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

A 67-year-old female enrollee has requested Orthovisc injections for treatment of her left knee osteoarthritis. Findings:  The physician reviewer found that the requested third series of Orthovisc injections for this patient has not been proven medically necessary in this clinical setting. The rationale is that this patient has x-ray documented degenerative osteoarthritis with structural abnormalities, specifically, varus deformity. The medical literature does not suggest that Hyalgan intra-articular injections will effectively alter an arthritic process, which is advanced and determined by structural alignment (i.e. varus deformity). In the study by Jorgensen and colleagues, 337 patients were treated in a randomized multicenter placebo controlled double blind trial with either hyaluronan injection or saline injections. The study group consisted of 167 Hyalgan injected patients and 170 saline injected patients. The injections were performed weekly for five weeks. Both providers and patients were blinded as to whether saline or hyaluronan was administered. The patients had been selected as fulfilling the American College of Rheumatology criteria for knee osteoarthritis with both clinical and laboratory studies supporting the diagnosis. They were followed with patient questionnaires at 3, 6, 9 and 12 months after treatment. Overall, the researchers observed no significant improvement in pain, function, or anti-inflammatory consumption between patients treated with hyaluronan and those given saline. Although some studies report improved relief of pain and stiffness with intra-articular sodium hyaluronan injections, their methodological flaws cannot be ignored. One study published by Turajane and colleagues evaluated 183 patients with osteoarthritis of the knee. The patients were administered a series of three intra-articular sodium hyaluronate injections. The authors concluded that intra-articular sodium hyaluronate injections were effective in improving pain, stiffness, and function. However, the design was not double-blinded, lacked proper controls, and the results are vulnerable to a placebo effect. As there is insufficient scientific evidence to support a further series of Orthovisc injections for this patient, the requested therapy has not been demonstrated to be medically necessary for management of her condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Envarsus XR 0.75 mg two tablets daily, Envarsus XR 1 mg three tablets in the morning, and Envarsus XR 4 mg one tablet in the morning. This patients history is concerning for recurring antibody mediated rejection (AMR) in light of infection and non-adherence with treatment. The patient is at extremely high risk of losing his allograft. The provider recommended that the patient switch from a twice-daily medication to Envarsus to encourage compliance with once-daily dosing. Researchers concluded that, once daily Envarsus has shown improved pharmacokinetic properties, rapid achievement of therapeutic trough levels, consistent exposure, non-inferior efficacy and similar safety, with lower tacrolimus dose than other tacrolimus formulations. Given this support, the requested Envarsus XR 0.75 mg two tablets daily, Envarsus XR 1 mg three tablets in the morning, and Envarsus XR 4 mg one tablet in the morning, is medically necessary for treatment of this patient. Final Result: The reviewer determined that the requested medication regimen 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 surgery with expertise in transplant 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 Thick-It. The documentation provided for review reports that this patient has significant debility consistent with common manifestations of Pallister-Killian syndrome, including dysphagia and aspiration. He has been stabilized on Thick-It with Pediasure without documented recurrent aspiration pneumonia despite finding of aspiration with unthickened liquids on imaging in the past. While thickeners can decrease the risk of aspiration and pneumonia in patients with dysphagia, various thickeners have negative effects including increased viscosity resulting in increased residue or decreased palatability or treatment compliance, which are not an issue when the patient uses an alternative thickener. In this case, Thick-It has been demonstrated to be effective and without adverse effects that may occur if the supplement is switched to a less effective alternative. For these reasons, Thick-It is supported as medically necessary for the treatment of this patients dysphagia.Final Result: The reviewer determined that the requested dietary supplement 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 gastroenterology 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 42-year-old female has requested coverage for past inpatient mental health level of care services provided for treatment of her behavioral health issues.  Findings:  The physician reviewer found that based on review of the available records, this was a chronically ill and labile patient who has a long history of a painful condition as well as PTSD and major depression that were complicated by borderline personality disorder. She presented as a significant risk for decompensation and self-harm had she been discharged prematurely. Her treatment plan was changed regularly, her aftercare planning was timely, and she was discharged to her spouses custody following improvement from the Ketamine therapy. All told, the inpatient mental health services provided were medically necessary for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned

A 52-year-old male enrollee requested authorization and coverage for lumbar epidural steroid injections for severe lower back pain.  The enrollees health plan denied the 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 plan's denial on the basis that the requested treatment is medically necessary.
Appeal type: Medical Necessity
Decision: Overturned

