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

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for right knee osteochondral allograft transplantation (CPT Code 27415-22).Medical literature supports that the services at issue were medically necessary. Articular cartilage lesions are difficult to treat in the knees and osteochondral allograft transplantation is a good option for the relatively large lesions described in the operative report. Wise and colleagues considered the use of this allograft in all four regions described in the operative report. They found that research has shown that patients undergoing this procedure have favorable outcomes and are satisfied with the procedure. A researcher studied osteochondral allograft transplantation and found that 88% of patients undergoing this procedure return to competitive sports, a fact which was not possible with other procedures in the past. In this case, the patient had injury related full thickness chondral lesions of the patella, trochlea, medial femoral condyle, and lateral femoral condyle as well as recurrent anterior cruciate ligament deficiency with instability. In this setting of full thickness chondral lesions, osteochondral allograft transplantation is supported by medical literature showing favorable outcomes and patient satisfaction. Accordingly, the right knee osteochondral allograft transplantation (CPT 27415-22) at issue was medically necessary to treat the patients medical condition.Final Result: The reviewer determined that the services at issue were medically necessary for the 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

Nature of Statutory Criteria/ Case Summary:  The enrollee requested coverage for the medications Crestor 10 mg tablets and Cozaar 50 mg tablets. Review of the records reveals only one blood pressure reading that was elevated on 2/10/17 as 160/80. There is no laboratory lipid data that would confirm whether the patient was or was not responding to the medication he was taking. There is also no evidence of a side effect that could be attributed the lipid lowering medications being taken, such as muscle aches. There is no information provided concerning response to the brand name medications requested compared to the generic equivalent. There is also no                                                                                                                                                                                                  information in the records of adverse drug effects to a generic version of both of these medications. Based on current literature, and medical records provided for review the requested brand name medications were not found medically necessary for this patient. Result: The reviewer determined that the medications Crestor 10 mg tablets and Cozaar 50 mg tablets are medically necessary for the treatment of the enrollees medical condition.Credentials/Qualifications: The physician reviewer is board certified in cardiology 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

Findings:  The physician reviewer found that Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Adderall XR 15 mg and/or Xanax 0.5 mg #15. The records provided for review document that this patient has diagnoses of autism, GAD, and ADHD. The patient has reportedly benefited from treatment with Adderall XR for ADHD and infrequent use of Xanax for breakthrough anxiety symptoms. On review of the peer-reviewed medical literature, this patients request for continued treatment with Adderall XR and Xanax is supported as medically necessary. As noted by Geffen and Forster, Adult ADHD responds well to integrated pharmacological and psychotherapeutic intervention. Given this patients compliant use of Adderall XR and Xanax, as well as documented benefit in ADHD symptoms from the medication regimen, continued treatment with Adderall XR is appropriate (Hoge, et al.). Moreover, the patient only requires treatment with Xanax infrequently as a rescue medication in addition to a selective serotonin reuptake inhibitor (SSRI) for management of the patient's panic symptoms. For these reasons, Adderall XR 15 mg and Xanax 0.5 mg #15 are medically necessary for treatment of this patient. Final Result: The reviewer determined that the requested medications are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Upheld

A 48-year-old female enrollee has requested Valium 3 month supply (#300) at one time, in lieu of receiving the medication on a monthly basis (#100) for treatment of her dizziness. Findings:  The physician reviewer found that in the medical literature, the use of sedatives, or hypnotics including Valium, are contraindicated and can cause respiratory arrest in patients with COPD or OSA. Since the patient has both COPD and OSA, she is at considerable risk for these complications. According to the Audio-Digest Foundation, caution should be exercised when using benzodiazepines in patients with respiratory conditions. Further, Valium is a long acting benzodiazepine, accumulates in the system, and has potential for addiction. It is in the patients best interest not to be prescribed three months of this medication at one time. Therefore, when Valium is prescribed, it should only be done so on a monthly basis under close physician monitoring. For these reasons, the requested medication quantity is not supported as medically necessary for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned

