Persius/imr-appeals huggingface dataset:
Appeal type: Experimental/Investigational
Decision: Overturned

A 42-year-old male enrollee has requested gastroplasty/vertical sleeve gastrectomy for the treatment of his morbid obesity. Findings:  Two physician reviewers found that sleeve gastrectomy was originally performed to bridge patients who were super-morbidly obese to a safer plateau at which point a malabsorptive procedure is performed. The study by Karamanakos and colleagues shows a greater weight loss at 12 months with sleeve gastrectomy with superior appetite suppression compared with laparoscopic Roux-en-Y gastric bypass. Furthermore, sleeve gastrectomy is now widely accepted by the American Society for Metabolic and Bariatric Surgery and is considered a standard procedure at medical centers of excellence. In sum, sleeve gastrectomy is the most appropriate option for this patient and should be authorized.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for a water birth. Findings:  The physician reviewer found that  two randomized controlled trials comparing underwater birth to birth on land have been published. Results suggest minimal benefit to mother and no benefit to the infant. Vanderlaan and colleagues conclude that there is no evidence of increased odds for any neonatal outcome with waterbirth. Moreover, most outcomes are unlikely to change with additional research. At this time, underwater birth requires more rigorous study. In the United States, underwater birth is not supported by American Academy of Pediatrics or American College of Obstetricians and Gynecology. In this case, the patient is a 25-year-old female with no medical or obstetric conditions that increase the risk for serious intrapartum or postpartum complications. However, water birthing is not supported by evidence based literature at this time. Therefore, the requested water birth is not medically necessary for the patients condition (pregnancy).Final Result: The reviewer determined that the requested service is not medically necessary for treatment of the patients condition (pregnancy). Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is board certified in obstetrics and gynecology 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 female enrollee requested authorization and coverage of extracorporeal shock wave therapy. The Health Plan denied the request indicating that the requested therapy is not medically necessary for treatment of the enrollees plantar fasciitis and calcaneal spur.One podiatry reviewer performed a medical necessity Independent Medical Review. The podiatry reviewer upheld the Health Plans denial on the basis that the requested therapy is not medically necessary.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for Prometheus Anser ADA diagnostic testing. Findings:  Three physician reviewers found that there is insufficient medical evidence to support the effectiveness of Prometheus Anser ADA diagnostic testing compared with conventional courses of action in the management ulcerative colitis. The published studies on the use of anti-adalimumab antibodies and serum levels are small, retrospective, and/or observational rather than controlled in nature, preventing firm conclusions about cause and effect. These small studies at best demonstrated correlations between treatment failure and the presence of anti-adalimumab antibodies, which do not allow firm conclusions regarding cause and effect. It is possible that active disease results in low adalimumab levels due to loss of adalimumab, rather than low adalimumab levels resulting in loss of disease control. Additionally, controlled studies are lacking to show that use of the test results in improved long-term health outcomes for patients with ulcerative colitis compared with conventional management.  For these reasons, the superior effectiveness of Prometheus Anser ADA diagnostic testing performed has not been established. Final Result: 3 of 3 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: All three reviewers are board certified in internal medicine with sub-specialty certification in gastroenterology 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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for 1 additional acupuncture session.Peer reviewed literature recommends an initial trial of five to six acupuncture appointments in combination with a conditioning program of aerobic and strengthening exercises to stimulate self-reliance. Future acupuncture appointments should be tied to improvements in objective measures to justify an additional 6 sessions, for a total of 12 sessions. Additional treatments should only occur based on progressively greater, incremental objective gains. In addition, passive care (acupuncture) should be combined with active care (conditioning-aerobic-stretching exercise program) to stimulate self-care and avoid medical dependency. Significant objective benefits include a decrease of pain (Visual Analog Scale), increased endurance, increased body mechanics and ability to perform ADLs (activities of daily living), increased ability to perform job-related duties, improved sleep or reduced pain behaviors, amongst others. Indications for care discontinuation would include resolution, intolerance, lack of measurable improvements, or non-compliance including non-compliance with aerobic and strengthening exercises.In this case, while the patient reported prior acupuncture as beneficial, no pre-acupuncture and post-acupuncture baselines were documented for comparison purposes. The patients medical records do not reflect the total number of sessions completed or the frequency of the visits. In addition, measurable, progressive, significant, objective benefits (quantifiable response to treatment) obtained with previous acupuncture, to support the reasonableness and necessity of the additional acupuncture requested, was not noted in the available records. There is also no indication in the patients records of whether the patient is undergoing an independent exercise program (conditioning-aerobic-stretching exercise program based on patient's tolerance), which is recommended by peer review literature. Under these circumstances, the requested 1 additional acupuncture session is not medically necessary to treat the patients medical condition.Final Result: The reviewer determined that the requested services are not medically necessary to treat the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is a licensed acupuncturist, board certified in oriental 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 Orthovisc injections.Findings:  The physician reviewer found that evidence-based medical peer-reviewed literature supports the use of repeat series of viscosupplementation injections for the treatment of pain in patients with osteoarthritis of the knee. Viscosupplementation has been found to be safe and effective and allows for delay of total knee replacement. A meta-analysis conducted by a study found that hyaluronic acid was the best pharmacologic intervention for knee osteoarthritis. 