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

Nature of Statutory Criteria/Case Summary: The patient is a 57-year-old male with bilateral primary osteoarthritis of the knees. X-rays reportedly demonstrated osteoarthritis of both knees, particularly severe in the right patellofemoral joint with abnormal configuration of the distal patella. The patient failed noninvasive treatment. Per the records, the patient benefitted from Euflexxa injections in both knees previously. The patient has requested authorization and coverage for Euflexxa injections. The Health Plan denied the request and reported that the requested services are not medically necessary for the treatment of this patient. This patient has had significant benefit from prior injections. Current literature supports the use of viscosupplementation for osteoarthritis of the knees. Intra-articular hyaluronic acid provides a moderate symptomatic benefit for knee osteoarthritis without major safety concerns. Viscosupplementation may offer one of the best benefit/risk ratios among pharmacologic options, as measured by improvements in knee osteoarthritis symptoms, gain in quality of life, and substantial delay in time to total knee replacement. There is evidence that intra-articular hyaluronic acid injections reduce pain and increase function in knee osteoarthritis, and the benefits are long-lasting as compared with intra-articular corticosteroids. Evidence from real-life studies of repeat courses of intra-articular hyaluronic acid demonstrates an improvement in pain or function that lasts up to 40 months (12 months after the last injection cycle), 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. The medical evidence supports the requested Euflexxa injections in this clinical setting. Therefore, the requested Euflexxa injections 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: Overturned

Nature of Statutory Criteria/Case Summary:  An enrollee has requested percutaneous ventricular assist device (PVAD) for treatment of the enrollees cardiogenic shock.  Findings: Three physician reviewers found that this patient presented with an acute myocardial infarction treated with urgent coronary artery bypass surgery.  This was followed by documented cardiogenic shock despite volume resuscitation and pressor therapy.  In this circumstance, temporary additional hemodynamic support using the Impella device was appropriate in an attempt to lessen cardiogenic shock while waiting for ventricular function to improve after coronary revascularization.  Seyfarth and colleagues performed a study of patients with cardiogenic shock after myocardial infarction randomly assigned to an Impella device or intra-aortic balloon pump, and the authors noted improved hemodynamic parameters with the Impella device.  All told, the device at issue was likely to have been of greater benefit than other treatment options in this clinical setting.Final Result: Three reviewers determined that the device at issue was 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 cardiovascular disease 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

A 50-year-old male enrollee has requested authorization and coverage for computed tomography (CT) scan of the heart for evaluation of his hyperlipidemia.  Findings:  The physician reviewer found that based on the records provided, the patient has mild coronary risk given his hyperlipidemia, no cardiac symptoms, and no history of heart disease. The applicable guidelines on the diagnosis and management of dyslipidemia are endorsed by the National Cholesterol Education Program (NCEP) and the American College of Cardiology Foundation (ACCF). These guidelines currently do not recommend routine screening with coronary CT in this patients clinical situation since there is no evidence that coronary CT scanning provides incremental benefit in improving cardiac outcomes beyond that obtained using standard clinical risk profiling alone. Based on this patients age, lipid status, and lack of other documented coronary risk factors, his estimated 10-year risk for developing a coronary event is less than 10% using data from the Framingham Heart study. In this low risk setting, screening coronary CT scanning is not supported as medically necessary for evaluation of this patients cardiac risk.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary:   An enrollee has requested a prostatic urethral lift implant (Urolift) for treatment of his medical condition. Findings:  Two physician reviewers found that the submitted records fail to demonstrate the superior effectiveness of the requested services.  The Urolift may be a temporary solution to lower urinary tract symptoms and may be considered a bridge to more definitive therapy.  There is a need for double-blind, long-term studies to determine the long-term efficacy of this modality.  In this patients case, the requested Urolift procedure is not likely to be of greater benefit than other treatment alternatives. Final Result: Two reviewers determined that the requested services are not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld.  Credentials/Qualifications: All three reviewers are board certified in urology 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: Upheld

