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

A 53-year-old female enrollee has requested a pain management consultation for treatment of her chronic pain. Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested services in this patients case.  There is lack of documentation of the patients response to conservative therapy, which may be appropriately ordered and assessed by the primary care physician.  Conservative therapy includes physical therapy and non-steroidal anti-inflammatory medications.  Additionally, the results of the x-rays do not demonstrate any pathology requiring a pain management consultation prior to failed conservative therapy.  The current medical evidence does not support the requested services in this clinical setting.  Niemisto and colleagues performed a prospective randomized controlled trial to examine the effectiveness of combined manipulative treatment, stabilizing exercises, and physician consultation compared with physician consultation alone for chronic low back pain.  The authors concluded that the manipulative treatment with stabilizing exercises was more effective than physician consultation alone.  All told, the requested pain management consultation is not medically indicated.
Appeal type: Medical Necessity
Decision: Overturned

The patient has requested authorization and coverage for Synvisc injections in the right knee. 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 a history of lasting benefit from prior injections. The patient has tried and failed other conservative treatments, including corticosteroid injections, with the alternative being a total knee arthroplasty. Given the patients limited options and based on the current medical literature, the requested services are medically indicated. Therefore, for Synvisc 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

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the genotype testing for genetic polymorphisms to determine drug metabolizer status for evaluation of the enrollees depression and possible bipolar disorder. Findings:  The 3 physician reviewers found that the Millennium Pharmacogenetic Testing (PGT) is a non-invasive genetic test utilizing either an oral swab or saliva specimen to identify how a patients genetic profile may impact his or her response to certain medications. Pharmacogenetic testing in psychiatry is a newly evolving field and is rapidly gaining wide acceptance but large randomized controlled trials are needed to further substantiate the utility of genetic testing in psychiatry. A review of the available literature regarding pharmacogenetic testing suggests that it has been studied that to the extent that genetic factors are associated with the efficacy, tolerability, and safety of different drugs, pharmacogenetic tests may be used to personalize medication treatments for an individual. However, there is a paucity of large randomized controlled trials that demonstrate the efficacy of pharmacogenetic testing in psychiatry. Based on the review of the submitted documentation, the genotype testing for genetic polymorphisms to determine drug metabolizer status performed was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Final Result: The 3 reviewers determined that the testing at issue was 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: Physician reviewer number one is board certified in psychiatry and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.Physician reviewer number two is board certified in psychiatry and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.Physician reviewer number three is board certified in psychiatry and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement and prospective authorization and coverage for skilled nursing facility (SNF) services. Functional impairments due to acquired brain insults such as stroke can be severe to profound. While functional recovery may be amenable to natural recovery processes and rehabilitative measures, the extent of initial injury is a major determinant of functional outcomes as it defines the residual neuronal reservoir that is capable of engaging in recovery (Alawieh, et al.). As noted in the medical literature, most of the significant neurological and functional recovery following a stroke occurs in the early stages after stroke and gains are slower in subsequent stages (Kubis). There is a general consensus that initiating rehabilitative measures earlier in the post-stroke course enhances outcomes (Belagaje, et al.). Comorbidities are associated with poorer outcomes after stroke (Desilles, et al.). This patients records document that they sustained an ischemic stroke in late January 2021. The patients condition was complicated by edema requiring hemicraniectomy and by hemorrhagic transformation of the stroke. These multiple cerebral insults caused a severe early neurological injury burden. The patient has severe to profound neurological deficits that have persisted with minimal improvement. Repeat imaging has shown encephalomalacia, atrophy, and ventriculomegaly. Functionally, they have plateaued at requiring maximum to total assistance for their basic self-care and transfers. The patient has remained non-ambulatory. They are tolerating their enteral tube feeds, which are supplemented by oral feedings. There is a lack of documentation to support an indication an ongoing need for skilled nursing or therapy services on a regular basis as of the date of denial. The patients medical needs have been custodial in nature. Therefore, the SNF services were not and are not medically necessary for treatment of this patient. Final Result: The reviewer determined that the services at issue were not and 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

