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

Nature of Statutory Criteria/Case Summary: : An enrollee has requested authorization and coverage for Lyrica 150 mg capsules. Findings:  The physician reviewer found that there is a lack of support for the requested medication in this patients case. Two separate articles have shown that pregabalin (Lyrica) is no better than placebo in pain relief for radicular pain. A study conducted a randomized controlled trial and did not find statistically significant differences in pain, disability, or patient satisfaction scores. Similarly, another study conducted a large, randomized, placebo-controlled trial with follow-up for 52 weeks. The authors found no reduction in pain in comparison with placebo and significantly more adverse effects with pregabalin. This medication is not likely to be efficacious for this patients pain. Therefore, Lyrica 150 mg capsules are not medically necessary for the treatment of this patient.  Final Result: The reviewer determined that the requested medication is 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 anesthesiology with sub-specialty certification in pain medicine 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

A 57-year-old female enrollee has requested for right total ankle replacement with the STAR ankle arthroplasty device for treatment of her advanced end-stage arthritis.  Findings:  Two physician reviewers found that the STAR total ankle replacement is relatively new in the U.S., it has been used in Europe for over 10 years with sufficient long-term follow-up studies reporting favorable results. Additionally, the medical literature and the U.S. Food and Drug Administration (FDA) support the utility and durability of the STAR total ankle replacement. Saltzman and colleagues concluded that, By 24 months, ankles treated with STAR ankle replacement (in both the Pivotal and Continued Access Groups) had better function and equivalent pain relief as ankles treated with fusion. Considering the scientific data proving the long-term safety and efficacy of the STAR total ankle replacement, this procedure should no longer be considered investigational or experimental.
Appeal type: Experimental/Investigational
Decision: Upheld

A 57-year-old female enrollee requested authorization and coverage of bariatric surgery through the duodenal switch surgical procedure. The Health Plan denied the request indicating that the requested procedure is considered experimental for treatment of the enrollees medical condition.Three physician reviewers performed an experimental/investigational Independent Medical Review. Two physician reviewers concluded that the requested procedure is not likely to be more beneficial for treatment of the enrollee's medical condition than any available standard therapy. One physician reviewer concluded that the requested procedure is 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 surgery is not likely to be more beneficial for treatment of the enrollee's medical condition than any available standard therapy, the Health Plans denial has been upheld.
Appeal type: Medical Necessity
Decision: Overturned

The mother of a 16-year-old female enrollee requested authorization and coverage of continued residential behavioral health services for the treatment of the enrollees medical condition. The Health Plan denied the request indicating that the requested services are not medically necessary for treatment of the enrollees behavioral health problems.One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer overturned the Health Plans denial on the basis that the requested services are medically necessary.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested Xyrem for treatment of his narcolepsy. Findings:  The physician reviewer found that the submitted documentation supports the medical necessity of the requested medication. Patients with narcolepsy have some degree of daytime sleepiness. The goal of pharmacologic therapy is to obtain normal alertness during important activities, such as working, going to school or driving.  Generally, first-line treatment of excessive daytime sleepiness is with a stimulant such as modafinil, methylphenidate or amphetamines. Xyrem is used for the treatment of continued daytime sleepiness despite the use of a stimulant.  In this case, the patient has been treated with a stimulant, Nuvigil 200 mg daily, with continued symptoms of daytime sleepiness. 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 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 37-year-old female enrollee has requested Lyrica for the treatment of her meningitis. Findings:  The physician reviewer found that the submitted documentation does not establish the medical necessity of Lyrica therapy. The patient did not have a diagnosed condition for which Lyrica was indicated. There were other therapies available for management of this patients condition. There is no indication for the use of Lyrica over standard therapies for treatment of headaches or meningitis.
Appeal type: Medical Necessity
Decision: Upheld

