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 Orthovisc injections. Researchers concluded that hyaluronic acid was the best pharmacologic intervention for knee osteoarthritis in their meta-analysis of 137 studies with 33,243 participants. Hyaluronic acid was found to be better than injected placebo or injected corticosteroids. Researchers concluded that repeated cycles of intra-articular sodium hyaluronate treatment was found efficacious in delaying a total knee replacement in patients with knee osteoarthritis that failed conservative treatment. The findings were documented from a 54-month follow-up period.In this case, the patient presents with chronic bilateral knee pain. The patient's functional limitations are noted in activities of daily living and recreational pursuits. The patients clinical examination findings and radiographic findings have been consistent with mild to moderate bilateral knee osteoarthritis. Reasonable conservative treatment, including activity modification, NSAIDs, cortisone injections, and ice, have failed to provide adequate symptom relief. The patient has undergone two prior series of Orthovisc injections to both knees with reported excellent symptom relief and improvement in activity tolerance for 6 months or longer. Evidence-based, medical peer-reviewed literature supports the use of viscosupplementation injections for the treatment of pain in patients with osteoarthritis of the knee as safe and effective and better than corticosteroid injections. Repeat viscosupplementation injections have been found to be safe and effective and allow for delay of knee replacement surgery. Therefore, the requested Orthovisc injections to both knees are medically necessary for treatment of the patients medical condition.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

A 55-year-old female enrollee requested authorization and coverage of a single proton emission computerized tomography (SPECT) brain scan to determine how to treat attention deficit disorder with medication.  The health plan denied the enrollees request indicating that the requested treatment is experimental.Three physician reviewers performed an experimental/investigational Independent Medical Review.  Each of the three physician reviewers concluded that a single proton emission computerized tomography (SPECT) brain scan to determine how to treat attention deficit disorder with medication is not likely to be more beneficial than any available standard therapy.  Because all three physician reviewers concluded that the requested treatment is not likely to be more beneficial for treatment of the enrollees medical condition than any available standard therapy, the review organization upheld the health plans denial.
Appeal type: Medical Necessity
Decision: Overturned

A 39-year-old female enrollee has requested a referral with a foot specialist for the treatment of her nerve problem. Findings:  The physician reviewer found that it appears medically necessary for the patient to have a consultation with a foot specialist (i.e., a podiatrist) to treat her foot pain/neuroma. This patient has had foot pain for three months. The foot pain has not responded to 10 days of non-steroidal anti-inflammatory drugs (NSAIDs). Neuromas are physically enlarged nerves and rarely respond to any conservative care and it may be necessary for a podiatrist to institute local steroid injections or fabricate orthotics with a neuroma pad. In addition, a podiatrist may more accurately assess the efficacy of the treatment and transition into surgical treatment if necessary.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Botox injections for treatment of the enrollees thoracic back pain. Fulfills Findings:  The physician reviewer found that the request for Botox injections are not medically necessary for treatment of the patients medical condition. There is a lack of medical literature supporting Botox injections in this clinical setting. The review did not support the use of Botox in myofascial pain syndromes. Similarly, the contradictory results regarding the efficacy of botulinum toxin A in [myofascial pain syndromes] MPS associated with neck and back pain do not allow this treatment to be recommended or rejected. In addition, there is no documentation the patient has trialed anticonvulsant medications such as Lyrica, undergone a neurosurgical consultation or has underwent evaluation with computed tomography (CT) scan of the thoracic spine as recommended in the interpretation of the MRI. For the reasons provided, the requested services have not been established as 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 anesthesiology with sub-specialty certification in pain medicine and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for positron emission tomography (PET) scan for evaluation of history of metastatic melanoma. Findings:  Three physician reviewers found that there has been a considerable amount of debate on imaging follow-up and surveillance in patients with history malignant melanoma. The National Comprehensive Cancer Network guidelines do not recommend routine imaging to screen for asymptomatic recurrence or metastatic disease. The guidelines noted the following, Routine imaging to screen for asymptomatic recurrence or metastatic disease is not recommended after 3-5 years. The records show that this patient did not have any signs or symptoms to suggest disease recurrence and was beyond three to five year interval. As such, PET scan performed was not likely to have been more effective than the standard methods available for the evaluation of this patient. Final Result: The reviewers determined that the services at issue were 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: Reviewers 1, 2 and 3 are board certified in diagnostic radiology 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

