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

A 49-year-old male enrollee requested authorization and coverage for continued treatment with an out-of-network allergist. The health plan has denied this request indicating that it is not medically necessary for the enrollee to continue services with an out-of-network allergist the enrollee's allergic symptoms caused by mold exposure.One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer upheld the health plans denial on the basis that the requested services are not medically necessary.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The enrollee requested authorization and coverage for Hyaluronan (Euflexxa) injections in the right knee. The Health Plan denied the request as not medically necessary.Findings:  The physician reviewer found that the requested treatments are medically necessary for treatment of the enrollees medical condition. Therefore, the Health Plans denial should be overturned.A review of current literature pertaining to viscosupplementation reveals mixed results. Maheu and colleagues found that intra-articular hyaluronic acid (HA) injections provide a moderate symptomatic benefit to knee osteoarthritis without major safety concerns. Researchers performed a meta-analysis of double-blinded, sham-controlled trials with at least 60 enrollees and concluded that the evidence did not show clinically important differences of HA over placebo. Researchers concluded that viscosupplementation increased functional scores in enrollees with severe osteoarthritis of the knee, especially within three months of injection. However, it was not superior to triamcinolone. In light of the foregoing, viscosupplementation is recommended in enrollees with a history of lasting benefit from prior injections, and in carefully selected cases where conservative modalities have failed and the remaining treatment options are limited. In this case, the options are limited, with the alternative being a total knee arthroplasty, which is not indicated for mild osteoarthritis. As such, the request for Hyaluronan (Euflexxa) injections in the right knee is medically necessary for treatment of osteoarthritis of the enrollees right knee.Final Result: The reviewer determined that the requested treatments are medically necessary for treatment of the enrollees 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: Urgent Care
Decision: Overturned

A 44-year-old female enrollee has requested for emergency services on an emergent basis. Findings:  The physician reviewer found that there were no symptoms that indicated a severe infection. Her migraine began the morning of her emergency room visit. The patient had a history of migraines. A migraine can be a particularly painful condition, and the patient did report nausea and photophobia. Migraine patients can occasionally experience acute episodes of severe pain that require emergency care for relief.
Appeal type: Medical Necessity
Decision: Overturned

A 45-year-old female enrollee requested authorization and coverage of the medication Vioxx. The Health Plan denied the request indicating that the requested medication is not medically necessary for the treatment of the enrollees joint inflammation.One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer overturned the Health Plans denial on the basis that the requested medication is medically necessary.
Appeal type: Medical Necessity
Decision: Upheld

A 75-year-old female enrollee requested endovenous chemical ablation procedure for medical treatment of her varicose veins.   Findings:  The physician reviewer found that the services at issue were not medically necessary for treatment of the patients medical condition. Typically procedural approaches including endovenous ablation is reserved for patients who fail conservative therapy. The documentation submitted for review fails to provide evidence of treatment of conservative therapy such as the use of prescription of medical grade compression stockings and several months of regular use. In addition, the patient presents with hypertension, diabetes, and hyperlipidemia and it is not possible to attribute leg pain to varicose veins without an assessment of lower extremity arterial perfusion. In sum, there was a lack of assessment provided describing the patients symptoms, a description of the examination, and an attempt to treat with conservative therapy.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for a compounded medication. Findings:  The physician reviewer found that the optimum duration of supplementation has not been established; it has been given until a positive or negative pregnancy test was obtained or as long as the end of the first trimester. Intramuscular progesterone (progesterone in oil) and the various vaginal progesterone preparations (suppositories, tablets, gel, or ring) are equally effective; oral progesterone appears to be less effective. These progesterone preparations and doses are not associated with birth defects or virilization. Intramuscular progesterone is more painful for the patient.  However, in this patients case, the provided records did not demonstrate that she required the compounded injectable form of progesterone in addition to the other routes, nor is there any documentation in the records for this approach. The meta-analysis by Polyzos and colleagues similarly concluded, This meta-analysis provides solid evidence that no significant difference exists between vaginal gel and all other vaginal progesterone forms in terms of clinical pregnancy rates. Final Result: The reviewer determined that the medications 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 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

