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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for an Orthovisc injection series. Findings:  The physician reviewer found that  The requested  Orthovisc injection series is medically necessary for treatment of the patients medical condition. There is sufficient evidence based peer-reviewed literature that supports the use of repeat series of viscosupplementation injections for the treatment of pain in patients with osteoarthritis of the knee. According to a study, hyaluronic acid was found to be better than injected placebo or injected corticosteroids. another study conducted a systematic review on the efficacy and safety of repeat courses of hyaluronan therapy in patients with osteoarthritis of the knee and concluded that repeat courses of the hyaluronans were safe and effective in the treatment of pain associated with osteoarthritis of the knee. Similarly,  another study reported that repeated cycles of intra-articular sodium hyaluronate treatment to delay time to total knee replacement in patients with knee osteoarthritis which failed conservative treatment was found efficacious during a 54-month follow-up period. In this case, the patient presents with bilateral knee pain and a history of bilateral knee osteoarthritis. The patient had failed conservative treatment to include physical therapy, NSAIDs, and corticosteroid injections. In addition, previous Euflexxa and Orthovisc injections in 2013 and 2015 have provided excellent long-term relief of the patient's bilateral knee pain. Therefore, the requested Orthovisc injection series is medically necessary for treatment of the patients bilateral knee osteoarthritis. 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: Physician 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 61-year-old male who has a history of right knee pain and degenerative joint disease. He received a series of Synvisc injections in December 2003. His physician indicates the patient experienced unsatisfactory results with the first series of injections. He has recommended the patient receive a second series of injections to achieve optimum results. The Health Plan has denied authorization and coverage for Synvisc injections on the basis the injections are not medically necessary. The patient has a degenerative knee joint. In light of the failure of the first series of Synvisc, a second series of Synvisc injections are neither medically indicated nor medically necessary. Further Synvisc injections will not alleviate his condition. Other treatment options including cortisone or knee replacement should be considered. Therefore, I have determined that the requested injections are not medically necessary for treatment of the patients medical condition. The Health Plan denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld

A 22-year-old female enrollee has requested residential treatment center (RTC) services for treatment of her opioid dependence.   Findings:  The physician reviewer found that the residential treatment center (RTC) services provided the time period specified were not medically necessary for treatment of the patients medical condition. The patient presented with tremors and cramping with a COWS score of 0. Although she was reported to have suicidal thoughts, this was not elaborated upon in the documentation submitted for review. She had no medical comorbidity. Her psychiatric comorbidity of depression was being treated psychopharmacologically and was not of a severity that required 24-hour monitoring. Her vital signs were stable. She had no history of having attempted treatment at any other level of care within the three months prior to this admission. Based on the medical literature cited above and the documentation submitted for review, the RTC level of care provided from the time period specified were not medically necessary for treatment of the patients medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld

A 20-year-old female enrollee has requested intrapulmonary percussive ventilation (IPV) machine for treatment of her cystic fibrosis.  Findings:  Three physician reviewers found that this patient has cystic fibrosis, and airway clearance therapy is considered one of the cornerstones of treatment in the management of this disease.  However, there is a lack of evidence demonstrating that use of IPV machine is superior to other airway clearance methods that are available and routinely used in treatment.  The standard of care is chest physiotherapy, which requires another trained caregiver to administer on a regular basis.  Flutter valves can be used without assistance.  External chest compression therapy is generally used for patients without the availability of another caregiver, for whom the flutter devices are ineffective.  In this patients case, the records do not demonstrate failure of other standard methods of airway clearance.  Thus, the requested IPV machine is not likely to be of greater benefit than other treatment options.
Appeal type: Medical Necessity
Decision: Upheld

A female enrollee requested Xyrem for medical treatment of her excessive daytime sleepiness.    Findings:  The physician reviewer found that  Xyrem is U.S. Food and Drug Administration (FDA) approved for the treatment of narcolepsy. According to the documentation submitted for review, the patient does not have a diagnosis of narcolepsy. Based on the clinical documentation submitted for review, Xyrem is not medically necessary for treatment of the patients excessive daytime sleepiness.
Appeal type: Medical Necessity
Decision: Overturned

