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

Nature of Statutory Criteria/Case Summary: An enrollee with primary osteoarthritis of the right knee has tried non-invasive treatment in the past and has benefitted from viscosupplementation of both knees. The enrollee is requesting repeat injections of Euflexxa for recurrent knee pain. The pain is mostly on the medial and posterior aspect and is associated with a positive patellar grind test, and with medial and lateral tenderness. Imaging studies confirm the presence of osteoarthritis. The submitted documentation supports the medical necessity of the requested services. The current literature continues to support the use of viscosupplementation for osteoarthritis of the knees. A study found that there is good evidence that intraarticular hyaluronic acid injections reduce pain and increase function in knee osteoarthritis, and the benefits are long-lasting as compared with intraarticular corticosteroids. Evidence from real-life studies of repeat courses of intraarticular hyaluronic acid demonstrates an improvement in pain or function lasting up to 40 months, a reduction in use of concomitant analgesia by up to 50%, and suggests that there may be a delay in the need for total knee replacement of around 2 years. Researchers performed a systematic review of overlapping meta-analyses comparing viscosupplementation with other nonoperative treatment modalities for knee osteoarthritis. Their review found that the current highest level of evidence suggests that intraarticular hyaluronic acid is a viable option for knee osteoarthritis and that its use results in improvements in knee pain and function that can persist for up to 26 weeks. Viscosupplementation has a good safety profile, and its use should be considered in patients with knee osteoarthritis. There is sufficient support for the requested services in this clinical setting. Therefore, Euflexxa injections in the right 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: Experimental/Investigational
Decision: Upheld

A 51-year-old female enrollee has requested a dynamic low load prolonged state stretching device (shoulder DynaSplint). for treatment of her frozen shoulder status post motor vehicle accident.  Findings:  Two physician reviewers found that this patient has made progress with her physical therapy program with some reduction in range of motion between therapy sessions. This occurrence can be attributed to multiple reasons, however this does not support the need for a DynaSplint device. Currently, the DynaSplint does not have sufficient clinical evidence to support its use beyond usual care. The study in this area performed by DynaSplint did not include a control group or sufficient power to demonstrate its efficacy. As such, the utility of the DynaSplint shoulder device remains uncertain in the treatment of patients with adhesive capsulitis and the Health Plan appropriately denied this request.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for laparoscopic anti-reflux surgery utilizing LINX reflux management system (esophageal sphincter augmentation device). Findings:  The physician reviewers found that the medical evidence supports the requested services in this patients case.  Appropriate patient selection is crucial before anti-reflux procedures.  In this patients case, the records document that the patient has undergone an appropriate preoperative assessment.  The LINX device is an appropriate option for the management of medically refractory gastroesophageal reflux disease.  This patient has gastroesophageal reflux disease based on pH recordings.  Per the records, she has not benefited to a significant degree from multiple combination acid suppression treatments.  As such, she can be considered medically refractory to acid blocker drugs.  The available records do not document contraindications to implantation of the LINX device. Therefore, the requested laparoscopic anti-reflux surgery utilizing LINX reflux management system is likely to be of greater benefit than other treatment options. Final Result: 2 of 3 reviewers determined that the requested services are 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: All three physician reviewers are board certified in internal medicine with sub-specialty certification in gastroenterology 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: Upheld

The patient is a 54-year-old female with a history of complex migraine headaches that have been treated with a triptan (Frova) and more recently an anticonvulsant medication (Topomax). She has asked for an increase in her Frova prescription to 18 tablets a month. The Health Plan has denied this request and has authorized nine tablets a month. The Health Plans denial should be upheld. There is no evidence demonstrating an increase in the patients Frova prescription is medically indicated or necessary. The patient has had a bubble study, which suggests a patent foramen ovale and could explain the source of her neurological symptoms. A common treatment regimen for patients with patent foramen ovale is Depakote for prophylactic treatment and Zomig nose drops for acute migraine episodes. Perhaps a change in the patients treatment regimen could be beneficial. The Health Plan is correct that there is no medical justification for increasing the patients Frova prescription. Therefore, I have determined the requested prescription increase is not medically necessary for treatment of the patients condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned

The patient is a 48-year-old woman who has been experiencing knee pain since at least September 2003. The patient was seen by her provider at least six times from September 2003 to March 2004, during which time the patient continued to complain of pain. The patient was given a knee brace and medication for arthritis was prescribed. Physical findings included tenderness, decreased range of motion, crepitus, and swelling. The patients provider has ordered an MRI of the knee to evaluate for a meniscal tear. The Health Plan has denied authorization for the requested MRI on the basis that it is not medically necessary.The patients persistence of symptoms and physical findings support further evaluation. MRI is the best non-invasive test to evaluate the knee. According to the article cited above, MRI of the knee is the imaging test of choice for meniscal pathology and is one of the most efficient uses of technology. Other evaluation techniques are less accurate, largely operator dependent or more invasive. The results of the MRI are necessary to determine further treatment options for this patient. Therefore, I have determined that the requested MRI is medically necessary for evaluation of the patients medical condition. The Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Upheld