An enrollee has requested authorization and coverage for continuing treatment with the Optune device and the medication Avastin.The patient has exhausted all treatment options involving surgical resection followed by radiation therapy with concurrent and adjuvant temozolomide. The submitted documentation includes two assessments from physicians caring for the patient that attest to his poor performance status, which would correspond with a grade of 4 on the ECOG Performance Status scale. The patients tumor is advanced, and the requested Optune device is not curative. Under these circumstances, continuing treatment with the Optune device and the medication Avastin is not medically necessary to treat the patients medical condition.Final Result: The reviewer determined that continued treatment with the requested device and medication 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 internal medicine, with subspecialty certification 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 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.  Findings:  The physician reviewer found that according to the most recent joint guidelines issued by the American Association for the Study of Liver Diseases and the Infectious Diseases Society of America, 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.  Per the 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.  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: Medical Necessity
Decision: Upheld

A 48-year-old female enrollee has requested authorization and coverage for lumbar epidural steroid injection and bilateral sacroiliac injections.  Findings:  The physician reviewer found that a review of available documentation demonstrates that this patient may be suffering with lumbar radiculitis on the left side. There is no objective evidence demonstrating that she has sacroiliac joint pain either on one side or bilaterally. The primary indication for sacroiliac joint blocks is to determine if a patients pain is arising from the sacroiliac joint.  Key indicators would be patients with chronic low back pain that is maximal below the level of L5 vertebra, with or without somatic referenced pain in the lower limb, in whom no other diagnosis is readily apparent, and whose pain is not evolving with passage of time or conservative therapy. Although this patient has failed multiple trials of medication therapy, there is no notation that she has failed other conservative treatment methods, including an exercise program and/or physical therapy. This patient does not meet the criteria for medically necessary epidural steroid injections or bilateral sacroiliac injections, as the source of her pain is not clearly defined, and she has not failed all conservative therapy.  All told, the requested lumbar epidural steroid injection and bilateral sacroiliac injections are not medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld

A forty-six year-old female who had ACL reconstruction and partial lateral meniscectomy is requesting reimbursement for use of a CPM device.Reviewers Findings:  The reviewing physician found that there is insufficient evidence to conclude that utilization of a CPM device following the type of surgery this patient underwent results in outcomes which are superior to those obtained with standard post-operative care and management without utilization of a CPM device.  The reviewing physician found that the Health Plan denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld

A 60-year-old male enrollee has requested allergy skin testing and exhaled nitric oxide measurement for evaluation of his chronic sinusitis. Findings:  The physician reviewer found that specific clinical criteria must be met for the substitution of radioallergosorbent (RAST) IgE for standard percutaneous testing. From a review of the available records, a referral for additional evaluation of the patients symptoms with the requested percutaneous skin testing is unwarranted at this time. As noted in UpToDate, Percutaneous skin testing is generally considered the optimal way of determining allergic sensitivity Positive tests are only meaningful if the results are compatible with the clinical history and physical findings.  In addition, this patients records reveal that the diagnosis of chronic sinusitis has not been established radiographically, by physical examination, or through bacteriologic cultures. The patients records describe normal physical examinations. There is no documentation of allergy symptoms, specific triggers, or seasonality which may be indicative of an underlying allergic disorder. For these reasons, the requested diagnostic testing consisting of allergy skin testing and exhaled nitric oxide measurement have not been established as medically necessary.
Appeal type: Medical Necessity
Decision: Upheld

An enrollee has requested authorization and coverage for facial feminization revision surgery (scalp advancement, forehead feminization, osteotomy, reconstruction and rhinoplasty, upper lip shortening primary, chin and jawline revision, trach shave primary with submental fat reduction and a chin tuck) performed during one surgery (as opposed to two surgeries). In this case, the estimated surgery time of 6 hours for the listed procedures in a single stage approximates the fastest that the surgery could be expected to be carried out by a surgeon with extensive experience, with the published procedures requiring up to 8 hours and 15 minutes. The surgery in this patient is almost all revisionary, and revision rhinoplasty, in particular, requires significant additional time as compared with primary rhinoplasty, because of adherent tissue and post-surgical scarring. The use of more than one surgical stage over a period of no less than 6 months is accepted scheduling and treatment of facial feminization. Under these circumstances, the requested facial feminization revision surgery performed during one surgery (as opposed to two surgeries) is not medically necessary. Accordingly, the requested facial feminization revision surgery (scalp advancement, forehead feminization, osteotomy, reconstruction and rhinoplasty, upper lip shortening primary, chin and jawline revision, trach shave primary with submental fat reduction and a chin tuck) performed during one surgery (as opposed to two surgeries) is not medically necessary to treat the patients medical condition.Final Result: The reviewer determined that the performance of the requested services during one surgery (as opposed to two surgeries) is not medically necessary to treat the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is board certified in plastic surgery 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

