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

Nature of Statutory Criteria/Case Summary: A patient has requested authorization and coverage for Orthovisc injections for treatment of the enrollees osteoarthritis of the left knee.  Findings:  The physician reviewer found that submitted documentation supports the medical necessity of the requested medication. Pagnano and Westrich 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 hyaluronan therapy were safe and effective in the treatment of pain associated with osteoarthritis of the knee. There is no maximum amount of injections established by high quality scientific evidence. This patient presents with a history of increasing left medial knee pain that is limiting the patients activities of daily living. The clinical examination findings are consistent with x-ray evidence of tricompartmental osteoarthritis, most severe in the medial compartment. The record indicates that reasonable conservative treatment, including pain medications, activity modification, weight loss, and corticosteroid injections, has failed to provide adequate symptom relief. The patient is unable to take nonsteroidal anti-inflammatory drugs due to prior gastric bypass surgery. The patient reported that prior viscosupplementation injections in 2015 and 2016 had been more effective than corticosteroid injections and had provided pain relief allowing the patient to exercise for weight loss. The medical literature supports the use of viscosupplementation injections for the treatment of pain in patients with osteoarthritis of the knee. Repeat viscosupplementation injections have been found to be safe and effective and allow for delay of knee replacement surgery. Therefore, the requested Orthovisc injections are medically necessary for 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 orthopedic surgery and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for Decision Dx-Melanoma test for evaluation of the enrollees melanoma. Findings:  Three physician reviewers found that the prognosis of cutaneous melanoma has classically been determined by applying the staging system spelled out by Balch. Mitotic index has also been thought to add a bit more to these statistics. By Balch staging, this melanoma would be classified as stage 1A, with an expected ten-year survival of greater than 89%. Decision Dx-Melanoma test is a study of 31 genes in an individuals melanoma cells. It then classifies that melanoma as either Class 1 (with a 90 to 92% rate of being disease-free at five years), or Class 2 (with a 65 to 80% rate). Researchers reported on 217 cases, with good correlation between prognosis and Decision Dx-Melanoma test classification, in patients undergoing sentinel node sampling, which this patient has not had. It is not clear how the five-year Decision Dx-Melanoma test data compares to the ten-year Balch data, and importantly whether Decision Dx-Melanoma test classification can be used to make clinical decisions. Final Result: The reviewers determined that the services at issue were not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: Reviewers 1, 2 and 3 are board certified in internal medicine with sub-specialty certification in medical oncology 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 44-year-old female enrollee has requested for a consultation with a plastic surgeon for treatment of her breast ptosis and excess skin condition. Findings:  The physician reviewer found that the submitted records fail to document convincing and confirmatory evidence of a chronic functional problem that has failed to respond to reasonable attempts at conservative therapy.  Nor does the patient have medical record documentation over time (e.g., series of office notes, dermatology consultations, pharmacy prescription records) of problems with skin folds. Photographs documenting cellulitis, ulcerations or rashes have not been submitted.  In addition, the medical records do not provide any documentation in the form of primary care physician or dermatology progress notes that describe ongoing clinically significant dermatologic problems that have either never responded to topical therapy or have recurred and caused significant functional impairment despite initial response.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: an enrollee has requested authorization and coverage for Repatha 140 mg/mL Sureclick. Findings:  The physician reviewer found that based on the records provided, the patient has known coronary disease and suboptimal lipid control intolerant of multiple statin medications.  Proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitors, including Repatha, have been studied in and approved for patients with heterozygous familial hypercholesterolemia or for patients with documented atherosclerotic heart disease who require additional lowering of LDL cholesterol.  This patient meets these criteria since trying other medication classes that have proven efficacy, without sufficient results.  Repatha, in this clinical setting has shown to be safe and effective at lowering LDL cholesterol, and also have outcome improvement demonstrated in post hoc analysis of trial data to date. 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 cardiovascular disease 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 62-year-old female enrollee has requested spinal neurostimulator pulse generator for treatment of her lower back pain.  Findings:  Three physician reviewers found that spinal neurostimulator pulse generator is not likely to be more beneficial at this time for treatment of the patients medical condition than any available standard therapy. There is peer-reviewed evidence supporting the efficacy of spinal neurostimulation in select patients. In order to determine those individuals who are likely to benefit from the procedure, a pre-procedure psychological assessment is required as part of the standard diagnostic work-up. The patient has not had a psychological evaluation to rule out a psychogenic cause for her pain. As such, based upon the information provided, the requested spinal neurostimulator pulse generator is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.
Appeal type: Medical Necessity
Decision: Upheld

