enrollee requested a comprehensive multidisciplinary diagnostic evaluation to formulate a treatment plan of care for the enrollees Chiari malformation with a cerebral spinal fluid (CSF) leak. Findings: The physician reviewer found that there are no studies that demonstrate improved health outcomes or superior management at a facility that specializes in the treatment of complex Chiari malformations when compared to other centers. Board certified neurologists and neurosurgeons are well-trained to address, diagnose, and manage this patients symptoms even in the setting of a Chiari I malformation. As long as the patient has access to a board certified neurologist and neurosurgeon, a referral to a facility that specializes in the treatment of complex Chiari malformations is not medically necessary for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for a series of three intra-articular injections of hyaluronic acid, a third epidural steroid injection, and celecoxib. Evidence from systematic reviews and randomized controlled trials indicate that although viscosupplementation may relieve knee pain in some patients with osteoarthritis, data has not established which patients will benefit. Guidelines from the American Academy of Orthopedic Surgeons (AAOS) indicate that the data on safety and efficacy of viscosupplementation remain inconclusive. As such, the AAOS does not currently recommend viscosupplementation as standard treatment for osteoarthritis of the knees. Viscosupplementation is reserved for patients with a history of lasting benefit from prior injections and in cases where the remaining options are limited. In this case, the patient has a history of severe osteoarthritis of the left knee described as bone on bone, related to an old knee injury. The medical records document prior viscosupplementation for the left knee with associated benefit. The provider has therefore recommended repeat viscosupplementation with three intra-articular injections of hyaluronic acid for the left knee. The records document that the patient previously obtained lasting benefit from prior injections. Furthermore, the options are limited with the alternative being a total knee arthroplasty. As such, the requested series of three intra-articular injections of hyaluronic acid are medically necessary for this patient. Given the support for continued use of epidural steroid injections for lumbar pain, the requested third epidural steroid injection is medically necessary for the treatment of this patient.In addition, a review of the literature indicates that celecoxib is one treatment option that will reduce mucosal harm throughout the entire gastrointestinal tract, which is important for patients with a diagnosis of GERD. This patient has a diagnosis of GERD, which supports treatment with celecoxib in lieu of standard non-steroidal anti-inflammatory drugs (NSAIDs). Accordingly, the requested celecoxib is medically necessary for this patient. Final Result: The reviewer determined that the requested services and medication 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

A 53-year-old female enrollee requested authorization and coverage of Hyalgan injections. The Health Plan denied the request indicating that the requested therapy is not medically necessary for treatment of the enrollees osteoarthritis.One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer overturned the Health Plans denial on the basis that the requested therapy is medically necessary.
Appeal type: Medical Necessity
Decision: Upheld

A 50-year-old male enrollee has requested for Proton Beam therapy his adenocarcinoma of the prostate.  Findings:  The physician reviewer found that proton beam therapy for prostate cancer is not medically necessary given that other treatment approaches (IMRT with or without IGRT) are highly effective and well tolerated. There is no literature stating that the outcome after proton beam therapy, either with respect to PSA control, tumor control or toxicity is better than IMRT.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the hip surgery performed for treatment of the enrollees left acetabular labral tear and femoral acetabular impingement. Findings: Three physician reviewers found that based on the clinical documentation provided for review, the patient had multiple hip injuries which would not have been expected to improve without the surgeries performed. Femoracetabular impingement refers to bony prominence around the joint which predisposes a patient to painful injuries such as labral tearing and articular cartilage damage. The bone shapes can only be altered by surgery. At the time of surgery, articular cartilage injury, labral tearing and a piece of bone broken off the acetabulum were identified. Articular cartilage has no healing potential and the unstable fragments were surgically removed. In addition, the hip surgery performed is the standard of care in this clinical setting. All told, the hip surgery performed was likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: The three reviewers determined that the procedure at issue was likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: All three physician reviewers are board certified in orthopedic surgery and are actively practicing. The reviewer 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: The parent of an enrollee has requested authorization and coverage for continuation of 20 hours per week of direct applied behavioral analysis (ABA) and 12.5 hours per month of supervision. Findings:  The physician reviewer found that a study of 726 children, ages 1.5 to 12, evaluated the relationship between ABA treatment intensity and treatment outcomes for individuals with ASD. The authors reported that a strong relationship between treatment intensity and mastery of learning objectives, where higher treatment intensity predicted greater progress was demonstrated. The authors concluded that These results add to the existing support for higher intensity treatment for children with ASD. In this case, the patient has made progress in many areas as evidenced by the progress notes. However, she continues to demonstrate impairment in self-injury, stereotypies and ritualistic behavior. The patients impairments make it increasingly difficult for her to be successful in more generalized environments. The providers recommendation of 20 hours per week of direct ABA and 12.5 hours per month of supervision is medically necessary and recommended for an optimal response. 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 physician reviewer is board certified in pediatrics with sub-specialty certification in developmental-behavioral pediatrics and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Urgent Care
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for emergency medical services. Findings:  The physician reviewer found that the medical services provided were not necessary for treatment of an emergency medical condition. The patient sustained a left shoulder injury when falling onto the patients left shoulder while snowboarding. He was evaluated in the emergency department on the date of injury and diagnosed with a large bony Bankart lesion with displacement. He was placed in a shoulder immobilizer and advised to follow-up with an orthopedic surgeon. The patient was stabilized in the emergency room and was not seen for orthopedic surgical evaluation for three additional days. The services provided thereafter were not emergent including the echocardiogram. Thus, the patient did not receive emergency medical services on the dates of service at issue. Final Result: The reviewer determined that the patient did not receive emergency medical services on the dates of service at issue. 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