A 22-year-old female enrollee has requested continued partial hospitalization or residential treatment for her bulimia nervosa and post-traumatic stress disorder.  Findings:  The physician reviewer found that the submitted documentation supports continued partial hospitalization services in this clinical setting.  Modern psychiatric practice aims to place patients in the least restrictive treatment setting.  In general, community intervention settings offer optimization of treatment gains.  However, transient placement in more restrictive settings is often clinically appropriate.  In this patients case, she has been receiving a full range of therapies since May 2013.  Her treatment has included family therapy, psychopharmacotherapy, individual therapy, an evidence-based psychotherapy for post-traumatic stress disorder, medical evaluation and nutritional/dietary counseling.  In May 2013, major depressive disorder was added to her diagnostic assessment and a serotonergic enhancing medication, escitalopram, was added her stimulant and anti-nightmare medication.  Although she has made clinical progress in some areas, she has continued to struggle with anxiety while her eating disordered behavior and thoughts of self-harm appear to be increasing.  Overall, the patient remains symptomatic with significant impairment due to her psychiatric conditions, and she has not consolidated the treatment gains necessary to succeed in a less restrictive setting.  Thus, continued partial hospitalization from the date in question forward was and is medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Synvisc One injection in the left 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 routine 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 a history of chronic left knee pain since 2018 with evidence of osteoarthritis. The patients condition has not substantially improved despite treatment with exercises and less than two weeks of benefit with corticosteroid injections. In light of the patients worsening pain, the provider has requested treatment with Synvisc One injection into the left knee before considering a total knee arthroplasty. Based on the current peer-reviewed medical literature, the requested Synvisc One injection in the left knee is 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

The parents of a five-month-old male enrollee have requested Synagis for the treatment of the enrollees risk of respiratory syncytial virus (RSV) infection. Findings:  Two physician reviewers found that although there is an older sibling in the home attending preschool and the pediatrician ordered Synagis therapy for the patient, he does not meet criteria for RSV prophylaxis. There are no indications for treatment with Synagis, and it is not the standard within the pediatric community to do so.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for brand name Lyrica. The records provided for review document that this patient has a history of metastatic breast cancer with bone pain and lumbar radiculopathy. The patients pain has been managed with a combination of opioid therapy and brand name Lyrica. The patient has been treated with pregabalin 50 mg twice daily, but this provided inadequate relief. The provider reported that the patients pain is controlled with a regimen including brand name Lyrica, Fentanyl patch, hydrocodone, and Calcitonin spray. Per the U.S. Food and Drug Administration (FDA), A generic drug is a medication created to be the same as an already marketed brand-name drug in dosage form, safety, strength, route of administration, quality, performance characteristics, and intended use. These similarities help to demonstrate bioequivalence, which means that a generic medicine works in the same way and provides the same clinical benefit as its brand name version. The FDA regulates the production of generic medications and requires manufacturers to meet strict quality standards to ensure the generic medication works just as well as the branded version. In this patients case, the lack of effect of the pregabalin, the generic formulation of Lyrica, is more likely attributable to dosing effects since the active ingredient in both the brand name and generic formulations is identical. For these reasons, the requested brand name Lyrica is not medically necessary for treatment of this patient. Final Result: The reviewer determined that the requested brand name 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 subspecialty certification in pain management 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 59-year-old female enrollee has requested cervical discography for evaluation of her neck pain and headaches. Findings:  Three physician reviewers found that the medical literature indicates that cervical discography is of equivocal help in terms of identifying a pain generator and predicting results from surgery. However, in this case, the patients history of chronic neck pain as well as associated fibromyalgia and multilevel degenerative findings on MRI are key factors. Regardless of the outcome of the multilevel discogram, this patient would be a poor candidate for cervical surgery.  Confirming a pain generator is particularly challenging given the comorbid diagnoses of fibromyalgia and chronic pain. For these reasons, the medical literature does not demonstrate that discography was indicated in this case, as it would not have been likely to alter the treatment plan
Appeal type: Medical Necessity
Decision: Overturned

A 57-year-old male enrollee has requested sexual reassignment surgery: free flap phalloplasty for treatment of his gender dysphoria.  Findings:  The physician reviewer found that the submitted documentation establishes the medical necessity of the requested procedure. Free flap phalloplasty is the preferred method for female-to-male genitalia reconstruction. This procedure is preferred to the pedicled groin flap. Neither of these techniques are single stage procedures. Multiple procedures are common for both, but there are usually fewer procedures required when using the free flap compared to the pedicled groin flap. The free flap procedure is better vascularized, has fewer complications and has better outcomes compared to the pedicled groin flap. Moreover, the free flap procedure meets all of the criteria sought by the patient. The free flap does not contain muscle and generally does not affect forearm or hand strength. Urinary problems are common long-term for both procedures and urology involvement and follow up is necessary. A penile prosthesis is necessary for intercourse in any free flap surgery except for the fibula free flap. The anterior lateral thigh flap and latissimus musculocutaneous flaps are less preferred than the free flap because they are usually much thicker tissues and are too large. All told, the requested free flap surgery is a well-accepted procedure and is medically appropriate and necessary for this patient.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a five-year-old female enrollee has requested speech therapy for the treatment of the enrollees selective mutism. Findings:  The physician reviewer found that selective mutism is a rare disorder in which a child refuses to speak in one or more social situations. Some consider it to be similar to social phobia. Speech therapy has been utilized successfully as part of a multimodal treatment approach because of the association with other speech and language disorders. The literature also supports the efficacy of speech therapy intervention for expressive language delay. In a large meta-analysis looking at studies of children with primary speech and language delay/disorder, Law and colleagues concluded that there is a positive effect of speech and language therapy interventions for children with expressive phonological and expressive vocabulary deficits. This patient suffers from multiple speech and language difficulties. It is important to address all of the co-occurring deficits with speech therapy now in order to improve communication skills, and prevent difficulties in the future that may not be so amenable to therapy.
Appeal type: Urgent Care
Decision: Upheld