A 48-year-old female has requested for bilateral knee MRI for evaluation of her knee pain.   Findings:  The physician reviewer found that x-ray evaluation was essentially normal and there is no history of instability of the knee joints. A trial of viscosupplementation has not been attempted and a medication history is not provided. In sum, MRI is not appropriate at this juncture.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the brand name drug, Asacol HD, for treatment of the enrollees ulcerative colitis. Findings:  The physician reviewer found that te submitted documentation supports the medical necessity of the medication at issue.  Asacol has proven to be effective for the treatment of ulcerative colitis. Although several 5-aminosalicylate medications and mesalamine formulations are available for the treatment of ulcerative colitis, each formulation results in release at distinct times and locations in the gastrointestinal tract. Specifically, Asacol has proven to be different from Apriso, Salofalk, Mezavant XL, and Pentasa, with release later and at a higher pH. The result of changing therapy can be inadequate control by a different formulation which directs the drug to a different part of the gastrointestinal tract. Additionally, ulcerative colitis flares can be induced by salicylate medications, and changing therapy can expose the patient to this risk. In this case, the change to generic mesalamine could have resulted in a different formulation with inability to control disease. Therefore, Asacol HD, was medically necessary for the treatment of this patient. Final Result: The reviewer determined that the medication at issue was 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 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

The parent of a two-year-old male enrollee has requested speech therapy for treatment of the enrollees speech delay. Findings:  The physician reviewer found that speech therapy can be extremely effective for a patient with speech delay as emphasized in the medical literature. Law and colleagues reported that cognitively intact children with speech delay are amenable to treatment as confirmed in reviews of the available clinical data. Prelock and colleagues discussed the evaluation and therapy of patients with speech delay. Emanuel and colleagues reported that referral of a two-year-old patient for speech therapy is usually an accurate and correct decision. As such, it is medically necessary for this patient to receive individualized speech therapy for an authorized period of time. Once the authorization expires and the patient's re-evaluation indicates progress, he should continue to receive speech therapy services.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the aortopathy/connective tissue disorders multi-gene panel genetic testing for evaluation of the enrollees joint hypermobility and subsequent joint pain. Findings:  The physician reviewers found that Hypermobile Ehlers-Danlos syndrome is diagnosed clinically based on findings of generalized joint hypermobility and soft skin without significant elasticity or fragility. These features distinguish this syndrome from classical Ehlers-Danlos syndrome, in which the skin is very elastic and fragile. Vascular Ehlers-Danlos syndrome is characterized by specific facial and skin features not described in this patient and high risk of arterial or organ rupture. The genetic testing provided in this case evaluates the genes associated with these conditions, as well as the genes associated with other inherited connective tissue disorders, such as Marfan syndrome and Loeys-Dietz syndrome, though the patient is not described as having features concerning for these. The testing also includes genes associated with non-syndromic thoracic aortic aneurysm and dissection, which this patient does not have. All told, the aortopathy/connective tissue disorders multi-gene panel genetic testing provided was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Final Result: Two of three reviewers determined that the testing at issue was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: Physician reviewers number one, two, and three are board certified in in internal medicine with sub-specialty certification in rheumatology and is 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: The patient has requested authorization and coverage for Xiidra 5% eye drops. Researchers found that treatment with lifitegrast twice a day for six months improved both signs and symptoms of chronic dry eye. In this case, the patient has tried Restasis and artificial tears and is still symptomatic. The records document burning, discomfort, itching and dryness in both eyes.  Based on the records, the requested medication is medically indicated for this patient. Therefore, Xiidra 5% eye drops are 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 ophthalmology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

The patient has requested authorization and coverage for Gazyva (obinutuzumab) 1,000 mg infusion on day one and day 15. In this case, the patient has refractory nephrotic syndrome. The patients degree of proteinuria places him at high risk of progressive renal failure and/or long-term dialysis. Gazyva works in a similar mechanism as rituximab, which was noted to have been beneficial in the past. Other therapy could cause substantial side effects. The medical evidence supports the requested medication in this clinical setting. Therefore, Gazyva (obinutuzumab) 1,000 mg infusion on day one and day 15 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 with sub-specialty 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