A 21-year-old male enrollee has requested residential treatment center (RTC) services for treatment of his behavioral health issues.  Findings:  The physician reviewer found that according to the American Psychiatric Association (APA) for individuals enduring an acute psychotic episode, the goals are to prevent harm to the patient and others, to control disturbed behavior, to reduce the severity of psychosis and associated symptoms. Although the patient in this particular case no longer posed an imminent threat to himself or others at the time of admission to the residential facility, he was still enduring an acute psychotic episode. He had recurrent explosive emotionality and behaviors, intrusive thoughts, psychosis and suicidality. The patient had difficulty tolerating antipsychotic and mood stabilizing medication. He had failed treatment in less restrictive settings and had required multiple acute hospitalizations. The disputed treatment was for both active treatment and purposes of diagnoses. The patient received evidence based services delivered in accordance with an individual treatment plan that were reasonably expected to improve his condition and prevent a more serious episode of illness. His antipsychotic medication was cross-tapered from lurasidone to olanzapine. He was trialed with an off-label medication for mood stability and continued with fluvoxamine, a serotonergic enhancing medication typically reserved for moderate to severe cases of obsessive compulsive disorder. Additionally, this anxious and psychotic patient had several concerning acute suicide risk factors which made the supervised treatment setting a safe and appropriate placement consistent with good medical practice in the United States.
Appeal type: Medical Necessity
Decision: Upheld

A 47-year-old female enrollee requested authorization and coverage of continued therapy (including paraffin baths and iontophoresis) for the treatment of the dislocation of the left, little finger.  The Health Plan denied the enrollees request indicating that the requested treatment is not medically necessary.One physician reviewer performed a medical necessity Independent Medical Review.  The physician reviewer upheld the health plans denial on the basis that the requested services are not medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld

A 42-year-old female enrollee requested authorization and coverage of Humatrope growth hormone. The Health Plan denied the request indicating that the requested growth hormone is not medically necessary for treatment of the enrollees possible growth hormone deficiency.One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer upheld the Health Plans denial on the basis that the requested therapy is not medically necessary.
Appeal type: Medical Necessity
Decision: Upheld

A 32-year-old female enrollee has requested panniculectomy with lipectomy for treatment of her excess skin.  Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested procedure.  A panniculectomy may be medically necessary for patients with a history of recurrent infections. The mere presence of a pannus does not automatically make its removal medically necessary.  There is no evidence in the reviewed materials that would support the medical necessity of a panniculectomy in this patients case. The documentation provided includes letters from the patients gynecologist and primary care physician in support of coverage for the requested surgery.  However, these letters lack objective data, such as dates of treatment of any skin condition related to the pannus or excess abdominal skin, or listing of any prescribed medications for such treatment. The proposed surgery will not improve function.  All told, the requested panniculectomy with lipectomy is not medically indicated for the treatment of this patient.
Appeal type: Experimental/Investigational
Decision: Overturned

A 62-year-old female enrollee has requested biofeedback therapy for the treatment of chronic pain. Findings:  Two physician reviewers found that review of the submitted clinical evidence demonstrates that the patient has maximized conservative treatment. The only option showing any benefit has been biofeedback therapy. As such, biofeedback therapy is medically appropriate and justified in this clinical context. The patient is not likely to experience better results with standard treatments given their failure to provide relief in the past.
Appeal type: Medical Necessity
Decision: Upheld

