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 Synvisc One injections in both knees. Medical literature concluded that hyaluronic acid was the best pharmacologic intervention for knee osteoarthritis in a meta-analysis of 137 studies with 33,243 patients. Hyaluronic acid was found to be better than injected placebo or injected corticosteroids. A study found that a systematic review of overlapping meta-analyses (total 20,049 patients) comparing intra-articular hyaluronic acid with other non-operative treatment modalities for knee osteoarthritis. They reported that the current highest level of evidence suggests that intra-articular hyaluronic acid is a viable option for knee osteoarthritis. Nationally recognized evidence based medical guidelines state that hyaluronic acid injections in the knee are recommended as a possible option for patients with severe osteoarthritis who have not responded adequately to recommended conservative treatments for at least three months, including failure to adequately respond to aspiration and injection of intra-articular steroids. Guidelines support hyaluronic acid injections to potentially delay total knee replacement for patients with pain that interferes with functional activities. Guidelines also indicate that if there is documented significant improvement in symptoms for six months or more, and symptoms recur, it may be reasonable to perform another series. There is no maximum amount of injections established by high quality scientific evidence. This patient presents with recurrent bilateral knee pain. Significant functional limitations are noted in weight bearing tolerance and activities of daily living. Clinical examination findings have been consistent with bone-on-bone bilateral knee osteoarthritis. Reasonable conservative treatments have failed to provide adequate symptom relief. The patient reported that several prior Synvisc One injections provided up to six months of significant pain reduction and functional restoration. Evidence based medical peer-reviewed 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 these findings, the requested Synvisc One injections in both knees are supported as medically necessary for treatment of this 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.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The guardian of an enrollee has requested general anesthesia for dental procedures for treatment of the enrollees medical condition.  Findings:  The physician reviewer found that the request for general anesthesia for dental procedures is medically necessary in this clinical setting. General anesthesia for pediatric dental procedures is generally considered to be a safe and effective practice. General anesthesia is often employed to facilitate extensive dental treatment particularly in younger pediatric patients who do not have the psychological or emotional maturity required to cooperate in an office setting. The combination of an inability to cooperate and a need for an extensive dental procedure makes general anesthesia an appropriate treatment modality for pediatric patients. A medical study reviewed and collected data from general anesthesia records for over 700 patients over a two-year period. The utilization of general anesthesia allowed for comprehensive and high quality dental care. This was particularly applicable in cases of young patients who required extensive dental treatment. The study explains the rationale for endorsement of general anesthesia by the American Academy of Pediatric Dentistry. This includes the ability to facilitate dental treatment in pediatric patients who are unable to cooperate, require significant surgical procedures or comprehensive oral care. In addition, this study also notes that despite the risk of adverse events, general anesthesia in a hospital operating room is considered safe, efficient and more cost effective than repeated dental visits for oral restoration. In this case, there is documentation of the need for extensive dental work and full mouth oral rehabilitation. For these reasons, the requested services are medically necessary and appropriate for 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 anesthesiology 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: A enrollee has requested reimbursement for the magnetic resonance imaging (MRI) of the breasts. Contrast enhanced breast MRI is a highly sensitive examination helpful in identifying abnormalities that may be are occult on mammography and ultrasound. The indications for breast MRI include high risk screening, new diagnosis of breast cancer to evaluate for additional sites of disease, and patients with positive margins after lumpectomy. Additional indications include evaluation of response to chemotherapy prior to surgery, evaluation for breast cancer recurrence, evaluation of metastatic cancer of an unknown primary source, and when mammographic or ultrasound findings are inconclusive. Studies show breast MRI may be used for lesion characterization in the setting in which mammographic and ultrasound findings are inconclusive and biopsy cannot be performed. This indication is only applicable after additional diagnostic mammographic views as well as targeted ultrasound examinations have been performed. Contrast enhanced breast MRI was therefore not indicated in this case. If the ultrasound findings were suspicious, then short-term ultrasound follow-up or biopsy should have been performed. Accordingly, the breast MRI was not likely to be more beneficial for evaluation of the patients condition than available standard imaging.One reviewer found that the breast MRI was likely to be more beneficial for evaluation of the patients condition than available standard imaging.Final Result: Two of the three 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:  One reviewer is board certified in radiology and is actively practicing. One Reviewer is board certified in radiology and is actively practicing.  One Reviewer is board certified in diagnostic radiology 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: Upheld

