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

Nature of Statutory Criteria/Case Summary: An enrollee has requested Otezla for treatment of his psoriasis. Findings:  The physician reviewer found that review of the submitted documentation and relevant literature fails to demonstrate the medical necessity of the requested medication. The patient presents with psoriasis and a history of elevated liver enzymes, making certain medications unfavorable therapy candidates for this patient. However, the patient has not had failure or intolerance of certain biologics. He has not failed therapy with phototherapy.  There is no mention in the medical records of a contraindication to treatment with phototherapy, or certain biologics. Given that the patient has not failed other systemic therapies, the request for coverage of Otezla 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 dermatology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned

The parent of an 18-year-old male enrollee has requested for a PET scan for evaluation of his neurological problems. Findings:  Three physician reviewers found that review of the peer-reviewed literature reveals multiple articles supporting the use of PET scan in the evaluation of neurologic paraneoplastic syndrome. One article described the use of the PET scan in the diagnosis of malignant thymoma (these tumors can be associated with paraneoplastic syndromes). As standard imaging (including CT, ultrasound and MRI) showed no evidence of cancer and no cause of this patients paraneoplastic syndrome, PET scan was medically appropriate for the diagnosis and treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned

The patient has requested authorization and coverage for treatment by an orthopedic specialist. Given the notes available, the patient has ongoing musculoskeletal complaints. She has pain in the cervical, thoracic and lumbar spine. On physical examination, the provider noted that there was tenderness to palpation over the cervical and thoracic spine paraspinals, positive straight leg raise bilaterally, and abnormal sensation in the L4 and L5 dermatomes. Her examination is concerning for L4 and L5 radiculopathy given her sensory changes and the positive straight leg raise. Referral to orthopedic surgery is indicated for further assessment of her radicular complaints. Therefore, evaluation by an orthopedic specialist is medically necessary for this patient. Final Result: The reviewer determined that the requested services are medically necessary for evaluation 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

Nature of Statutory Criteria/ Case Summary:  The enrollee is requesting authorization and coverage for right hip replacement surgery. The enrollee has a medical history of hypertension and osteoarthritis of the right hip and was seen by an orthopedic surgeon for right hip pain. At a visit several years later with a different orthopedist, the enrollee complained of right hip pain which began several years prior and has continued despite conservative management, which has included weight loss, oral non-steroidal anti-inflammatory drugs, bracing, physical therapy, and injections. He is unable to perform activities of daily living without pain. An x-ray of the affected hip showed degenerative changes including joint space narrowing, subchondral sclerosis, and osteophyte formation.  The enrollee was told to stop smoking. Right hip replacement was discussed after which the enrollee indicated he wanted to proceed with the surgeryThe enrollee indicated he was unable to proceed with the surgery because he was a former smoker and still uses nicotine gum and spray. His pain medication was changed to hydrocodone-acetaminophen and he was advised to stop using nicotine replacement if that is what was advised by the orthopedist. This enrollees physical examination revealed the right hip had a range of motion from 10-90 degrees, with zero degrees internal rotation and 20 degrees external rotation.  There was positive impingement. The enrollee was advised to undergo a pre-operative appointment and to follow up in two weeks.  The surgeon did not want to perform the procedure due to the enrollees inability to discontinue smoking.  The enrollee detailed he was vaping. However, the most recent notes indicate he has been utilizing nicotine gum and spray.  Therefore, it does appear the enrollee has attempted smoking cessation. Given the enrollee's clinical picture, it does not appear any other treatment will provide benefit.  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 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 similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Orthovisc injections in the left knee. An exhaustive review of the current medical literature pertaining to viscosupplementation reveals mixed results. Evidence from eight systematic reviews and six randomized controlled trials indicates that although viscosupplementation may relieve knee pain in some individuals with osteoarthritis, it is not known as to which individuals will benefit. Different studies have tried mixing hyaluronic acid with corticosteroids, platelet rich plasma, and other agents to make it more effective. 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 has a history of prior viscosupplementation, which was beneficial. The patient has not received any viscosupplementation since May 2020. Furthermore, cortisone injections were not effective in the past. There is sufficient support for the requested services in this clinical setting. Therefore, Orthovisc injections in the left knee are medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested services are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in orthopedic surgery and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for residential treatment services. The current medical evidence supports the services at issue in this clinical setting. The American Psychiatric Association treatment guidelines indicate that residential treatment is indicated for patients who do not meet the clinical criteria for hospitalization but whose lives and social interactions have come to focus predominantly on substance use, who lack sufficient social and vocational skills, and who lack substance-free social supports to maintain abstinence in an outpatient setting. Patients requires safe and stable living environments in order to develop their recovery skills. The submitted documentation supports residential treatment in this clinical setting. Residential treatment was in accordance with generally accepted standards of medical practice and clinically appropriate for the patients illness. Per the records, the patient could not have been safely and effectively treated at a lower level of care. Therefore, residential treatment services were medically necessary for the treatment of this patient.Final Result: The reviewer determined that the services at issue were 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 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: Overturned