The parent of a 16-year-old female enrollee has requested emergency services for treatment of the enrollee's medical condition. Findings:  The physician reviewer found that at issue in this case is whether a prudent layperson in the patients circumstances would believe she was experiencing an emergency medical condition. California law defines an emergency medical condition as a medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain) such that the absence of immediate medical attention could reasonably be expected to result in any of the following: (1) Placing the patients health in serious jeopardy; (2) Serious impairment to bodily functions; (3) Serious dysfunction of any bodily organ or part. The patient had a cough with a runny nose and cold symptoms for three days prior and had no chronic medical conditions. Vital signs and pulse oximetry were normal on arrival, except for a slightly elevated temperature of 100.5 and a pulse of 130.   The patient did not have any concerning signs such as lethargy, vomiting, seizure activity or decreased responsiveness.  On physical examination, the physician noted the lungs were clear, without rales or rhonchi.  The patients symptoms did not meet prudent layperson criteria for emergency care. A prudent layperson in the patients circumstances would not reasonably expect the absence of emergency care to jeopardize her health in this clinical situation.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: A patient has requested authorization and coverage for Entyvio infusion treatments (J3380) every four weeks (300 mg for a total of six visits given over 27 weeks). The Health Plan has denied this request indicating that the requested medication regimen is not medically necessary for treatment of the patients ulcerative colitis (UC). The submitted documentation supports the medical necessity of the requested medication regimen. The study by Loftus and colleagues showed that patients with ulcerative colitis who had lost response to Entyvio every eight weeks regained response with  four-week dosing in a significant fraction of cases. Other studies have shown similar improvement. In this case, the patient had some residual colonic inflammation on colonoscopy even after increasing to Entyvio every four weeks. A change back to Entyvio every eight weeks, or a change to an alternative therapy, may result in worsening disease or disease complications such as disease flare, toxic megacolon, need for hospitalization, or need for a surgery. For these reasons, Entyvio infusion treatments (J3380) every four weeks (300 mg for a total of six visits given over 27 weeks) is medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested medication regimen 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 gastroenterology 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 enrollee has requested authorization and coverage for gloves (HCPCS code A4927).Urinary incontinence is a common problem that can have a considerable effect on an individuals quality of life, but can be significantly improved with correct assessment, treatment and management (Bardsley, A.). Functional incontinence is a type of incontinence that is caused by cognitive or mobility impairments, and not a failure in bladder function or in the neurological control of urination (Khandelwal, C., and Kistler, C.). This condition may require interventions such as timed voids, incontinence briefs, routine perineal cleansing, and application of various dermatological products (e.g., moisturizers, protectants, no-rinse cleansers, and antifungals) for prevention and/or treatment of incontinence-associated dermatitis (Gray, M.).In this case, the patient has a history of functional urinary incontinence, and records reflect that the patient receives and uses incontinence briefs and bed liners on a regular basis. There is no documentation, however, that indicates the intended use for the requested gloves or specifies the reason for their prescription. There is also no indication in the submitted records that the patient is able to don the gloves and use them for any medically related purpose, including for any bowel-related care. Under these circumstances, the requested gloves (HCPCS code A4927) are not medically necessary to assist with the patients condition.Final Result: The reviewer determined that the requested equipment is not medically necessary to assist with the patient's 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 authorization and coverage for lumbar kyphoplasty. Findings:  The physician reviewer found that there is a lack of support in the medical literature for the requested services in this clinical setting. The records show a mild L1 endplate compression fracture of unknown age. Kyphoplasty has not been shown as a superior treatment option for lumbar compression fractures. Recent literature shows it is not more effective than sham treatment. As such, lumbar kyphoplasty is not likely to be more beneficial than other available options for treatment of this patients medical condition. Final Result: Two of the three reviewers determined that requested services are 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.