A 33-year-old female enrollee requested magnetic resonance imaging (MRI) of the neck for medical evaluation of her migraines.   Findings:  The physician reviewer found that the American College of Radiology (ACR) does not include MRI of the cervical spine or neck for this patients medical condition.  This patients records indicate that previous CT imaging of the head was unremarkable and an MRI of the brain stem revealed no evidence of ischemia or other abnormality of the brain. All told, this patients records do not support the medical necessity of an MRI of the neck.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for  monitored anesthesia care (MAC) services provided during an endoscope procedure. The current guidelines for sedation and anesthesia in gastrointestinal endoscopy concluded that that use of a combination of an opioid and benzodiazepine is a safe and effective regimen for achieving minimal to moderate sedation for upper endoscopy and colonoscopy in patients without risk factors for sedation-related adverse events. The guidelines further state that, Minimal and/or moderate sedation can be delivered safely by endoscopists to patients who are ASA Class I, II, or III. Other candidates for minimal or moderate sedation include those with a history of previously successful procedures with moderate sedation and an expectation for moderate sedation as well as those undergoing a procedure that is expected to be uncomplicated or routine. Researchers cautioned that their findings suggest that use of anesthesia service was associated with a 13% increase in the risk of any complication within 30 days. In this case, the patient presented for a routine endoscopy. The patient does not have any documentation of significant heart, lung, kidney, or liver disease. There is a lack of documentation of a history of alcohol or substance abuse, previous history of difficulties with anesthesia, or sedation with past colonoscopies documented in the records provided for review. The provider assessed the patient to have an airway classification score of 2 and there was no evidence that he presented with a difficult airway. For these reasons, the MAC services provided during an endoscope procedure were not medically necessary for 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 anesthesiology with subspecialty certification in pain medicine 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

The parents of a two-year-old female enrollee have requested  for speech and physical therapy for treatment of the enrollees medical condition. Findings:  The physician reviewer found that this patient has gross motor delays, with decreased trunk rotation and internal rotation of her right lower extremity (which is causing gait abnormalities and difficulties with sitting and half-kneeling). The patient has showed some improvement with her prior speech and physical therapies. However, she needs these therapies on an on-going basis to address her communication and feeding difficulties and gross motor delays.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Synvisc injections of both knees. 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. 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. 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. Intra-articular hyaluronic acid 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, Synvisc injections of both knees are medically necessary to treat the patients medical condition at this time.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

A 39-year-old male enrollee has requested for the prescription medication Fentora for treatment of his back pain.  Findings:  The physician reviewer found that it is not possible to ascertain how the diagnosis of intractable back pain was reached from these records. The progress notes submitted are succinct and provide very little clinical information regarding the providers evaluation of the patients response to previous pharmacological and non-pharmacological interventions or the patients physiological response to the current pain management regimen.
Appeal type: Medical Necessity
Decision: Upheld

A 53-year-old female enrollee has requested magnetic resonance imaging (MRI) of the thoracic spine for evaluation of her back and leg pain.  Findings:  The physician reviewer found that while the patient has a history of ankylosing spondylitis, there is no detailed information in the records suggestive of a neurological concern for thoracic spine pathology. There is no history of fever, trauma, thoracic spine focal tenderness or abnormal finding on a thoracic spine series which would require MRI imaging at this time. Ankylosing spondylitis commonly involves the thoracic spine in the form of syndesmophyte formation and there is increased risk of compression fracture. As this patient is scheduled to undergo an MRI of the lumbar spine, which will involve the T11 and T12 levels, the additional MRI of the thoracic spine is not indicated. Thus, the requested MRI of the thoracic spine is not medically necessary for evaluation of this patients medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned

A 62-year-old male enrollee has requested transcranial magnetic stimulation for treatment of his depression. Findings:  Two physician reviewers found that the NeuroStar TMS system has obtained Food and Drug Administration (FDA) approval for the treatment of patients with major depressive disorder who have failed to achieve satisfactory improvement from antidepressant medication. The efficacy and benefit of TMS for major depression was also advocated during several presentations at the American Psychiatric Association (APA) Annual Meeting in May 2010. Janicak and colleagues note that TMS has demonstrated efficacy in the treatment of major depressive disorder. Demitrack and Thase indicate that TMS is clearly safer and better tolerated than many other pharmacotherapeutic options or ECT. In addition, Avery and colleagues controlled study suggests that TMS can produce statistically and clinically significant antidepressant effects in patients with medication resistant major depression, while Schutter and colleagues concluded that TMS represents an alternative for patients who do not tolerate the side effects of medications. Given this patients clinical history, TMS was likely to be more beneficial than any other available  standard treatment and should not be considered investigational in this clinical setting.
Appeal type: Medical Necessity
Decision: Upheld