Nature of Statutory Criteria/Case Summary: The patient who was diagnosed with obesity. She underwent a sleeve gastrectomy and lost a significant amount of weight, resulting in loose and excess abdominal tissue. The patient reported frequent rashes and difficulty with hygiene due to the excess lower abdominal skin. The patients body mass index was 32.81. Her abdominal pannus was noted to cover the region of the mons pubis. No evidence was noted of a rash under the skin fold, and no active wounds or infections were present. Preoperative photographs demonstrate a large lower abdominal pannus that hangs below the pubis. There is also a smaller upper abdominal pannus overhanging the umbilical area. The patient has requested reimbursement for abdominoplasty with flank liposuction surgery that was provided. The Health Plan denied the request and reported the services at issue were not medically necessary for the treatment of this patient and were not reconstructive in nature. At issue in this case is whether abdominoplasty with flank liposuction surgery that was  provided was medically necessary for the treatment of the patients medical condition and whether the services at issue were reconstructive in nature. Abdominoplasty is typically performed for cosmetic purposes and involves the removal of excess skin and fat from the pubis to the umbilicus or above. When abdominoplasty or panniculectomy are performed solely to enhance a patients appearance in the absence of signs or symptoms of functional abnormalities, the procedure is considered cosmetic in nature. In this case, there is no report of intractable intertrigo, skin ulceration, chronic pain, or inability to walk as a result of the patients upper abdominal pannus. Therefore, abdominoplasty with flank liposuction surgery that was provided was not medically necessary for the treatment of this patient. An abdominal pannus is not an abnormal structure of the body. It is a normal structural change that is an accommodative response to gain or loss of body mass. The appearance of the patient is consistent with the gain and loss of weight. Therefore, abdominoplasty with flank liposuction surgery that was provided on 11/28/18 was not reconstructive in nature.Final Result: The reviewer determined that the requested services were not medically necessary for treatment of the patients medical condition and were not reconstructive in nature. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is board certified in plastic 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 Supartz injections for treatment of his medical condition.  Findings:  The physician reviewer found that the submitted documentation supports the medical necessity of the requested services.  The evidence-based peer-reviewed literature supports the use of repeat series of viscosupplementation injections for the treatment of pain in patients with osteoarthritis of the knee. This has been found to be safe and effective and allowed for delay of total knee replacement. There is a lack of evidence that one brand of hyaluronic acid is better than any other brand. This patient has been diagnosed with knee osteoarthritis and reports long-term use of Supartz injection series with good pain reduction. Therefore, the requested Supartz injections are medically indicated 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: Urgent Care
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for emergency ambulance services. Findings:  The physician reviewer found that the services at issue were necessary for treatment of an emergency medical condition. In this case, the patient was discharged from the hospital but remained significantly ill and required oxygen. The complexity of the patients chronic illness coupled with multiple evolving serious complications required ongoing hospitalization which was not an option in Mexico. Readmission to the local hospital for further care would have wasted valuable time given the patients serious medical issues. The patient had an evolving emergency medical condition with the oxygen requirement at a minimum, requiring emergent transport. The complexity of the patients chronic condition with evolving serious complications made the most appropriate receiving facility one in which his already familiar, multi-specialty team of providers would be present to address this evolving multi-organ system emergency, particularly in the context of such a long-distance transport. Transport to any other facility would have resulted in a delay in definitive care as well as an inevitable second transport. In addition, the patient required IV pain medication and breathing treatments during flight and these interventions are not routinely available on commercial flights. In sum, the ambulance services provided were emergent, and could not have been provided by treatment locally or transport to any other closer facility. Thus, the ambulance services provided were for emergency services. Final Result: The reviewer determined that the patient received emergency medical services on the date of service at issue. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in emergency 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: Medical Necessity
Decision: Upheld