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for magnetic resonance imaging (MRI) of the left hand, MRI of the left wrist, MRI of the right ankle, and MRI of the right foot. Findings: The American College of Radiology (ACR) indicated that MRI can be beneficial in specific circumstances after baseline x-rays have been obtained. On review of the ACR criteria, this patients records do not support the MRI studies performed on the left hand and wrist, or MRI of the right ankle and foot as medically necessary. There is a lack of documentation that the patients physical examination had joint-specific provocative orthopedic examination findings, which are reported as one of the ACR appropriate use criteria requirements. Although MRI studies can be used for evaluation of known or suspected autoimmune disease, the patients prior x-rays did not demonstrate any abnormality or non-diagnostic findings to require additional assessment with MRI. Moreover, the records fail to document participation in physical therapy or other non-operative treatments prior to the MRI studies being performed. All told, the MRI of the left hand, MRI of the left wrist, MRI of the right ankle, and MRI of the right foot were not medically necessary for evaluation of this patient. Final Result: The reviewer determined that the services at issue were 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 orthopedic surgery and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested Harvoni for treatment of his hepatitis C virus genotype 1a.  Findings:  The physician reviewer found that according to the most recent joint guidelines issued by the American Association for the Study of Liver Diseases (AASLD) and the Infectious Diseases Society of America (IDSA), all patients with chronic hepatitis C should be treated except those with limited life expectancy due to non-liver-related conditions. This applies regardless of fibrosis stage or viral load, and advanced fibrosis is not required for treatment. Per guidelines, treatment-naive genotype 1 patients should be treated with Harvoni. Patients with viral load of less than 6,000,000 IU/mL can be treated for eight weeks. These guideline recommendations are based on multiple randomized clinical trials (Kowdley, et al; Afdhal, et al). Moreover, the AASLD and IDSA guidelines cite data showing reduced survival with delayed treatment (Jezequel, et al). For these reasons, the requested treatment with Harvoni is supported as medically necessary for the treatment of this patients hepatitis C infection. Final Result: The reviewer determined that the requested medication is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.  Credentials/Qualifications: The reviewer is board certified in internal medicine with sub-specialty certification in gastroenterology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for the combination of Otezla (titration pack followed by 30mg twice a day) with Inflectra infusions.Findings: Two out of three physician reviewers found that the requested combination of Otezla (titration pack followed by 30mg twice a day) with Inflectra infusions is not likely to be more beneficial than any other available standard treatment for the patients medical condition.American College of Rheumatology/National Psoriasis Foundation guidelines state that in those patients with active psoriatic arthritis despite TNFi monotherapy, switching to a different TNFi biologic monotherapy is recommended over switching to IL-12/23i biologic, an IL-17i biologic, abatacept, or tofacitinib monotherapy or adding methotrexate to the current TNFi biologic. The largest study for using combination therapy is a retrospective, open label study by Metyas and colleagues involving 22 patients diagnosed with plaque psoriasis and psoriatic arthritis. They concluded that apremilast (Otezla) can be safely combined with all biologic agents in patients with plaque psoriasis or psoriatic arthritis not responding adequately to biologics alone. There are case reports demonstrating efficacy and safety but the current literature fails to demonstrate any large randomized controlled trials. There are no national recommendations for combination therapy for the treatment of psoriatic arthritis with apremilast and another agent. In this case, the patient has active psoriasis and psoriatic arthritis. She has failed 2 TNFi (Humira due to dental infections, and Inflectra due to an incomplete response), IL-17I (Cosentyx due to abdominal pain) and methotrexate (due to abdominal pain). Based upon the submitted documentation, there are other medication classes that the patient has not tried. There is no evidence of subcutaneous methotrexate, another TNFi, abatacept or interleukin (IL) 12/23 (ustekinumab) trials. Therefore, the requested combination of Otezla (titration pack followed by 30mg twice a day) with Inflectra infusions is not likely to be more beneficial than any other available standard treatment for the patients medical condition.Final Result: The reviewers determined that the requested combination of medications is not likely to be more beneficial than any other available standard treatment for the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: Physician reviewers 1, 2 and 3 are board certified in internal medicine, with subspecialty certification in rheumatology, and are actively practicing. All three reviewers are experts in the treatment of the enrollees medical condition and are 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

This patient has Erdheim-Chester disease (ECD) and bone metastasis from prostate cancer. He is being treated with Mekinist with a good response, per the medical records. At issue is whether the requested whole body Positron Emission Tomography (PET) Scan with Computed Tomography (CT), is medically necessary to treat the enrollees medical condition. The patients ECD disease process and response to treatments has been monitored with PET-CT scans. Treatment is largely experimental since there are no clear recommendations or outcomes to guide therapy. Thus, monitoring response to therapy is largely on a case-by-case basis. The literature reports that PET-CT scans are used to determine response and adjust treatment based on imaging results and are performed every 2-6 months after initiation of a new therapy for response assessment. Final Result: The reviewer determined that the requested service is medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The physician reviewer is board certified in medical oncology        and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