Nature of Statutory Criteria/ Case Summary:  The enrollee requested authorization and coverage for arthroscopic osteochondral allograft surgery. The patient has a history of right knee pain. A magnetic resonance imaging (MRI) many years ago showed a meniscal injury, but the patient declined surgery at that time. During a more recent routine office visit, she described her knee pain as increasing in severity and frequency to seven to eight on a scale of one to ten over the previous two months. The pain is sharp and stabbing; waking her at night. She tried ibuprofen and Tylenol without relief. A repeat MRI of the right knee showed flattening and deformity of the lateral femoral condyle. The orthopedic surgeon prescribed osteochondral allograft surgery because the patients condition is not a simple chondral defect. The patient has a big crater in the bone with no support for the overlying cartilage, which is causing the pain and she has failed an extensive course of conservative management. He asserts that the patient meets guidelines for osteochondral transplantation. She has either failed or is ineligible for all other recommended treatment as she is too young for arthroplasty and aligned too well for osteotomy. In a recent study in the medical literature of 149 patients with femoral allograft transplantation, 71% of the patients reported having very good to excellent function, and 79% were able to participate in a high level of activity (moderate, strenuous, or very strenuous) six years after the procedure. Another group reviewed the results from five studies involving 291 patients.  While they noted differences in technique and patient characteristics among the studies, they found significant clinical improvement using standard knee society scores and good durability in 75% of the patients at over 12 years of follow-up. The treatment options for this patient are relatively limited. Knee arthroscopy and debridement is not effective in these cases, nor is microfracture because the patients underlying bone is not thought to be healthy. Cartilage restoration, such as autologous chondrocyte implantation (ACI) or matrix-induced autologous chondrocyte implantation (MACI) is not indicated in the setting of bony changes such as condyle flattening.  Therefore, the most reasonable treatment is an osteochondral allograft transplant. 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 Orthopedic Surgery and Sports 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 similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary:  The enrollee has requested an ultrasound of both breasts. Findings:  The physician reviewer found that according to the record, breast examination was within normal limits and ultrasound results were discussed. The recommendation was for a clinical breast exam every year, annual mammogram, and a genetics referral, given family history. The enrollee was to undergo genetic screening prior to any screening imaging. A mammogram was negative.  The genetic counselor recommended genetic testing for hereditary cancer syndromes with screening recommendations deferred until genetic test results are available. The enrollee has a family history of Ashkenazi Jewish ancestry and reports that none of her relatives has undergone any genetic testing to her knowledge.  The enrollees mother, maternal grandmother, paternal aunt and paternal cousin all have history of breast cancer.  The patient requested her physician to order a breast ultrasound.  However, it was explained that if a hereditary mutation were identified appropriate screening/surveillance management would be advised for her based on the respective findings. According to the medical literature, breast sonography is indicated for evaluation and characterization of palpable masses and other breast related signs or symptoms including evaluation of suspected or apparent abnormalities detected on mammography, screening for occult cancers in certain populations, including heterogeneously or extremely dense breasts. The documentation indicates the enrollee underwent a mammogram that was negative. A family history of cancer and patient history of dense breast tissue is noted. However, there is no indication the patient has a palpable mass, which required ultrasound evaluation. Further, there was insufficient documentation in the record of recommendations by the genetic counselor for additional screening for occult cancers that may occur in certain populations. Therefore, the requested bilateral breast ultrasound is not medically necessary for treatment of the patients medical condition. Final Result: The reviewer determined that the service at issue is not medically necessary for treatment of the enrollees condition. Credentials/Qualifications: The physician reviewer is board certified in Diagnostic Radiology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