The patient is a four-year-old male who was diagnosed with autism in June 2003. He began receiving speech therapy in February 2003 and occupational therapy in November 2003. Currently the patients receptive and expressive speech is delayed with only one to two word combinations. The patient follows one-step commands and can respond to direction with context. He engages in parallel play, but has minimal interactive socialization. He continues to have significant concentration/distractibility issues and continues to have difficulty with fine motor skills and poor motor planning. He is imitating sounds in his environment and is able to respond to simple questions. The Health Plan has denied coverage for occupational and speech therapy services on the basis they are no longer medically necessary.I have reviewed all the information provided, including the DVDs. While the DVDs demonstrate some improvement with the patients ability to respond to his environment and simple use of language, the occupational and speech therapists do not document substantial gains over the two years of therapy the patient has received. The patients initial evaluations do not include objective testing to document the patients deficits. Although the patient made some progress towards his goals in speech therapy, he has not met any of his goals over two years of therapy. Furthermore, there is no evidence of follow-up, objective testing. Regarding occupational therapy there is no evidence of objective standardized testing or intermittent reports and the daily reports are not specific and do not relate to specific goals.Because of the lack of objective evidence regarding the patients deficits as well as the lack of evidence demonstrating substantial gains during the patients course of therapy, I have determined the requested services are not medically necessary. Therefore, 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 bariatric consultation and bariatric surgery for treatment of the enrollees obesity. Findings: The physician reviewer found that there is a lack of published literature to support mandated preoperative weight loss efforts prior to bariatric surgery. In this case, the patient documents obesity with a BMI of 35 and sleep apnea. A bariatric consultation as well as a multidisciplinary team evaluation is clinically indicated as she is a potential candidate for bariatric surgery. This patient has previously failed both dietary and supervised efforts at weight loss without success. A bariatric team is best able to evaluate the candidacy of an obese patient. Although the patient is a potential candidate for bariatric surgery for treatment of obesity, it cannot be determined that bariatric surgery is medically necessary as she has not completed the bariatric consultation and multidisciplinary evaluation. Final Result: The reviewer determined that a portion of the requested services are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be partially overturned. Credentials/Qualifications: The reviewer is board certified in 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

The patient is a 53-year-old female with depression treated with Lexapro and Effexor and a listed diagnosis of idiopathic hypersomnia. The patients provider indicates Provigil was prescribed for a diagnosis of idiopathic hypersomnia rather than for treatment of the patients depression. There is no documentation in the clinical material that the patient has had a multiple sleep latency test (MSLT). The Health Plan has denied coverage for Provigil on the basis it was not medically necessary for treatment of the patients sleep disorder.The International Classification of Sleep Disorders Diagnostic and Coding Manual lists the alternate name for idiopathic hypersomnia as non-REM narcolepsy. Idiopathic hypersomnia is a clinical variant of narcolepsy and is treated the same way. In both disorders the MSLT reveals a mean sleep latency of less than 5 minutes.  In narcolepsy there is REM sleep documented and in idiopathic hypersomnia the sleep latency is identical but there is no REM sleep documented. Provigil is FDA approved for the treatment of narcolepsy and its clinical variant, idiopathic hypersomnia. However, in the case of this patient there are no objective clinical findings (i.e., a MSLT) to substantiate the diagnosis. Thus, there was no documented FDA approved indication for the use of Provigil in this patient.Based upon the information set forth above, I have determined the medication at issue was not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Experimental/Investigational
Decision: Overturned

A 43-year-old female enrollee has requested past and future coverage for transcranial magnetic stimulation (TMS) for treatment of her major depressive disorder.  Findings:  Two physician reviewers found that the patient has a history of major depressive disorder. She had been tried on several different pharmacologic agents including Cymbalta, Lexapro, Prozac, Effexor, Remeron, Pamelor, Zoloft, Trazodone, Abilify, Celexa, Paxil, Wellbutrin and Pristiq. The patient has continued to have symptoms of anhedonia, decreased energy, cognitive impairment, interpersonal withdrawal, trouble sleeping, irritability, weight change, fatigue and suicidal ideation. This patient has been diagnosed with major depressive disorder and her condition has been refractory to numerous medication trials. Given her failure to respond to various medications, her provider recommended TMS as approved by the US Food and Drug Administration (FDA). In addition, this patient has not responded to conventional medications or therapies for the treatment of her sustained depression. It is thus reasonable that she receive TMS therapy for her diagnosis of major depression.
Appeal type: Medical Necessity
Decision: Upheld