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. Moreover, a study concluded that repeated cycles of intra-articular sodium hyaluronate treatment, to delay time for total knee replacement in patients with knee osteoarthritis and who have failed conservative treatment, was found efficacious during a 54-month follow-up period. In this patients case, she has been diagnosed with osteoarthritis of both knees. She has undergone prior left knee arthroscopic surgery. She has undergone multiple prior viscosupplementation injections for over 10 years in an attempt to delay total knee replacements. Prior injections have resulted in pain reduction and improvement in function ability. She has worsening bilateral knee pain and functional impairment that has failed to respond adequately to other conservative treatments. 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 52-year-old male enrollee has requested prolotherapy for treatment of his back and buttock pain. Findings:  Three physician reviewers found that prolotherapy describes a variety of treatment approaches using repeated injections of irritant solutions to strengthen ligaments and reduce some types of chronic pain (Dagenais and colleagues). Generally, a concentrated dextrose solution is injected into a ligament or tendon where it attaches to the bone. These injections are intended to cause a localized inflammation with the increased local blood flow thought to carry in nutrients and stimulate the presumably damaged tissue to repair itself. Kim and colleagues reported that there is no high-grade evidence in the published peer reviewed medical literature that establishes the efficacy of prolotherapy on health, pain or functional outcomes in the setting of musculoskeletal complaints, including chronic low back pain. Some anecdotal reports and low quality studies offer suggested response, but a marginal improvement in outcomes greater than placebo therapy has not been established for this intervention. Further, Dagenais and colleagues noted adverse effects related to prolotherapy in their 2006 study. Thus, prolotherapy is an unproven treatment for any condition.
Appeal type: Experimental/Investigational
Decision: Upheld

A 41-year-old female enrollee has requested for various medical services for treatment of her pelvic inflammatory disease and anaerobic bacterial infections.   Findings:  Three physician reviewers found that the treatment outlined in the records has no evidence-based data showing that it is more beneficial for treatment of the patients medical condition than the standard therapy available. The CDC treatment guidelines cited above are the gold standard for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement and prospective authorization and coverage for skilled nursing facility services. Findings:  The physician reviewer found that Solvang and colleagues note that people experiencing multitrauma will often live with problems in functioning for a profound period in life. In this case, the patient sustained severe trauma due to a motorcycle accident resulting in major injuries to multiple body regions, including the urinary bladder and the pelvis. He underwent multiple procedures and surgeries. The patient continued to have a suprapubic catheter. He remained non-weight bearing in the bilateral lower limbs. While the patient has undergone inpatient rehabilitation, he has largely plateaued with respect to functionality on account of ongoing bilateral lower limb non-weight bearing restrictions, which were necessitated by the severity of his original injuries and the time required for proper healing of the injured/repaired tissues. The records also note an endurance deficit and motivation issues, as the patient has elected to truncate therapy in order to attend to a visitor and has also refused therapy.  The patient continues to require extensive physical assistance for his lower body self-care activities. The records do not state when the patient may undergo an orthopedic reevaluation, or when his weight bearing status might be upgraded. In this case, the patients rehabilitation goals revolve around optimizing his compensatory skills at a wheelchair level while he waits for his bones to heal sufficiently enough for significant weight bearing activities such as stand pivot transfers, standing, ambulation, and climbing stairs. Given that there is no indication that the patients functional status is improving, and as the submitted records do not document a need of inpatient level of care for rehabilitation, medical, or nursing care, the services at issue were not and are not medically indicated. Therefore, skilled nursing facility services were not and are not medically necessary for the treatment of this patient.