A 54-year-old female enrollee has requested epidural injections and other related services for treatment of neck pain.  Findings:  Three physician reviewers found that there is no class I data to establish the benefits of epidural injections and radiofrequency facet neurolysis for the treatment of neck pain and cervical degenerative disc disease. Significant trials showing their effectiveness have not been performed and there is only anecdotal information regarding the possible efficacy of the therapy. Additional outcome data is needed to establish the effectiveness of the procedures at issue in this appeal.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a 2-year, 7-month-old male enrollee has requested 1-2 sessions per week of speech therapy for treatment of the enrollees speech delay.  Findings:  The physician reviewer found that in child development, delay in speech acquisition is an important predictor for later problems. Research over the past 50 years has yielded several promising approaches and many specific intervention techniques designed to enhance the communication and language development of young children with intellectual and developmental delays and disabilities. In the clinical literature, Gallagher and Chiat found that, Studies of children with language impairment have reported emotional and behavioral problems in 50-75% of that population. In addition, various authors describe children with delayed speech development as being at high risk for other cognitive, social-emotional, and school-related problems. As such, language development is one of the most significant processes of early childhood development. With regard to diagnosis, language disorders are identified when a patient has difficulty with expressive language, receptive language, or pragmatic language. Speech disorders are identified when a patients voice, fluency, or articulation call attention to the speaker because his or her speech is sufficiently different from the norm. Speech and language development should be consistent with a patients overall development and can be tracked using typical milestone markers. As speech therapy is recommended for young patients with speech delay, the primary goal of treatment is to give the patient a reliable way to exchange ideas and information in his or her daily social and educational environment. Speech therapy is the standard of care for patients with speech delay and this patient presents with significant delays in speech and language skills. Therefore, the requested therapy is medically necessary for this patient for 1 hour sessions at a frequency of 2 sessions per week.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/ Case Summary:  The enrollee is requesting authorization and coverage for the medication Enbrel. The enrollee has a diagnosis of rheumatoid arthritis.  She has been off prednisone and does not use ibuprofen often.  The enrollee was provided with a one-month supply of Enbrel samples. After using the medication, she reported an improvement of about 40-50 percent.  She continues to have some mild shoulder pain, but she thinks this is due to her work. The enrollees physician reports the enrollee cannot use standard medications because she has liver problems. This reviewer found no study data that addresses the question of what the relative gastrointestinal risks, especially liver, and side-effects are among these four medications. All of them can affect the liver but the relative risks are different. Methotrexate is well-known to require liver function monitoring and can result in liver toxicity. Sulfasalazine requires regular monitoring. There is also a small risk of idiosyncratic severe hepatitis. Limiting the risk of that in a person with fatty liver is reasonable if there are other alternatives, which there are. Enbrel is Food and Drug Administration-approved as a monotherapy for rheumatoid arthritis. Plaquenil can cause liver problems but this is rare. However, Plaquenil usually takes months to work and this enrollees is steroid-dependent, so using a medication that is likely to work faster and better, once again, is a reasonable choice.Final Result: The reviewer determined that the requested service is medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The physician reviewer is board certified in rheumatology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or similar medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld

An enrollee has requested authorization and coverage for surgery to fuse bones in base of spine to pelvis. This patient presents with complaints of low back and right hip/buttock pain. She underwent L4-5 laminectomy with resolution of her radicular symptoms, but persistent SI joint pain. Functional limitations are noted in activities of daily living, ambulatory ability, and work ability. The records document that she underwent SI joint injection. The patient reported this injection was not successful, and the provider noted up to 25% pain relief. She underwent right S1-4 radiofrequency ablation injection with some relief and improvement with mobility. She has reportedly failed all available conservative treatment options. She has been diagnosed with SI pain, lumbar post-laminectomy syndrome, lumbar spondylosis and chronic pain. There is imaging evidence of L5-S1 disc protrusion with abutment of the right L5 nerve root. According to the International Society for Advancement of Spine Surgery (ISASS), there are specific indications for spine surgery. In this case, there is no evidence of confirmation of the SI joint as a pain generator with at least 75% decrease in pain following fluoroscopically guided diagnostic intra-articular SI joint block in the immediate post-injection period. In addition, there is no imaging study presented to evidence SI joint spondyloarthropathy, degenerative sacroiliitis, or SI joint disruption. Given these findings, the requested surgery to fuse bones in base of spine to pelvis 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 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 orthopedic 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.