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

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Synvisc One injection in the right knee. A recent health technology assessment concluded that evidence from eight systematic reviews and six randomized controlled trials suggests intra-articular hyaluronic acid injections may relieve osteoarthritic knee pain in some patients. However, there are questions remaining about the most effective formulations, which patients benefit most, and whether hyaluronic acid injections combined with other agents will increase effectiveness. Current evidence based medical guidelines support hyaluronic acid injections in the knees for patients who have failed to respond adequately to conservative treatment and to potentially delay total knee replacement in patients with severe osteoarthritis and pain that interferes with functional activity. In this case, this patient presents with complaints of severe right knee pain with associated cracking and inward tilting. Clinical examination findings are consistent with imaging findings of moderate tricompartmental osteoarthritis. The requested Synvisc One injection in the right knee is not medically necessary for treatment of this patient.Final Result: The reviewer determined that the requested services 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 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

A 57-year-old male has requested biliopancreatic diversion/duodenal switch for treatment of morbid obesity.  Findings:  The physician reviewer found that the American Society for Bariatric Surgery endorses the requested procedure for the surgical treatment of morbid obesity.  The issues noted by the Health Plan regarding intractable diarrhea and malabsorption were from the earlier short-common-channel experience (less than 100 cm). Current data does support the need for vitamin supplementation. However, the reoperation rate with the duodenal switch procedure in experienced hands is low.
Appeal type: Medical Necessity
Decision: Upheld

A 44-year-old female enrollee requested the eRapid Nebulizer System for medical treatment of her chronic obstructive pulmonary disease (COPD), asthma, and factor V Leiden.  Findings:  The physician reviewer found that there is a lack of evidence in the medical literature that supports the use of the eRapid Nebulizer System over a standard nebulizer in patients with chronic obstructive pulmonary disease. Both are portable systems, deliver medications rapidly, and have similar nebulizer particle characteristics. Thus, the requested the eRapid Nebulizer System is not supported as medically necessary for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary:  An enrollee has requested transcranial magnetic stimulation for treatment of her major depressive disorder.  The physician reviewer found that transcranial magnetic stimulation is a non-invasive brain stimulating procedure utilized in the treatment of major depressive disorder.  This treatment modality tends to be well-tolerated with fewer barriers than electroconvulsive therapy.  The American Psychiatric Association has endorsed transcranial magnetic stimulation for the acute phase treatment of major depressive disorder after failure of at least one antidepressant trial.  There is sufficient evidence in the peer-reviewed medical literature to support the use of transcranial magnetic stimulation in this clinical setting.  In this case, the patient has pursued other standard therapies.  Considering the medical records and the expanding peer-reviewed literature base, the requested transcranial magnetic stimulation is medically indicated 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 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: An parent of an enrollee has requested reimbursement and prospective authorization and coverage for continued residential treatment at Paradigm Malibu for treatment of enrollee's behavioral health issues.  Findings: The physician reviewer found that the records indicate that this patient could have been transitioned to treatment at a lower level of care. The documentation states that the patient was not at risk of harm to herself or others. Her mood and anxiety symptoms were improving, she has been cooperative with her treatment, and her family was supportive. She has not been receiving any specialized medical or nursing treatment that requires 24-hour monitoring and care. All told, the continued residential treatment at Paradigm Malibu was not and is not medically necessary for treatment of this patients behavioral health issues.  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 psychiatry with sub-specialty certification in child and adolescent 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: Overturned