The patient is a 48-year-old female with a 33-year history of bulimia nervosa and bipolar disorder who was admitted to residential treatment on 12/27/04 for treatment of the former. At that time the patient had been restricting calories, binging on donuts and ice cream, engaging in reflex vomiting two to three times a day, and exercising about an hour to an hour and half a day. She presented to residential treatment with a regimen of Trazadone, Seroquel, Celexa, Cymbalta, and Wellbutrin SR. Though she had been treated with Depakote in the past, there is no other record of treatment with mood stabilizers, such as Lithium or Lamictal. She noted struggling not only with bulimia, but also with depression, part of which was related to having lost her job and coping with five adopted children, one of whom has epilepsy.Review of the submitted treatment notes indicates the patient mostly struggled with depression, not bulimic episodes though admittedly ruminated about feeling fat. Regardless, none of her psychotropic medications were changed and she was thereby treated via the various psychotherapies offered. In addition to feeling anxious and depressed, many of the notes point to the patient feeling rather angry and having a pessimistic perspective. There is no documentation regarding her binging or purging while in the program and post-meal observation was apparently discontinued by 1/24/05. The patients stay was denied beyond 1/25/05 and she was referred to a partial hospitalization program. The patient has requested authorization and coverage to return to residential treatment level of care. Review of the records provided reveals a prevailing affective and character pathology, the latter initially considered as that of borderline and obsessive-compulsive disorder origins. However, it appears this was given little attention during the course of the patients residential treatment. In addition, given her diagnosis of bipolar disorder, her medication regimen seems rather askew. It appears a mood stabilizer would have been appropriate rather than a multitude of antidepressants. Based upon the information provided, treatment focused on bulimia rather than mood-related problems. The submitted records include little documentation pertaining to the patients bulimia while in residential treatment, in contrast to the actual plethora of documentation pointing to mood-related problems. At the time of her discharge the patient was stable from a purely eating disorder standpoint. Partial hospitalization services, which have been authorized by the Health Plan, are medically reasonable and appropriate for treatment of the patients bulimia. She can also receive treatment for her bipolar disorder and character pathology in a partial hospitalization program. The submitted documentation does not demonstrate that residential level of care is medically warranted.Based upon the information set forth above, I have determined that 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 surgery for treatment of his medical condition.   Findings:  The physician reviewer found that the evidenced-based medical literature supports the recommended surgical treatment plan. In the setting of necrotic tissue with possible residual osteomyelitis, adequate debridement of the surgical area prior to attempted revision fusion is crucial, as any retained necrotic tissue could result in recurrence.  The re-implantation of hardware in this patients case would not be supported, as it tends to become secondarily infected. The use of a circular fixation device would be supported to maintain hindfoot alignment following bone grafting. Therefore, the requested surgery is medically necessary for the 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.  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

The patient is a 48-year-old woman with left leg pain and dermatitis associated with varicose veins. She has worn compression stockings for over two years without relief. A venous duplex exam showed no saphenofemoral junction reflux, but did show a perforating vein of the lower leg that refluxed into the great saphenous vein below the knee. The provider requests authorization for endovenous laser ablation treatment (EVLT) of the distal great saphenous vein and the incompetent perforating vein. The Health Plan denied the request citing a lack of medical necessity.The patient has met the requisite symptom severity and conservative therapy criteria for treatment of her varicose veins. However, endovenous laser therapy (EVLT) has been shown to be inferior to both endovenous radiofrequency ablation (RFA) and traditional surgical ligation and stripping. The study cited above found that treatment failure was twice as common with EVLT as with RFA. RFA has been shown to have efficacy similar to surgical therapy in a randomized study. In general, studies of EVLT have been limited to patients with proven saphenofemoral junction reflux. Appropriate therapy in this patient would involve ligation of the incompetent perforating vein, which appears to be responsible for the distal great saphenous vein reflux.Based upon the information set forth above, I have determined the requested procedure 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  reimbursement for the nerve stimulation treatment for his overactive bladder.Findings: Three physician reviewers found that the nerve stimulation treatment, procedure were likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. There is sufficient support in the peer-reviewed literature for the services at issue in this clinical setting. The medical literature demonstrates significant improvement in overactive bladder symptoms using posterior tibial nerve stimulation (Burton, et al). In this case, the documentation submitted for review demonstrates that the patient tried on multimodal therapy without significant improvement in voiding symptoms. Given his lack of improvement with standard therapies, the services at issue were likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Final Result: Three reviewers determined that the services at issue were 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: All three reviewers are board certified in urology 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: Experimental/Investigational
Decision: Overturned

A 35-year-old female enrollee has requested for distal left greater saphenous vein ultrasound-guided transcatheter endovenous chemoablation (sclerotherapy) for treatment of her varicose veins. Findings:  Two physician reviewers found that the reflux at the saphenofemoral juncture was successfully treated by VNUS Closure as proven by the latest venous Doppler study. Ultrasound-guided sclerotherapy is a logical approach to removal of the residual small segment of distal left greater saphenous vein. The greater saphenous vein toward the ankle is of much smaller diameter, therefore wall approximation after sclerotherapy is more easily accomplished. There is very little chance of injuring the saphenous nerve using sclerotherapy when compared to stripping or the VNUS techniques. The resultant neuropraxia can be very annoying and can even become permanent. The venous Doppler study showed no reflux or incompetence in either the greater or lesser saphenous systems on the right, therefore sclerotherapy for the solo right calf varicosity would also seem to be the best approach.