A 52-year-old female enrollee requested laser treatment of nasal telangiectasias for the treatment of her medical condition.  Findings:  The physician reviewer found that this patient is status post multiple rhinoplasties and the medical records indicate that further surgery was not recommended by at least one physician.  The patients telangiectasia does not constitute an abnormal structure of the body, as these can develop normally on the face with time.  The requested procedure would not be expected to improve function or more than minimally improve the appearance of the patient.  All told, the requested laser treatment of nasal telangiectasias is not reconstructive in nature and is not medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for breast reduction surgery for treatment of the enrollees hypertrophy of breast. Findings:  The physician reviewer found that in this case, the patient has documented evidence of symptomatic macromastia. Her symptomatology, examination detail and review of the photographs are supportive of this diagnosis. She has multiple functional deficits supported by typical signs and symptoms associated with macromastia. She has neck, back, shoulder and breast pain. She has evidence of significant macromastia on review of the photographs. Her chronic pain has failed conservative management with multiple medications and physical therapy. The degree of resection planned of 800 grams is also supportive of significant macromastia. The patients macromastia is causing functional problems are directly related to her macromastia. Breast reduction is a well-known procedure that directly addresses functional compromise. Final Result: The reviewer determined that the requested surgery 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 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: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/ Case Summary: The enrollee is requesting authorization and coverage for intense pulse light (IPL) treatment. This is a patient with dry eye syndrome (DES), bilateral blepharitis (eyelid inflammation), keratoconjunctivitis sicca (dryness of the membrane that lines the eyelids and covers the white of the eye, and the clear layer in front of the iris and pupil) and meibornian gland dysfunction (MGD or lack of adequate oil secretion in tears). The provider reported that the patients visual acuity is 20/30 in the right eye and 20/20 in the left eye. The patient experiences a little DES improvement with topical cyclosporine (Restasis) eye drops, preservative-free artificial tears (PFATs), fluorometholone (FML) steroid eye drops, and nightly eye ointment. The current treatment plan is to continue the PTATs, eye ointment, to increase Restasis drops to three times a day, and to continue FML drops four times a day for two weeks. The provider requested intense pulse light (IPL) treatment. The scientific evidence in peer-reviewed literature does not support a result of improvement in health outcome to support IPL therapy as likely to be more beneficial than any other standard treatment (PFATs, eye drops, and ointments) for this patients eye conditions. According to the Preferred Practice Patterns of the American Academy of Ophthalmology 2018, there are several in-office procedural treatments available that may unclog the meibomian gland such as IPL therapy or mechanical means such as gland probing or microblepharoexfoliation (a micro-sponge to physically scrub the edge of the eyelids and eyelashes). Although there have been industry-sponsored studies, independent, randomized, masked clinical trials have yet to be performed to assess efficacy of these treatments. IPL therapy/treatment has not received final approval from the appropriate regulatory bodies for the patient's diagnoses of dry eye syndrome, blepharitis, keratoconjunctivitis, or MGD. Final Result: Three of the three reviewers determined that the requested services were not likely to have been more beneficial than any available standard therapy for treatment of the enrollees medical condition.Credentials/Qualifications: Three reviewers are board certified in ophthalmology        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 similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for speech therapy for treatment of his phonological childhood onset fluency disorder. Findings:  The physician reviewer found that the medical records include a neurologists evaluation which states that the patient likely suffered perinatal hypoxia which manifested as left cerebral hemispheric damage. There was also evidence of motor coordination abnormalities. Therefore, the patients current speech disorder likely originated from cerebral hypoxia. Since the patients speech disorder is likely due to a hypoxic event, the requested speech therapy services are medically necessary. 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 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

A 65-year-old male enrollee has requested eyebrow corrective surgery for the treatment of his eyebrow loss. Findings:  The physician reviewer found that this patient had a brow lift via superciliary brow incisions. He has visible unsightly incision scars above each brow that are not totally correctable by any means. It cannot be covered over by hair grafting because it lies at the edge of the eyebrows where the hairs are normally sparse. Filling it with sufficient grafts to hide it would result in a very unnatural looking eyebrow. The current condition does not constitute an abnormal structure of the body, such as a mutilated digit. The requested surgery would be done to improve appearance rather than improve function, and will likely not end up improving appearance. Improvement, if any, will not create a normal appearance or offer more than a minimal improvement in appearance. The requested procedure is not medically indicated and the California statute relative to reconstructive surgery does not apply.