A 29-year-old female enrollee requested authorization and coverage of a panniculectomy for the treatment of abdominal panniculus.  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 overturned the health plans denial on the basis that the requested surgery is medically necessary for treatment of the patients medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested a heart positron emission tomography (PET) scan for evaluation of his medical condition.  Myocardial ischemia is generally evaluated by imaging the patient both at rest and after stress. The stress can be performed via a treadmill or can be done pharmaceutically.  In patients with suspected ischemia, simply visualizing coronary artery anatomy is insufficient, as patients may have narrowing of the coronary vessels without ischemia, or alternatively, they may have ischemic changes with vessels that are not grossly narrowed. Hence, routine cardiac catheterization does not solve the clinical problem. To better evaluate ischemic changes, a routine procedure would be a single photon emission computed tomography (SPECT) scan utilizing sestamibi. However, one of the problems with a sestamibi SPECT scan is poor spatial resolution. Maddahi and colleagues reported that PET myocardial perfusion imaging is increasingly being used for noninvasive detection and evaluation of coronary artery disease. As the radiopharmaceuticals become more widely available, and in view of the significant improvement in spatial resolution, it is likely that PET cardiac scanning will become more widely utilized than SPECT scanning in this clinical setting. For these reasons, the heart PET was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.  Final Result: Three reviewers determined that diagnostic procedure at issue was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.  Credentials/Qualifications: All three reviewers are board certified in 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.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: A parent of an enrollee has requested authorization and coverage for Xeljanz (tofacitinib).Findings: According to the most recent published guidelines, standard of care for the treatment of alopecia totalis would include methotrexate and contact sensitization with diphenylcyclopropenone (DPCP) or squaric acid. Additionally, few treatment methods have been evaluated by randomized control trials to determine the most efficacious modalities to treat alopecia areata. Therefore, it is challenging for clinicians to guide patients regarding the best therapeutic options. JAK inhibitors, like Xeljanz, show excellent promise and some great results in treating extensive alopecia. In this case, the patient has been diagnosed with alopecia areata. They have tried and failed treatments such as topical steroids, intralesional steroids, and oral steroids. There is sufficient support for the requested medication in this clinical setting. Therefore, Xeljanz (tofacitinib) is medically necessary for the treatment of the patients medical condition.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: Medical Necessity
Decision: Upheld

The parent of a 15-year-old male enrollee has requested for Focalin 25mg for treatment of the enrollees attention deficit disorder (ADD). Findings:  The physician reviewer found that Focalin XR contains both an immediate release as well as delayed release of Dexmethylphenidate, thus making twice daily dosing not medically necessary.  Although an increase of the medication beyond the recommended maximum of 20mg may be considered for a patient, the increase ought to be on the order of 5 to 10mg.  There is no pharmacologic merit in transitioning from 20mg per day to more that double the dosage.
Appeal type: Medical Necessity
Decision: Upheld

The parent of a 10-year-old male enrollee has requested a WalkAide therapeutic functional electrical stimulator (FES) for treatment of the enrollees cerebral palsy.  Findings:  The physician reviewer found that the WalkAide has shown benefits in several small studies. However, there are no high quality studies documenting long-term functional improvements and defining appropriate candidates for the device. Prosser and colleagues found benefits for children with cerebral palsy who used the device. However, the study was weak for a number of reasons including the facts that it was uncontrolled study, had a small sample size. The authors stated that, To our knowledge, this is the only trial so far in this population evaluating this novel device. Additional studies done in this population have similar methodological limitations (Postans and Granat). Durham and colleagues noted that, further research is needed to refine selection criteria of subjects who may benefit and to optimize use of stimulation. Consistent with these findings, the requested device is not supported as medically necessary for treatment of the patients medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld

Physician 1: The patient is a 41-year-old female who underwent a cervical discectomy and fusion at C5-6 and C6-7. Her physician has recommended she receive a Spinal Logic bone growth stimulator post-operatively. The Health Plan has denied this request indicating the efficacy of the requested equipment has not been established.Bone growth stimulators are of proven efficacy as is demonstrated by the studies provided. They have been used for nearly two decades to increase bone growth for fractures and other orthopedic ailments. Numerous studies, including those that have been provided, have shown increased bone growth with the use of bone growth stimulators. There is sufficient data demonstrating that use of the requested equipment is likely to result in a superior outcome to standard treatments. Therefore, I have determined that the requested equipment is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Plans denial should be overturned. Physician 2: The patient is a 41-year old woman who underwent cervical fusion in November 2004. Her physician has recommended she use a bone growth stimulator to improve bone healing. The Health Plan has denied coverage for the requested equipment on the basis it is considered experimental for treatment of patients such as this patient.There is inadequate data to support the use of a bone growth stimulator in this patient. Use of the device for patients who have undergone cervical surgery has not been shown to be beneficial in peer-reviewed literature. Given the lack of evidence-based literature involving post cervical fusion patients, a bone growth stimulator cannot be recommended. Accordingly, I have determined that the requested equipment is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Plans denial should be upheld. Physician 3: The patient is a 41-year-old woman who, after a long history of neck, shoulder, and arm pain, underwent an anterior cervical disc excision and fusion at C5-6 and C6-7. Her physician has recommended she use a bone growth stimulator to expedite healing of her fusion. The Health Plan has denied coverage for the requested equipment on the basis that it is considered experimental.There is no prospective data establishing the efficacy of spinal bone growth stimulation. All evidence of its efficacy is anecdotal at best. There is no evidence of clearly established benefit resulting from use of the device. As such, there is no clinical indication for use of the requested equipment in this patient. Therefore, I have determined that the requested equipment is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Plans denial should be upheld.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for computed tomography (CT) of the heart without contrast, and with quantitative evaluation of coronary calcium. In this case, notes reported that the patient had a marked elevation of low-density lipoprotein (LDL) cholesterol. CT calcium scoring results reported that the patient had undergone prior coronary calcium scoring. In this clinical setting, current American College of Cardiology (ACC) guidelines recommend maximally tolerated statin therapy, and a repeat coronary artery calcium scoring was not reasonably expected to alter that recommendation. Therefore, CT of the heart without contrast, and with quantitative evaluation of coronary calcium, was not likely to have been more beneficial for evaluation of the patients condition than any available standard therapy.Findings:  Three of the three physician reviewers found the computed tomography (CT) of the heart without contrast, and with quantitative evaluation of coronary calcium, at issue was not likely to have been more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the service at issue was not likely to have been 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 and 3 are board certified in internal medicine with sub-specialty certification in cardiovascular disease and are actively practicing. Physician reviewer 2 is board certified in internal medicine with sub-specialty certifications in cardiovascular disease and in adult congenital heart disease and is actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld

 A 54-year-old female enrollee requested real-time intra-fraction target tracking (CPT code 0197T) during radiation treatments for treatment of the enrollees breast cancer.  Findings:  Two physician reviewers found that the medical records do not demonstrate that the services were likely to have been superior over other treatment modalities.  Intra-fraction localization/tracking is a radiation delivery method in which the target is tracked in real-time, and the treatment is adjusted to compensate for this movement.  In this patients case, there is no indication from documentation provided that real-time tracking was used.  There is no rationale for the use of real-time tracking in this case.  Thus, the superior benefits of real-time intra-fraction target tracking used during radiation treatments has not been established.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for customized oral mouthpiece device/appliance. As noted by the American Academy of Sleep Medicine (AASM) and American Academy of Dental Sleep Medicine (AADSM), an oral appliance is indicated for the treatment of patients with mild-to-moderate obstructive sleep apnea (OSA) as first-line treatment, or as alternative therapy when a patient fails continuous positive airway pressure (CPAP) therapy (Patil, et al.). The available records report that this patient was diagnosed with mild OSA with an apnea/hypopnea index (AHI) of 10.4 episodes per hour on home sleep study, which can underestimate the severity of a patients OSA. The patients AHI did not substantially improve despite treatment with an oral appliance. The provider noted that the oral appliance failed to control the patients OSA symptoms, as evidenced by minimal improvement in AHI. In this clinical setting, a custom oral appliance is not likely to add substantial benefit since the patients OSA symptoms did not respond to the first oral appliance. A prior dental examination confirmed that the patient was not a good candidate for a second oral appliance due to dentition not being able to support the appliance. Per the current guidelines and recommendations, treatment with CPAP is recommended for management of this patients mild OSA symptoms. The records do not adequately document failure of treatment with CPAP. For these reasons, the requested customized oral mouthpiece device/appliance is not medically necessary for treatment of this patient.Final Result: The reviewer determined that the requested device 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 internal medicine with subspecialty certification in sleep 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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Supartz injections for 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. Current literature states 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. Campbell and colleagues performed a systematic review of overlapping meta-analyses comparing viscosupplementation with other nonoperative treatment modalities for knee osteoarthritis. Their review found that that the current highest level of evidence suggests that intraarticular hyaluronic acid is a viable option for knee osteoarthritis and that its use results in improvements in knee pain and function that can persist for up to 26 weeks. Viscosupplementation has a good safety profile, and its use should be considered in patients with knee osteoarthritis. There is sufficient support for the requested services in this clinical setting. Therefore, Supartz injections of the knees 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.