The patients parent has requested authorization and coverage for mastectomy (chest masculinization). The World Professional Association for Transgender Health (WPATH) states that the surgery can be performed in patients under the age of 18 after ample time of living in the desired gender roles and after a year of testosterone treatment. Researchers noted that, chest dysphoria was high among presurgical transmasculine youth, and surgical interventions positively affected both minors and young adults. A psychological evaluation indicates that this patient is depressed from the presence of a feminine-appearing chest. Moreover, the patients providers support the requested procedure to address the patients distress related to gender dysphoria. Given these findings, the requested mastectomy (chest masculinization) is medically necessary for 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 psychiatry with subspecialty certification in child and adolescent 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: Experimental/Investigational
Decision: Upheld

A 41-year-old female enrollee has requested artificial disk replacement for the treatment of her degenerative disc disease. Findings:  Three physician reviewers found that artificial disc replacement is not yet considered a standard of care.  While there is FDA approval for the devices, they are considered investigational due to the lack of long term peer reviewed literature outlining their efficacy and safety. Continued research is required to address development of adjacent segment disease, implant debris, risk of dislodgement and other potential risks.  Disc replacement would, therefore, not be considered more beneficial than the traditional use of fusion.  Based on the lack of long term studies, use of an artificial disc replacement would not be considered medically appropriate.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for a Synvisc injection. Per the medical literature, although viscosupplementation may relieve knee pain in some individuals with osteoarthritis, it is not known as to which individuals will benefit. 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 had tried and failed conservative treatments with ibuprofen, ice packs, and a corticosteroid injection, with the alternative being a total knee arthroplasty. Given the patients limited options and based on the current medical literature, the service at issue was medically indicated. Therefore, the Synvisc injection was medically necessary for the treatment of this patient.Final Result: The reviewer determined that the service 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 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: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested breast tomosynthesis for evaluation of her medical condition.  Findings:  Two physician reviewers found that there is sufficient support for the services at issue in this clinical setting.  The advantage of breast tomosynthesis relates to its ability to separate out normal glandular elements of the breast from underlying mass/architectural distortion, thereby resulting in a decrease in callbacks and increase in detection of small cancers.  Thus, the addition of breast tomosynthesis to the two-dimensional imaging protocol of digital mammography was likely of greater benefit to the patient than had her examination been done with two-dimensional imaging alone. Final Result: Two 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:  All three reviewers are board certified in diagnostic radiology 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 Synvisc-One (hyaluronan) injection in both knees. Findings: Per the medical literature, although viscosupplementation may relieve knee pain in some individuals with osteoarthritis, it is not known as to which individuals will benefit. 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 chronic severe pain in both knees and has tried and failed other conservative treatments, including steroid injections, and surgical intervention. Given the patients limited options and based on the current medical literature, the requested services are medically indicated. Therefore, Synvisc-One (hyaluronan) injection in both knees is 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: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollees parent has requested reimbursement for wilderness therapy services. Current medical literature suggests that wilderness therapy may be an effective treatment option for a wide variety of adolescents, including youth with substance abuse problems and adolescents suffering from depression and various other clinical disorders, and improve interpersonal relationships. However, there is a lack of evidence supporting the claim that outdoor behavioral healthcare programs are superior to standard therapies as a treatment intervention for adolescent substance use and mental health disorders. Few studies directly compare outcomes of outdoor behavioral healthcare programs to other therapeutic interventions. Researchers note that in a scoping review of direct comparison trials in adventure therapy, only 13 studies met the full inclusion criteria. The authors found few significant differences to isolate specific therapeutic factors. While literature on outdoor behavioral healthcare programs suggest that participants show some level of improvement on behavioral health outcomes, the results are not conclusive. There is a lack of randomized controlled trials or well-designed cohort studies that would allow for causal conclusions about the impact of outdoor behavioral healthcare programs. In this clinical setting, there is a lack of data to support the claim that outdoor behavioral healthcare programs were more effective than other therapies. Therefore, wilderness therapy services were not likely to have been more beneficial for treatment of the patients condition than any available standard therapy.Final Result: The reviewers determined that the services at issue were not likely to have been 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 and 3 are board certified in psychiatry with sub-specialty certification in child and adolescent psychiatry and are actively practicing. Physician reviewer 2 is board certified in psychiatry 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: Experimental/Investigational
Decision: Upheld