A 35-year-old female enrollee requested authorization and coverage of heparin and prednisone. The Health Plan denied the request indicating that the requested medications are not medically necessary for treatment of the enrollee status post two spontaneous abortions.One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer upheld the Health Plans denial on the basis that the requested medications are not medically necessary.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary:  An enrollee has requested epidural steroid injections for treatment of his medical condition.  Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested services.  This patients prior treatment has included physical therapy.  However, details regarding the duration of physical therapy and documentation of a home exercise program were not provided.  The current medical evidence supports active exercise with the physical therapy in this clinical setting.  The medical literature indicates that a home exercise program after physical therapy independent of an epidural may provide lasting results. Additionally, the patient does not have any recent physical examination findings supporting a diagnosis of lumbar radiculopathy.  Per the records, magnetic resonance imaging (MRI) scan did not show evidence of nerve root compromise.  There are other tests that could be done to demonstrate a nerve problem which have not been performed.  All told, the requested epidural steroid injections are not medically indicated for the 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 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: Medical Necessity
Decision: Overturned

A 43-year-old male enrollee has requested three days of acute inpatient psychiatric services for treatment of his behavioral health condition. Findings:  The physician reviewer found that the submitted documentation supports the medical necessity of the services at issue.  Modern psychiatric practice aims to place patients in the least restrictive treatment setting.  In general, community intervention settings optimize treatment gains.  However, episodic placement in more restrictive settings is often clinically appropriate for those with serious mental illness.  The patient was diagnosed with bipolar disorder, a serious mental illness that elevates suicide risk and is consistent with poor outcomes.  The records noted comorbid chronic anxiety disorders.  The patient presented with a heightened anxiety titer and mood symptoms including suicidal ideation that were compensating global functionality.  He was overwhelmed, hopeless and at high-risk for relapse.  He was active in treatment in a less restrictive setting immediately prior to the disputed service.  He was prescribed multiple medications at significantly higher than ordinary doses.  The services at issue were medically appropriate and reasonably expected to improve the patients condition while preventing a more serious episode of illness such as suicide attempt or drug relapse.  All told, three days of acute inpatient psychiatric services provided during the time period specified were medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld

 A 69-year-old male enrollee has requested substance abuse residential treatment center (RTC) services for treatment of his substance abuse. Findings:  The physician reviewer found that this patients treatment could have been completed safely and effectively in a less restrictive environment than the RTC. The American Psychiatric Association (APA) practice parameters for treatment of patients with substance abuse disorders list categories that require hospital-level of care, such as RTC and inpatient services. This patients records do not establish that he met these criteria during the period at issue. Specifically, he did not present status post drug overdose that produced severe respiratory depression or coma, was not at risk for severe or complicated withdrawal syndrome, and did not have any acute or chronic general medical conditions that could make detoxification in an ambulatory setting unsafe. In addition, this patient does not have a documented history of engaging in or benefiting from treatment in a less intensive setting, or any marked psychiatric co-morbidity which placed him in acute danger to him self or others. Overall, there were no barriers to his receiving treatment in an intensive outpatient or partial hospitalization program in lieu of the more intensive and structured RTC during the dates of service at issue.
Appeal type: Medical Necessity
Decision: Upheld

A 58-year-old male enrollee has requested coverage for proton beam radiation therapy for treatment of his prostate cancer. Findings:  The physician reviewer found that according to all resources, including the Partin tables, this patient has an early cancer with no involvement of the seminal vesicles or the pelvic lymph nodes. Additionally, his total volume of tumor burden is less than 20% of the right lobe. With this presentation, any form of radiation therapy would effectively destroy this cancer, including 3DCRT and brachytherapy, which were offered by the Health Plan. The patient was concerned about a secondary bladder cancer from standard radiation therapy. There is a very low incidence of this and the risk is present even with proton beam radiation.
Appeal type: Experimental/Investigational
Decision: Upheld

The representative of a 52-year-old female enrollee  requested authorization and coverage of an alternative medicine program. The Health Plan denied the request indicating that the requested therapy is considered experimental for treatment of the enrollees metastatic lung cancer.Three physician reviewers performed an experimental/investigational Independent Medical Review. All three physician reviewers concluded that the requested therapy is not likely to be more beneficial for treatment of the enrollees medical condition than any available standard therapy. Because all three physician reviewers concluded that the requested therapy is not likely to be more beneficial for treatment of the enrollees medical condition than any available standard therapy, the Health Plans denial has been upheld.
Appeal type: Medical Necessity
Decision: Overturned