A 36-year-old female requested authorization and coverage of a colonoscopy for colon cancer screening. The health plan denied this request, indicating that a colonoscopy is not medically necessary.One physician reviewer performed a medical necessity Independent Medical Review.  The physician reviewer upheld the health plans denial on the basis that the requested colonoscopy is not medically necessary and that the health plans recommendation of a sigmoidoscopy is appropriate.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested Harvoni for treatment of his hepatitis C. Findings: The physician reviewer found that there is sufficient support for the requested medication in this clinical setting.  The medical records noted that the patient has been diagnosed with hepatitis C, genotype 1a.  The request for Harvoni has been denied given the lack of evidence of moderate to severe liver disease.  However, per American Association for the Study of Liver Diseases and Infectious Diseases Society of America guidelines, the medical necessity of hepatitis C eradication exists irrespective of fibrosis score.  All told, the requested Harvoni is medically indicated 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 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 the compounded medication, guaifenesin/pseudoephedrine HCL, for treatment of her medical condition.  Findings:  The physician reviewer found that based on the documentation submitted for review, the requested compounded medication is not medically necessary for treatment of the patients medical condition. The patient is chronically taking the compound guaifenesin/pseudoephedrine. The U.S. Food and Drug administration (FDA) approved package insert recommends the use of this medication for a maximum of seven days for an acute problem, not chronically as taken by this patient.  The pseudoephedrine part is a sympathomimetic that is chronically stimulating her heart. It is a stimulant, and is currently banned from many sports competitions in various countries. The patient reports tachycardia which is an effect of chronic sympathetic stimulation. There is a lack of indication for treatment of this compounded medication. In sum, the requested compounded medication chronically is not consistent with the FDA approved indications and not medically necessary for treatment of the patients medical condition.  Final Result: The reviewer determined that the requested compounded 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 pulmonary disease 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 23-year-old female enrollee has requested inpatient hospitalization services for treatment of her bipolar affective disorder. Findings:  The physician reviewer found that according to the medical records, the patient in this case revealed a significant life stressor near the end of her hospitalization.  She had not consolidated the event from her past.  She reported additional anxiety symptoms consistent with a trauma-related disorder.  On the date indicated, she remained depressed, and a suicide risk assessment returned with a moderate rating in the outpatient setting.  Thus, the physician continued an order for suicide precautions with nursing checks every 15 minutes.  Additional consideration of her mental health history, limited social support, symptom severity and diagnosis of bipolar disorder, which carries the highest risk of suicide among psychiatric disorders, supported inpatient services.  It was reasonable to expect that the inpatient services would improve her condition and prevent a more serious illness.  All told, inpatient hospitalization services provided from the time period specified were medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld

The patient is a 37-year-old man with dental malocclusion, mandibular retrognathia, and CPAP resistant sleep apnea.  Evaluations by two maxillofacial surgeons resulted in recommendations for the extraction of the third molars, pre-operative orthodontic treatment and bi-maxillary advancement with maxillary and mandibular osteotomies.  The patient had the third molars removed and he now wishes to forego pre-operative orthodontic treatment against the advice of the surgeons.Pre-operative orthodontic treatment in anticipation of orthognathic surgery is the usual and recommended sequence of case management.  A stable dental occlusion is key to the success of the surgery and necessary to prevent a relapse of the bone fragments into an undesirable post-operative position. To proceed with surgical correction without pre-operative orthodontic treatment would pose the unnecessary risk of a poor surgical outcome. The patients surgeons are correct to insist on pre-operative orthodontic treatment if, in their judgment, the quality of care would be diminished without this treatment. Therefore, I have determined the requested surgery is not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for an Eversense continuous glucose monitor (CPT 0448T) with sensor implantation every 90 days. In a comparative accuracy study of continuous glucose monitoring (CGM) devices in the home-use setting, Jafri and colleagues found that the Senseonics Eversense CGM device was better than the Dexcom G5 and Abbott Freestyle Libre Pro devices when comparing point-of-care plasma-glucose values. Joseph notes that a majority of studied patients described a positive experience managing their diabetes with the Eversense CGM System and requested implantation of a new sensor 90 or 180 days later. Sanchez and colleagues reported that real-world data from the Eversence CGM system showed promising glycemic results, sensor accuracy, and safety. CGM devices may help improve control and decrease the frequency of low blood sugars in patients with type 1 diabetes over patients using a glucometer alone. In a letter, the patient reported that she was allergic to adhesives and that she experienced good control with the Eversense implantable CGM. In this clinical setting, the patient would likely not realize the same level of control with a glucometer alone. Therefore, the requested Eversense continuous glucose monitor (CPT 0448T) with sensor implantation every 90 days is likely to be more beneficial for treatment of the patients condition than any available standard therapy.Findings:  Three of the three physician reviewers found the requested Eversense continuous glucose monitor (CPT 0448T) with sensor implantation every 90 days is 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 equipment is 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: Physician reviewers 1, 2, and 3 are board certified in internal medicine with sub-specialty certification in endocrinology, diabetes and metabolism 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.