A 54-year-old male has requested acupuncture for treatment of neck and back pain.  Findings:  The physician reviewer found that the patient appears to have experienced some relief from the pain medication, epidurals, etc. There is potential that acupuncture will provide this patient sustained relief. A trial course of acupuncture is a reasonable course of treatment for this patient. The patient should receive 8 acupuncture treatments at a frequency of not less than twice a week, with evaluation upon completion.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Boost Nutritional Supplement. The records provided for review document that this patient has a history of feeding difficulties and human immunodeficiency virus (HIV). The provider charted that the patient requires soft foods, due to poor fitting dentures. The patient had unintentional weight loss before starting Boost Nutritional Supplements and she has lost weight since she stopped taking Boost. The patients recent body mass index (BMI) was 24.5 kg/m2. As noted in the medical literature, a lower BMI is associated with poorer health outcomes in HIV patients on treatment. Nutritional supplementation can increase lean body mass and grip strength in patients with HIV (Olson, et al.). Moreover, nutritional supplementation has been shown to decrease loss of muscle mass and onset of frailty (Nowson and OConnell). Undernutrition and underweight status is common in older patients, and oral liquid energy-dense and high-quality protein supplements have been shown to increase energy and protein intake. For these reasons, the requested Boost Nutritional Supplement is medically necessary for treatment of this patient. Final Result: The reviewer determined that the requested nutritional supplement 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 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

A 50-year-old male has requested IVIG therapy for treatment of his painful weakness of the arms.   Findings:  The physician reviewer found that the submitted documentation demonstrates the medical necessity of the requested therapy.  This patient has had progressive painful upper limb weakness, with examination and test results showing lower motor neuron abnormalities.  The medical records indicate that the patient has had findings that may be due to a variant of chronic inflammatory demyelinating polyneuropathy.  As IVIG therapy has been shown to be appropriate for chronic inflammatory demyelinating polyneuropathy, and this patient has had findings which may be due to this or a similar autoimmune disease, the requested IVIG therapy is medically appropriate.
Appeal type: Medical Necessity
Decision: Upheld

A 44-year-old female enrollee requested authorization and coverage of an MRI of the spine. The Health Plan denied the request indicating that the requested MRI is not medically necessary for evaluation of the enrollees back and hip pain.One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer upheld the Health Plans denial on the basis that the requested MRI is not medically necessary.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the Guardant360 genetic testing provided by Guardant Health. Molecular diagnostic studies in non-small cell lung cancer (NSCLC) are considered with the current standard of care. Numerous gene alterations have been identified that impact therapy selection. The National Comprehensive Cancer Network (NCCN) guidelines strongly recommend broad molecular profiling with the goal of identifying rare driver mutations for which effective therapies may already be available, or to appropriately counsel patients regarding the availability of clinical trials. Testing of lung cancer specimens for these alterations is important for identification of potentially efficacious targeted therapies, as well as avoidance of therapies unlikely to provide clinical benefit. Integration of plasma next generation sequencing into the routine management of stage IV NSCLC demonstrates a marked increase of the detection of therapeutically targetable mutations and improved delivery of molecularly guided therapy. Given this support, the Guardant360 genetic testing provided by Guardant Health was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.  Findings:  Two of the three physician reviewers found the Guardant360 genetic testing provided by Guardant Health was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.  Final Result: The 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: Physician reviewer 1 is board certified in internal medicine with subspecialty certifications in medical oncology and hematology and is actively practicing. Physician reviewer 2 is board certified in internal medicine with subspecialty certification in medical oncology and is actively practicing. Physician reviewer 3 is board certified in internal medicine with subspecialty certifications in medical oncology and hematology 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