A 39-year-old female enrollee has requested sacroiliac injections for the treatment of her back pain. Findings:  Three physician reviewers found that the injections at issue are not generally accepted treatment for the patients condition. There is inadequate data to show that the injections result in superior clinical outcomes. Additional studies are needed to demonstrate the efficacy of these injections.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary:   An enrollee has requested a dermatology consultation for evaluation of her changing mole.  The physician reviewer found that according to the documentation from the primary care providers notes, the patients mole in question does not exhibit any concerning signs or symptoms for skin cancer. The patient reports that the mole has been enlarging. She also stated that her mother passed away secondary to skin cancer. However, based on the documentation provided, the requested referral for consultation with a dermatologist is not medically necessary in the absence of any concerning signs or symptoms for skin cancer. Final Result: The reviewer determined that the requested referral is not medically necessary for evaluation 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: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for physical therapy. The submitted documentation fails to demonstrate the medical necessity of the requested services. Per the current medical evidence, the focus of treatment should be patient education, self-care, analgesics, independent exercise and remaining active.  The benefit of prolonged formal exercise therapy services is not established in the medical literature for this patients condition. There is no proven marginal benefit of passive modalities, such as massage/manual therapy, and modalities provided in a formal setting on a prolonged basis on pain, health or functional outcomes over self-massage and topical treatments, such as ice or heat applied independently. There is as lack of proven benefit of manual therapies for idiopathic scoliosis. In this case, the patient does not have documented impairments that would preclude her from performing an appropriate exercise program, including stretching and strengthening, as well as independent soft-tissue and palliative interventions, such as self-massage using foam rollers or massage balls, and topical treatments, such as ice or heat. Overall, although the patient has ongoing symptoms, there is no expectation of a marginally significant difference in clinical course or outcomes with the proposed therapies in question over an independent program. Therefore, the requested physical therapy is not medically necessary for the 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 physical medicine and rehabilitation 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

The parent of a 21-year-old male enrollee has requested a mandibular positioning device and related medical services for the treatment of the enrollees sleep apnea. Findings:  The physician reviewer found that the central problem with determining medical necessity in this case is that the patient has not had a sleep study using the oral/dental positioning device to determine if it is effective in reducing the episodes of obstructive sleep apnea (OSA). The Practice Parameters referenced above indicate that `Although not as efficacious as CPAP, oral appliances are indicated for use in patients with mild to moderate OSA who prefer OAs (oral appliances) to CPAP, or who do not respond to CPAP, are not appropriate candidates for CPAP, or who fail treatment attempts with CPAP or treatment with behavioral measures such as weight loss or sleep position change.` The Parameters state, however, that `Because of the inability to predict success reliably, when OAs are selected, follow-up testing should be obtained to ensure treatment effectiveness.` The patient travels frequently and therefore CPAP may be difficult at those times. As such, an oral positioning device might be a reasonable alternative. However, the patient has not had follow-up testing to demonstrate effectiveness. The device cannot be considered medically necessary if it has not been demonstrated to be effective in treating the patients sleep apnea.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a 10-year-old male enrollee has requested for growth hormone (GH) therapy for treatment of the enrollees idiopathic short stature. Findings:  The physician reviewer found that review of the submitted clinical evidence demonstrates that the patient fulfils the Food and Drug Administration criteria for GH therapy for the treatment of idiopathic short stature. He is abnormally short and has a projected adult height of 63 to 64 that is well below his mid-parental target of 70. The patient has had a positive response to GH therapy, further supporting the recommendation for continued treatment.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for a Synvisc-One (hyaluronan) injection in both knees. 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. 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 patients case, there is a history of lasting benefit from viscosupplementation in the past, and it helped more than any other treatment. There is sufficient support for the requested services in this clinical setting. Therefore, the requested Synvisc-One (hyaluronan) injection in both knees is 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.