A 33-year-old male enrollee has requested inpatient psychiatric hospital services for treatment of the enrollees behavioral health condition.  Findings:  The physician reviewer found that the inpatient psychiatric services provided were medically necessary for treatment of the patients medical condition. According to the physician progress notes, the patient remained psychotic, unable to take care of himself and continued to have delusions and auditory hallucinations. On the date indicated, the patient was no longer suicidal and agreed to take his medications at discharge. As such, the patient would not have been able to be discharged to a lower level of care without a high risk of relapse and readmission. The days in dispute were medically necessary and meet the standard criteria for inpatient psychiatric services. All told, the acute inpatient psychiatric services provided from the time period specified were medically necessary for treatment of the patients behavioral health condition.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for radiofrequency ablation (RFA). This patient presents with residual pain status post traumatic pelvic fracture. She has undergone multiple surgeries, including open reduction and internal fixation of the pelvic fracture, debridement of a left gluteus maximus infection, and partial hardware removal. Conservative treatment has included extensive physical therapy, a home exercise program, medications, activity modification, and RFA. Current evidence-based medical literature indicates that there is limited data supporting the safety and efficacy of RFA for long-term management of this patients chronic pain. Schmidt and colleagues concluded that RFA may offer a potential benefit as therapeutic modalities for sacroiliac joint pain, although limited data supports the use of this procedure as a primary treatment modality. Yang and colleagues reported that current evidence suggests that RFA can provide relief of pain that originates from the posterior sacroiliac joint complex, but interpretation of this literature is limited by variability in patient selection criteria, the specific nerves targeted for ablation, and the types of RFA technology and technique utilized. In this patients clinical setting, there is a lack of clinical documentation from the provider including a current pain assessment, functional assessment, or sacroiliac joint pain or positive provocative testing to support an indication for RFA to the left sacroiliac region. For these reasons, the requested RFA is not medically necessary for 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: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for hematopoietic stem cell transplantation (bone marrow transplant).  Findings:  Two of the three physician reviewers found: Overall, the accepted role for stem cell transplant (either autologous or allogeneic) in the treatment of diffuse large B-cell lymphoma is when treating relapsed or refractory disease that is still chemotherapy sensitive. CAR-T cell treatment is a relatively new treatment for this disease. Even in heavily pretreated patients, this treatment results in an approximately 50% rate of complete remission, many of which are sustained. Although transplant has been used in patients prior to CAR-T cell therapy, there is a lack of studies exploring its use after CAR-T cell complete remission. There is concern for combining toxicities. The current medical evidence does not support the services at issue in this setting of complete remission with CAR-T cell therapy. Therefore, the requested hematopoietic stem cell transplantation (bone marrow transplant) is not likely to be more effective than other treatment options. Final Result: The reviewers determined that the requested services 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 internal medicine with sub-specialty certification in medical oncology and are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for oxycodone for treatment of the enrollees pain. Findings:  The physician reviewer found that the step wise World Health Organization (WHO) ladder for pain relief is considered the reasonable approach to pain control in the palliative and the non-palliative settings. The Centers for Disease Control and Prevention (CDC) also state when opioids are started, providers should prescribe the lowest effective dosage. Providers should use caution when prescribing opioids at any dosage, carefully reassess evidence of individual benefits and risks when considering increasing dosage of 50 or more morphine milligram equivalents (MME) per day, and should avoid increasing dosage to 90 or more MME per day. In this case, the patient was recently taking 122 MME per day. However, in the documentation provided for review, no objective treatment goals for pain and function are noted for the requested medication and several requirements for opioid prescribing have not been documented. Further, no medical evidence based rationale is given for this patients high level of MME per day. Dose escalation is a short-term, not long-term plan, for the treatment of tolerance and no clear objective goals with this high of a dose of opioid has been established. Increases in the past appear to have been done only on the basis of the patients pain levels and not all other non-pharmacological methods such as behavior therapy of treating the patients pain have been addressed. For these reasons, the requested oxycodone is not medically necessary for treatment of the patients medical condition. 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 internal medicine with sub-specialty 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

The parent of a five-year-old female enrollee has requested speech therapy for the treatment of the enrollees delayed speech. Findings:  The physician reviewer found that the submitted clinical evidence indicates the patient has a neurological deficit of unknown etiology. She benefited from a course of speech therapy for six months. Based on the patients previous response to private speech therapy, she is likely to continue to benefit from additional therapy. She should receive speech therapy once a week for six months with re-evaluation at the end of the six-month period.
Appeal type: Experimental/Investigational
Decision: Overturned

A 51-year-old male has requested a microprocessor controlled lower limb prosthesis for treatment of above knee amputation. Findings:  Two physician reviewers found that use of a microprocessor controlled lower limb prosthesis will increase stability, reduce energy consumption, limit low back pain from biomechanic alterations and reduce skin breakdown. The literature cited by the Health Plan compares amputees using conventional prosthetic knees (i.e., hydraulic) with computer-controlled devices; however, these patients did not suffer from the above mentioned complications. The patient is an active person who would benefit from the increased stability provided by a microprocessor controlled prosthetic lower limb.