A 53-year-old male enrollee requested authorization and coverage of external counterpulsation therapy. The Health Plan denied the request indicating that the requested therapy is experimental for treatment of the enrollees congestive heart failure.Three physician reviewers performed an experimental/investigational Independent Medical Review. Two of the three physician reviewers concluded that the requested therapy is likely to be more beneficial for treatment of the enrollee's medical condition than any available standard therapy. One of the three physician reviewers concluded that the requested therapy is not likely to be more beneficial for treatment of the enrollee's medical condition than any available standard therapy. Because two of the three  physician reviewers concluded that the requested therapy is likely to be more beneficial for treatment of the enrollee's medical condition than any available standard therapy, the Health Plans denial has been overturned.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for the Intracept procedure. According to the U.S. Food and Drug Administration (FDA), Intracept is recommended for use in conjunction with radiofrequency generators for the ablation of basivertebral nerves of the L3 through S1 vertebrae for the relief of chronic low back pain of at least six months duration that has not responded to at least six months of conservative care. Patients should also have features consistent with Type 1 or Type 2 Modic changes on an magnetic resonance imaging (MRI). Fischgrund and colleagues concluded patients treated with radiofrequency ablation of the basivertebral nerve for chronic low back pain exhibited significantly greater improvement at three-month follow-up and a higher responder rate than sham treated controls. This patient is being treated for spondylosis without myelopathy or radiculopathy in the lumbar region. She noted the symptoms are worsening and now radiate into pelvis, hip, and thigh areas. The patients records lack detailed documentation to support the patients spinal vertebral bodies as the primary generators of her chronic persistent pain. The available clinical and imaging findings suggest significant plausible symptom contribution from disc herniation, nerve root impingement, and/or spinal stenosis. Overall, there is a lack of long-term, published peer-reviewed literature showing that the Intracept procedure is an effective and safe treatment at long-term follow-up. Therefore, the requested Intracept procedure is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Findings:  Two of the three physician reviewers found the requested Intracept procedure is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the requested services are not likely to be 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, 2, and 3 are board certified in orthopedic surgery and are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

A 58-year-old female enrollee requested authorization and coverage of blepharoplasty. The Health Plan denied the request indicating that the requested procedure is not medically necessary for the treatment of the enrollees impaired vision.One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer overturned the Health Plans denial on the basis that the requested procedure is medically necessary.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for residential treatment center (RTC) services. The American Association of Community Psychiatrists Level of Care Utilization System (LOCUS) provides a reliable framework for determining the appropriate level of care for adults needing mental health treatment. Using LOCUS, providers score patients on a scale of 1-5 using a six-pronged Dimensional Rating System. The six dimensions include: (1) risk of harm; (2) functional status; (3) medical, addictive and psychiatric comorbidity; (4) recovery environment (a. stressors and b. supports); (5) treatment and recovery history; and (6) engagement. The composite score is then used to determine the level of care needed. With regard to risk of harm, the records support a score of 2. The patient had some potential for risk of harm due to a history of self-harm. The records did not note current suicidal ideation or significant distress. In terms of functional status, the records support a score of 3. The documentation noted moderate functional impairment due to ongoing, variably severe deficits in function. With regard to comorbidity, the records support a score of 2. The patient had minor comorbidity due to a history of cannabis use. In terms of level of stress of the recovery environment, the records support a score of 2.  The patient had a mildly stressful environment as the patient did well in protected environment but was facing some transitions. With regard to level of support of the recovery environment, the records support a score of 2 as the patients parents are supportive and participatory in treatment. In terms of resiliency and treatment history, the records support a score of 2. The patient had a significant response to intensive treatment but was not always able to sustain gains made.With regard to treatment acceptance and engagement, the records support a score of 2. The patient had a positive attitude toward treatment and recovery.Thus, the patient has a total score of 15. In this case, the recommended level of care is low intensity community-based treatment. In this patients case, RTC level of care was not in accordance with the generally accepted standards of mental health and substance use disorder care. Additionally, the services at issue were not clinically appropriate in terms of type, frequency, extent, site, and duration. Therefore, RTC services were not medically necessary for the treatment of this patient.Final Result: The reviewer determined that the services at issue were 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 psychiatry with sub-specialty certification in addiction 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.