A 32-year-old female enrollee has requested Afinitor for treatment of her metastatic endocervical adenocarcinoma.  Findings:  The physician reviewer found that based on review of the available records, this patients tumor has progressed through multiple standard regimens. She has stage IV disease which has been well managed by enrollment in clinical trials as recommended by the National Cancer Institutes Physicians Data Query. Next generation sequencing has been used by several large comprehensive cancer centers that have instituted targeted screening of solid tumors for mutations in oncogenes that have FDA-approved targets. A study of 86 patients published by Von Hoff and colleagues evaluated progression-free survival on regimen selected by molecular profiling and compared this data to results with the last chemotherapy regimen. The regimen selected by molecular profiling offered a 27% survival advantage. As this patient has undergone genetic testing of her tumor to try and identify driver mutations that may targeted, the use of Afinitor is medically necessary for this patient.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a two-year-old male enrollee has requested a speech therapy evaluation and speech therapy services for treatment of the enrollees expressive speech and language delay. Findings:  The physician reviewer found that speech therapy is indicated with any delay greater than 25%.  Extensive review of the literature, including a meta-analysis by Law et al., noted the positive effect of speech and language therapy interventions for children with expressive phonological and expressive vocabulary difficulty. Feldman and Messick note that treatment for language disorders is predicated primarily on the patients language profile and level of communication skills. Those children with mild to moderate disorders are more likely to resolve their delay compared to those with severe disorders. Children who participate in speech-language treatment show better improvement than those children who have no treatment. This patient has a history of a global developmental delay and should receive appropriate intervention including a speech and language evaluation with speech therapy. Such services are medically necessary in this setting and should be authorized.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for custom oral sleep device Vivos Airway Device. This patients records document a history of OSA. The provider reports that treatment with two CPAP machines has not provided the patient with substantial improvement in her symptoms of OSA including excessive daytime sleepiness. The patient has requested a Vivos custom oral sleep device. Per the American Academy of Sleep Medicine (AASM), there is a paucity of data reported in the medical literature demonstrating the efficacy and safety of the Vivos oral sleep device in the treatment of patients with OSA (Patil, et al.). The AASM and American Academy of Dental Sleep Medicine (AADSM) guidelines recommend that a qualified dentist use a custom, titratable appliance over non-custom oral devices (Ramar, et al.). The current medical literature and guidelines report the benefit of treatment with mandibular advancement devices and CPAP therapy for treatment of patients with OSA. This patients records document intolerance to a replacement CPAP device after her previous CPAP device was recalled. Thus, the next logical treatment option is a mandibular advancement device. However, because of a lack of literature support for the Vivos system, the requested custom oral sleep device Vivos Airway Device (CPT 21089, E0486, and 21299) 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 certifications in pulmonary diseases, critical care medicine, and 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: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for implantation of vagus nerve stimulation (VNS) device. In this case, the patient meets the criteria for treatment-resistant depression since she has failed treatment with numerous antidepressants with appropriate adjunctive medications, as well as electroconvulsive therapy (ECT) and psychotherapy. The patient has been in the current depressive episode for five years with little improvement despite exhaustion of standard treatment options. Based on the treatment guidelines and the available evidence, vagus nerve stimulation (VNS) is the next appropriate step in the treatment of this patients refractory depression. Bottomley and colleagues concluded that their comprehensive summary of VNS with treatment as usual (TAU) for patients with treatment resistant depression supports that this treatment provides improving benefit and hope for this very hard-to-treat chronic population. Given these findings, the requested implantation of VNS device is 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 implantation of VNS device is 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 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: Physician reviewer 1 is board certified in psychiatry and is actively practicing. Physician reviewer 2 is board certified in psychiatry and is actively practicing. Physician reviewer 3 is board certified in psychiatry 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: Medical Necessity
Decision: Overturned

The parent of a four-year-old male enrollee has requested neuroimaging with high-resolution magnetic resonance imaging (MRI) and co-registered interictal positron emission tomography (PET) conducted on an inpatient basis and using epilepsy protocol MR imaging with anesthesia and subsequent PET with anesthesia and continuous EEG monitoring during radionucleotide uptake and actual image acquisition. for evaluation and treatment of the enrollees infantile spasms/epilepsy.  Findings:  The physician reviewer found that in this case, the young patient has been diagnosed with medically refractory epilepsy. Although there may be services available at a local facility for evaluation of his condition, the potential for controlling the intractable seizures require specialized techniques found only in limited facilities within the US. The current medical standards in the diagnosis of epilepsy involve use of a high resolution MRI using a 3T MRI scanner preferably, or at the very least, a 1.5T MRI scanner. These instruments are used to obtain the best yield in identifying certain lesions in the brain, in this case cortical dysplasia. In fact, high resolution MRI has been shown to be extremely helpful in identifying candidates for potential surgery. In addition, a PET is also utilized to look for hypometabolism in particular areas that would correlate with the MRI and EEG. This patients provider indicates the local facility does not likely have the capability to perform the requested studies as there are only a few places that perform this type of high volume epilepsy processing and evaluation. Further, the medical literature supports the utility of the requested diagnostic procedures to enable decision making regarding this patients treatment. If indeed this patient has a resectable lesion, removal would lead to an improvement in the patients quality of life, with fewer hospitalizations, and a possible decrease in the amount of medications taken as well. For these reasons, the requested services including the MRI with PET and EEG co-registration is within the best care for this patient and has been established as medically necessary.