A 30-year-old female enrollee has requested a full body scan for evaluation of her persistent abdominal and back pain.  Findings:  The physician reviewer found that despite the negative imaging of the abdomen and pelvis as well as the negative MRI of the lumbar spine, the patient still has left flank pain and elevated ESR and CRP as well as a history of abnormal urinalyses. The abnormal urinalysis showing increased white and red blood cells are of concern and the recommendation to refer the patient back to her primary care provider is appropriate. The provider may order repeat evaluations of certain laboratory tests including CRP, ESR, and urinalysis, to determine if there has been a change. If such a change is noted, further imaging may be indicated. Specifically, if the patients urinalysis continues to be abnormal, an ultrasound of the kidneys may be indicated to evaluate the patient for urinary tract calculi producing hydronephrosis. However, given the records provided for review, the requested full body scan is not medically necessary for evaluation and treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for hyaluronic injection to the right knee. Evidence from systematic reviews and randomized controlled trials indicate that although viscosupplementation may relieve knee pain in some patients with osteoarthritis, data has not established which patients will benefit. Guidelines from the American Academy of Orthopedic Surgeons (AAOS) indicate that the data on safety and efficacy of viscosupplementation remain inconclusive. As such, the AAOS does not currently recommend viscosupplementation as standard treatment for osteoarthritis of the knees. Viscosupplementation is reserved for patients with a history of lasting benefit from prior injections and in cases where the remaining options are limited. In this case, the patient has tried and failed other conservative treatments with the alternative being surgery. Therefore, whether hyaluronic injection to the right knee are medically necessary for treatment of this patient.Final Result: The reviewer determined that the requested services are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in 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 38-year-old female has requested MaterniT21 test for evaluation of her fetus for Trisomy 21.  Findings:  Two physician reviewers found that the patient has chronic hypertension. The records indicate that she underwent sequential screening for fetal aneuploidy, which reportedly revealed an increased risk for Down syndrome.  While noninvasive detection of fetal aneuploidy by free fetal DNA in the maternal circulation has been shown to be an effective screen, diagnostic testing with amniocentesis remains the gold standard. Based on the current peer-reviewed medical literature and practice guidelines, free fetal DNA testing is not supported to be as effective as standard testing. Since amniocentesis is available and the requested testing is not more beneficial than amniocentesis, the MaterniT21 is not likely to provide novel and useful data relevant in managing this patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld

A 60-year-old male enrollee requested zoledronic acid (Zometa) for medical treatment of his metastatic prostate cancer.  Findings:  The physician reviewer found that the two major indications for Zometa include treatment for bony metastases and osteoporosis.  Zometa is indicated in the treatment of metastatic prostate cancer to the bone (Ross, et al; Saad, et al). This patients records do not include a diagnosis of bony metastases. The diffuse marrow signal cannot be assumed to be metastatic cancer since it may be due to a primary marrow process or due to changes after radiation therapy.  A bone biopsy or marrow biopsy is needed to confirm the presence of bony metastases.  In addition, the patients PSA remains low, suggesting that his back pain may be originating from severe degenerative disease, spinal stenosis, or radiculopathy.  Consistent with these findings, the requested Zometa is not supported as medically necessary for treatment of this patients medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary:  An enrollee has requested platelet rich plasma therapy for treatment of her medical condition.  Findings:  Three physician reviewers found that in current peer-reviewed medical literature, Moraes and colleagues reviewed 19 randomized and quasi-randomized controlled trials with 1,088 participants that compared platelet-rich therapy with either placebo, autologous whole blood, dry needling or no platelet-rich therapy for people with acute or chronic musculoskeletal soft tissue injuries, including Achilles tendinopathy. The authors concluded that there is currently insufficient evidence to support the use of platelet-rich plasma for treating musculoskeletal soft tissue injuries. Similarly, DiMatteo and colleagues concluded there was a paucity of high-level literature regarding the application of platelet-rich plasma in the management of patellar and Achilles tendinopathy. Overall, evidence based medical guidelines and peer-reviewed literature does not support the use of platelet-rich plasma injections in the treatment of Achilles tendinopathy, or for intraoperative use to help with wound healing. Consistent with these findings, platelet-rich plasma treatment was not likely to be more beneficial for treatment of this patients medical condition than any standard therapy.  Final Result:  Three reviewers determined that the services at issue were 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 orthopedic surgery 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

The patient has requested reimbursement and prospective authorization and coverage for residential treatment center (RTC) services. Per the American Society of Addiction Medicine (ASAM) criteria, this patient does not meet Level 3.5 criteria for clinically managed high-intensity residential services. ASAM criteria focuses on six dimensions to determine the appropriate level of care, which includes: (1) intoxication and withdrawal potential; (2) biomedical conditions; (3) emotional, behavioral and cognitive conditions; (4) readiness to change; (5) relapse, continued use, or continued problem potential; and (6) recovery environment. Given the findings, the RTC level of care 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 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 expertise in addiction medicine 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.