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 physical medicine and rehabilitation 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 platelet-rich plasma injection provided for treatment of the enrollees posttraumatic osteoarthritis. Findings:  2/3 of the physician reviewers found that current, evidence-based guidelines do not recommend platelet-rich plasma injection for ankle or foot conditions, with higher quality evidence showing this treatment to be no better than placebo. In their review of 17 randomized and two quasi-randomized trials with 1088 participants. Colleagues concluded that overall, and for the individual clinical conditions, there is currently insufficient evidence to support the use of platelet-rich therapies for treating musculoskeletal soft tissue injuries. This patient presented with persistent lateral ankle pain that limited his activity level. He was status post right ankle lateral ligament reconstruction, tibial exostectomy, and talus osteophyte excision. He had been diagnosed with right ankle posttraumatic osteoarthritis. Detailed evidence of a recent, reasonable and/or comprehensive nonoperative treatment protocol trial and failure has not been submitted. There is insufficient evidence to support the use of platelet-rich plasma therapies in the ankle. There is no compelling rationale presented to support the services at issue over standard therapy for this patients residual ankle pain. Therefore, the platelet-rich plasma injection provided was not likely to have been of greater benefit than other treatment alternatives. Final Result: 2/3 of the 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: Physician reviewer number one 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.Physician reviewer number two 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.Physician reviewer number three 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

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for prostatic artery embolization. There is a lack of clinical experience or peer-reviewed medical literature to support the routine use of prostatic artery embolization in the treatment of patients with benign prostatic hyperplasia outside of a clinical trial. However, prostatic artery embolization is appropriate to manage this patients symptomatic benign prostatic hyperplasia as less invasive to open simple prostatectomy or staged transurethral resection of prostate (TURP) given the likelihood for symptomatic relief (Malling, et al.). This patients prostate is large and measures 140 cc, which limits his surgical options. Wang and colleagues found that, The clinical and imaging outcomes of prostatic artery embolization were better in patients with larger prostate glands than medium-sized ones. Moreover, treatment with prostatic artery embolization will not prevent future treatment with open surgery if prostatic artery embolization fails. Given these findings, the requested prostatic artery embolization is 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 urology 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 29-year-old woman who has severe cystic acne of the back, thighs, buttocks, and face with scarring. Her acne has been minimally responsive or unresponsive to oral antibiotics, topical antibiotics, benzyl peroxide, Retin A, Ortho Tri-cyclen, and oral Aldactone. The patient has had consultations with dermatologists who use Smoothbeam laser for treatment of acne. She states that her primary care physician does not prescribe Accutane for women of childbearing age. The Health Plan has denied authorization and coverage for Smoothbeam laser therapy on the basis that it is not medically indicated.Accutane is the gold standard for treatment of severe cystic acne that is resistant to other forms of treatment. The submitted information documents that the patient has been tried on all of the other conventional forms of treatment. Though Accutane is contraindicated in pregnant women or women who plan to become pregnant while on Accutane, Accutane is not contraindicated in women of childbearing age. The manufacturer and the standard of care require a pregnancy test at the patients first visit and three days after the patients next menstrual period, prior to initiating Accutane. It is essential that a pregnancy test be performed monthly approximately one week prior to the office visit in order to reevaluate the patient and prescribe the next months prescription. The patient is required to use two effective forms of contraception from one month prior to one month after cessation of treatment. Adherence to the pregnancy prevention program should be explained to and required of patients who use Accutane. Although there are strict precautions associated with the use of Accutane, the effectiveness of Accutane may persist for years after Accutane cessation. While Smoothbeam laser therapy may be effective, the medical literature does not establish that it results in the same degree of efficacy that is associated with Accutane. As such, the medically necessity of Smoothbeam laser therapy for treatment of the patients acne has not been established.Based upon the information set forth above, I have determined that the requested therapy is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary:  An enrollee has requested skilled nursing facility care for treatment of his medical condition.  Findings:  The physician reviewer found that the medical literature does not indicate whether the long-term outcomes in adults with ankle fracture are superior with surgical versus conservative treatment (Donken, et al). In addition, there is limited high quality data published with respect to specific rehabilitation measures following conservatively managed ankle fractures (Lin, et al). In this case, the patient sustained an ankle fracture and has been immobilized with non-weight bearing restrictions. He would have been expected to have improved to a fully independent ambulator with crutches and fully independent with all of his self-care on the basis of an ankle fracture, even with ongoing non-weight bearing restrictions. However, the patient has multiple conditions that reduced his premorbid function and limited his capacity for more significant functional gains in the inpatient rehabilitation setting. He has undergone a prolonged period of inpatient rehabilitation and has plateaued. Therefore, there was no further need for medical, nursing or rehabilitation services in an inpatient setting. Further care could have been provided in a custodial level setting. All told, the services at issue were not and are not medically necessary for treatment of the patients medical condition. 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 physical medicine and rehabilitation 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.