This patient is a 42-year-old male with an apparent substance abuse disorder and sexual addiction who was admitted to a partial hospitalization program in July 2005. In August 2005 the patient was apparently diagnosed with major depression and was treated with Wellbutrin. It appears the patient responded well to treatment and was cooperative. The Health Plan indicates the submitted documentation does not demonstrate that partial hospitalization services were medically necessary beyond August 2005. The patient has requested coverage for partial hospitalization services after August 2005.Review of the clinical evidence provided indicates the patient was stable by August 2005 with his substance abuse, sexual addictive problems and depression. He was not suicidal, homicidal or psychotic. He was motivated to continue sobriety and further treatment. As such, continued partial hospitalization was no longer medically necessary for any of his psychiatric conditions. A lesser level of continued treatment was appropriate after August 2005. Therefore, I have determined the requested services are not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary:  An enrollee has requested authorization and coverage for Orthovisc injection series.Findings: 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 good relief from prior viscosupplementation. Furthermore, the patients options are limited. The patient has tried and failed steroid injections, with the alternative being total knee arthroplasty. Therefore, the requested Orthovisc injection series knee is 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: Overturned

A 38-year-old female enrollee has requested for a duodenal switchfor treatment of her morbid obesity. Findings:  The physician reviewer found that the duodenal switch procedure is more appropriate for this patient than any other weight loss procedure available in this setting. Furthermore, there is no compelling evidence that duodenal switch results in significant perioperative risks or postoperative nutritional complications
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Ozempic pen. Findings: A study notes that while lifestyle modification is recommended as the cornerstone of obesity management, as many patients do not achieve long-lasting benefits due to difficulty with adherence as well as physiological and neurohormonal adaptation of the body in response to weight loss, there are currently multiple pharmacologic therapies which are available for weight management. Another study reports that glucagon-like peptide-1 (GLP-1) analogs, such as Ozempic, improve glycemic control, reduce body weight, and decrease cardiovascular risk. Cornell notes that GLP-1 receptor agonists have an established efficacy and safety profile. Given that current medical literature supports the use of the Ozempic in promoting weight loss and the low likelihood of health risks associated with this medication, the requested medication is medically indicated. Therefore, Ozempic pen 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 endocrinology, diabetes, and metabolism 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 Afirma Gene Expression Classifier test for evaluation of his thyroid nodule. Findings:  Three physician reviewer found that while a FNA biopsy of a suspicious thyroid nodule is typically an accurate means of assessing whether the nodule is benign or malignant, approximately 15% of FNA biopsy results are considered to be indeterminate. Until recently, the only way to establish whether the nodule was thyroid cancer was via surgical excision even though the majority of the cases turned out to be benign. The Afirma test utilizes a gene expression classifier in order to help determine the likelihood of malignancy of nodules with indeterminate cytology on FNA biopsy. Because it is sensitive and has a high negative predictive value, a negative Afirma result is suggestive of a benign nodule and can therefore preclude such surgical procedures. Final Result: The reviewers determined that the testing at issue was 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: Reviewers 1, 2, and 3 are board certified in internal medicine with sub-specialty certification in endocrinology, diabetes and metabolism 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

The patient has requested reimbursement for a mandibular reposition. The patient is diagnosed with mild obstructive sleep apnea. The provider noted that the patient was not able to tolerate continuous positive airway pressure (CPAP) in the past. Researchers notes that the mandibular advancement appliance (MAA) is the most common type of a dental device in use today. The device makes the mandible protrude forward, preventing or minimizing the upper airway collapse during sleep. A significant variability in the patients response to treatment has been observed, which can be explained by the severity of sleep apnea at baseline and duration of treatment. In some trials, patients with mild OSA show a similar treatment effect after the use of CPAP or MAA. It is worthwhile to give it a try with an oral appliance of MAA type in snoring, mild-to-moderate sleep apnea, and in individuals who are intolerant to CPAP treatment. In this case, the patient has been diagnosed with OSA and was intolerant of CPAP. The medical evidence supports the device at issue in this clinical setting. Therefore, a mandibular reposition device was medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested device 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 a licensed D.D.S., certified in oral facial and maxillary 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.