The enrollee is requesting authorization and coverage for right breast implant replacement surgery. The enrollee has a history of breast augmentation. She experienced pain during a mammogram. She reported that two days later she noticed deflation of her right breast implant. An evaluation by a plastic surgeon showed the right implant was smaller. The treatment options discussed were observation, removal of the implants, or replacement of the implant. The enrollee's breasts are not currently causing any health problems, and she will not suffer any adverse health consequences if plastic surgery on the breasts is not performed.  In fact, breast augmentation puts the enrollee at risk for functional problems. A study concerning the psychological benefits of breast augmentation showed that, though improvements in body image were found postoperatively and remained throughout the study, improvements in health-related quality of life were not observed.  The proposed surgery will not improve the health-related quality of life, and the surgery will increase the risk for health problems in the future.Final Result: The reviewer determined that the requested service is not medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The physician 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 similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

The patient is a 37-year-old male who has experienced headaches (muscle tension and cluster headaches) since the age of 19. Results of a neurological exam and MRI scan were negative. The submitted medical records reveal the patient has been tried on a large number of medications and treatment modalities without success. The patients neurologist provided Botox injections to the patient, which were effective for a five-month period. The patients neurologist has suggested further use of Botox injections. The Health Plan indicates Botox is not medically necessary for this patient. Upon review of the submitted clinical evidence, the diagnosis of cluster headaches appears appropriate. Cluster headaches are a form of migraine, typically seasonal, that are very debilitating and exceptionally difficult to treat. Cluster headaches can be devastating and should be treated by effective means. Botox injections have proven effective for this patient and should be continued as long as the patient experiences benefit. Therefore, I have determined that the requested therapy is medically necessary for treatment of the patients medical condition. The Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Upheld

A 53-year-old female enrollee has requested  for Avastin therapy for treatment of her glioblastoma multiforme. Findings:  The physician reviewer found that Avastin is one of a newer class of drugs, which interferes with the development of the blood supply feeding tumor cells. It has been FDA approved for use, along with chemotherapy, in metastatic lung and colon cancers. There is some preliminary, pre-clinical data suggesting that Avastin might also be useful in the treatment of brain tumors. There have been a few studies combining it with irinotecan, mostly to determine toxicity and feasibility. There is no convincing data as yet to demonstrate that Avastin alone, or with chemotherapy, has a significant impact in terms of either tumor responsiveness or survival benefit for the patient.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/ Case Summary:  The enrollee requested reimbursement for care at a wilderness program. The enrollee was admitted to a wilderness program to which she was admitted for severe depression and a suicide attempt. She regularly used marijuana and alcohol, as well as occasional cocaine. She reported feeling isolated and not connected with herself or with her friends. The enrollee became aware that she was not in a healthy place and requested treatment from her family who helped her get to a wilderness program. Throughout her time at the wilderness program, she developed healthy coping skills, communication skills, problem solving skills and awareness. She participated in individual and group therapy, as well as organic gardening milieu. Treatment for substance abuse included individual sessions and group sessions, through which she identified triggers to her use. Recent criteria emphasize the availability of treatment for co-occurring mental disorders and medical conditions in conjunction with substance use disorder (SUD) care, because higher rates of these conditions are seen in enrollees with SUD compared with the general population. The study also showed that, compared to residential and intensive outpatient programs, outpatient programs were more likely to provide dual-diagnosis services, which correlates with this enrollees dual diagnoses of mental disorders and substance abuse. Wilderness therapy includes interventions that may not be available in a traditional outpatient weekly therapy format. However, the literature notes additional studies are needed to gain a better understanding of the foundations and components of wilderness therapy. As well, the quality of the programs is variable. Literature support for wilderness therapy program (also known as adventure therapy) is weak. Due to the lack of uniformity, framework, and clarity on the therapeutic process and treatment outcomes of these programs, studies in support for these programs efficacy and safety for the treatment of psychiatric illness among youths are not substantiated. As a result, there is insufficient literature evidence and guidance to determine who may or may not benefit from wilderness therapy.Final Result: Three of the three reviewers determined that the requested services were not likely to be more beneficial than any available standard therapy for treatment of the enrollees medical condition. Credentials/Qualifications: Three reviewers are board certified in Psychiatry and Child & Adolescent Psychiatry 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: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for a multi-chamber programmable lymphedema pump (Flexitouch system). Head and neck lymphedema is a side effect from cancer treatment which is difficult to treat. Early institution of complete decongestive therapy is indicated for head and neck lymphedema. Complete decongestive therapy generally consists of a two-phase treatment program that can be used in both adults and children. The first phase includes a massage-like technique called manual lymphatic drainage and limb compression. The second phase is the maintenance phase and consists of compression garments worn during waking hours, exercises and self-manual lymphatic drainage. Intermittent pneumatic compression (IPC) is another method of compression therapy. IPC may be most effective in addition to a multimodality lymphedema treatment. IPC may also be an alternative maintenance program for lymphedema patients that have difficulty in performing self-manual lymphatic drainage secondary to weakness, fatigue, or range of motion deficits.  The Flexitouch system is an advanced intermittent pneumatic compression device used to self-manage lymphedema and non-healing venous leg ulcers. In this case, the patient has head and neck lymphedema which has not been found to be improved with IPC as much as limb lymphedema. Complete decongestive therapy is indicated for the treatment of this type of head and neck lymphedema. Thus, the multi-chamber programmable lymphedema pump (Flexitouch system) is not likely to be superior over other available methods of evaluating this patient. Findings:  Three physician reviewers found Final Result: The reviewers determined that the requested device is 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 internal medicine 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