A 58-year-old female has requested speech therapy for the treatment of her habit cough. Findings:  The physician reviewer found that this patient has a chronic cough that had failed to be diagnosed and treated through prior extensive evaluation. Although her main complaint is the chronic cough, her history and examination show evidence of vocal straining with use of the false cords for phonation. Endoscopy showed significant plica ventricularis, which is a laryngeal function disorder caused by phonation of the ventricular folds (false folds) rather than the true vocal folds. The patients condition traditionally is responsive to speech therapy.  Given the patients laryngeal dysfunction, speech therapy is medically indicated and appropriate.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested a computed tomography (CT) angiogram with three-dimensional imaging for evaluation of her medical condition.   Findings:   Two reviewers found that per the documentation submitted for review, it appears this patient had a previous coronary angiogram which did not reveal any significant abnormalities. Hence, pursuing a coronary CT angiogram in the absence of any symptoms is not indicated in this patient. However, she does have a history of abdominal pain and was previously found to have celiac artery stenosis and renal vein stenosis. The CT angiogram of her coronary arteries seems unlikely to be beneficial for her medical condition given a prior coronary angiogram did not show coronary anomalies. However, a CT angiogram of her mesenteric and renal arteries is likely to be beneficial for her medical condition as she has a documented history of mesenteric artery stenosis and renal vein stenosis. Given the above, a portion of the requested services are likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.  Final Result:  Two reviewers determined that a portion of the requested services are likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be partially overturned.  Credentials/Qualifications: All three reviewers are board certified in internal medicine with sub-specialty certification in cardiovascular disease 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: The patient has requested authorization and coverage for Orthovisc injections. This patient has been diagnosed with bilateral knee osteoarthritis. She has worsening knee pain and functional impairment in activities of daily living that has failed to respond adequately to conservative treatment. Prior Orthovisc provided pain reduction and functional improvement lasting at least six months, followed by recurrence of pain and functional limitations. She is not currently a candidate for total knee replacement due to her age. Evidence-based medical guidelines and peer-reviewed medical literature supports the use of viscosupplementation injections for the treatment of pain in patients with osteoarthritis of the knee. Repeat viscosupplementation injections have been found to be safe and effective and allow for delay of knee replacement surgery. Given this patients previous response and to assist in delaying total knee replacement, repeat Orthovisc injections are indicated. Therefore, the request for bilateral Orthovisc injections are medically necessary for treatment of the patients medical condition.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: Upheld

A 55-year-old female enrollee requested authorization and coverage of a colonoscopy. The Health Plan denied the request indicating that the requested procedure is not medically necessary for evaluation of the enrollees medical condition.One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer upheld the Health Plans denial on the basis that the requested procedure is not medically necessary.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a 15-year-old female enrollee has requested 5 hours per week of direct care (code H2019), 4 hours per week of supervision (code H0032) and 8 hours per month of parent consultation (code H0032) of applied behavioral analysis (ABA) services for treatment of the enrollees autism.  Findings:  The physician reviewer found that applied behavioral analysis (ABA) has been shown to be effective in treating behaviors associated with autism spectrum disorder (Kelley et al). Granpeesheh and colleagues note that although substantial gains are made after one year of ABA therapy when compared to controls, further gains have been noted in subsequent years. Additional studies have shown that ABA methods continue to result in positive outcomes in individuals with autism and intellectual disability (Grey et al). Evidence-based studies also noted improvement of function in older children with autism spectrum disorders using intense ABA interventions (Grey et al). The goals for older children are frequently to identify and remediate particular deficits.Treatments based on operant principles of learning have been noted to be more effective for reducing problem behaviors displayed by individuals with intellectual disabilities and autism than were alternative treatments (Grey et al). The behaviors in this patient to address include maladaptive behaviors of communication and noncompliance, and increasing functional life skills. Improvement has been noted with the patients current ABA plan. Continued ABA therapy including parent consultation/training is medically necessary to effectuate further gains. The proposed frequency of 5 hours per week of direct care (code H2019), 4 hours per week of supervision (code H0032) and 8 hours per month of parent consultation is medically reasonable and appropriate based upon this patients 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 a durable medical equipment, the Pedicraft Homecare Canopy Bed for treatment of the enrollee's congenital ganglioneuroblastoma.  Findings:  The physician reviewer found that there is support in the medical literature for the requested durable medical equipment in this clinical setting. This patient has cerebral palsy and global developmental delay as a result of congenital ganglioneuroblastoma and central nervous system recurrence. The patient is unable to clearly communicate the patients wants and needs. The patient is able to pull to stand but cannot walk independently. The patient has outgrown his current sleeping situation, and is able to put one leg over the side rail even when it is in the highest position. In addition, he has history of hitting the patients head on the side rails. Because of the patients increasing size, neurologic deficits, and developmental delay, he is no longer safe in his current sleeping environment. The patient requires a canopied bed without side rails or other metal surfaces to prevent injury. The patients current crib does not offer this. The Pedicraft Canopy enclosed crib bed provides a safe environment that this patient requires as the patient continues to grow and develop in a least restrictive environment. Final Result: The reviewer determined that the requested equipment 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 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.