Nature of Statutory Criteria/Case Summary: The patients parent has requested authorization and coverage for Dupixent. A study reports dupilumab (brand name Dupixent) is approved for the treatment of uncontrolled moderate-to-severe atopic dermatitis. In a systemic literature review, another study concluded for severe atopic dermatitis refractory to topical therapies, the strongest evidence currently existed for dupilumab and cyclosporine at improving clinical disease severity. An additional study notes during the COVID-19 pandemic, for patients with moderate-to-severe atopic dermatitis whose disease requires a new systemic agent during this time, starting dupilumab may be preferable to starting a traditional immunosuppressant. In this case, the patient has tried and failed topical therapies and emollients. Given that current medical literature reports that Dupixent is safe, well tolerated and effective in treating children with atopic dermatitis, the requested medication is medically indicated. Therefore, Dupixent is medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested medication is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in 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: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary:  An enrollee has requested reimbursement for positron emission tomography for evaluation of the enrollee who has a history of breast cancer and neurocognitive disorder.  Findings:  The physician reviewer found that Mild cognitive impairment (MCI) is a clinical presentation that is in the transitional stage between normal aging and frank dementia. When memory loss is the predominant symptom, it is referred to as MCI amnestic type. One distinguishing factor from Alzheimers disease is that patients with MCI with generally have preservation of general cognitive and functional abilities. Neuroimaging has helped to narrow the differential diagnosis. Most patients will initially have either a computed tomography scan (CT) or magnetic resonance imaging (MRI) study of the brain. These studies provide structural or anatomic information, and are useful in excluding such entities as tumors, strokes, subdural hematomas, or normal pressure hydrocephalus. But they do poorly in evaluating metabolic abnormalities. On the other hand, functional evaluation of the brain is best performed with PET/CT scanning which generally report higher accuracy (Davison, et al). The patient was also evaluated for routine follow up for her breast cancer in December. At that time, she had no symptoms directly referable to her breasts or possible metastases. While it is accepted that the early initial detection of breast cancer greatly increases the likelihood of survival and cure there is a lack of data demonstrating that early detection via surveillance imaging studies provides substantial benefit as opposed to watchful waiting. In conclusion, there is considerable literature supporting the use of PET scanning in the evaluation of possible dementia. As such, the PET scan provided  was likely to have been more efficacious in the evaluation of this patients condition than the available standard modalities, while the use of PET scan provided for the routine surveillance follow up of breast cancer was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Final Result: Two of the three reviewers have determined that a portion of 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 partially overturned.Credentials/Qualifications:  All three reviewers are board certified 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.