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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Beeks arch support shoes and a Simmons 6th generation bed including Super Plush Pillow Topper.Researchers state that excessive foot pronation during gait is a risk factor in medial tibial stress syndrome (MTSS). Researchers studied the effects of bilateral foot orthoses during running on dynamic foot-pressure distribution patterns in recreational runners with MTSS and found that arch-support foot-orthoses may help with conditions such as MTSS. Hsieh and colleagues conducted a randomized controlled trial to examine the short-term effects of customized arch support insoles on symptomatic flexible flatfoot in children. They concluded that children with flexible flatfoot who wore customized arch support insoles for 12 weeks exhibited significantly improved pain/comfort, physical health, stair ascent time, upper extremity and physical function, and transfer and basic mobility.In this case, the submitted records do not indicate that the patient has any musculoskeletal condition that would benefit from shoes with arch supports. Records specifically indicate that there are no musculoskeletal abnormalities (such as pes planus) in the patients feet and that the patients gait is normal. Moreover, records indicate that the patient has polyneuropathy, which is not a condition for which arch supports are an established treatment. Under these circumstances, the requested Beeks arch support shoes are not medically necessary to treat the patients condition.There are also no indications in the submitted records that the patient has any medical conditions for which she requires a specialty medical bed or specialty pillow/bedding/mattress surface. In addition, there are no features of the requested bed and pillow topper that are proven to provide any clinically and marginally significant benefit for any health condition over a standard, commercially available bed and pillow. Therefore, the requested Simmons 6th generation bed including Super Plush Pillow Topper is not medically necessary to treat the patients condition.Final Result: The reviewer determined that the requested durable medical equipment is not medically necessary to treat the patients 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: Overturned

A 47-year-old male enrollee has requested the use of a Meniett device for the treatment of his Menieres disease. Findings:  Three physician reviewers found that though time may show this device to be an effective and consistent treatment for the condition, at this point it remains experimental for most patients, pending further studies. On the other hand, Menieres patients are sometimes disabled by their symptoms, which can lead to invasive surgical procedures with significant risks and side-effects as in this patients case. According to the note from his physician, this patient has experienced significant improvement in symptoms from this non-invasive device. For this reason, I recommend reimbursement for this device, as its surgical alternative (standard therapy) carries greater risk.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Intracept spine procedure. The U.S. Food and Drug Administration (FDA) has approved the Intracept procedure for use in conjunction with radiofrequency generators for the ablation of basivertebral nerves of the L3 through S1 vertebrae. The FDA has endorsed use of the Intracept procedure for patients with chronic low back pain of at least six months duration that has not responded to at least six months of conservative care accompanied by features consistent with Type 1 or Type 2 Modic changes on an MRI. This patient has history of spondylosis without myelopathy or radiculopathy, lumbar region, disease of the musculoskeletal system and connective tissue, and other intervertebral disc degeneration, lumbar region. The patients MRI showed mild endplate spurring at L2-3 and L3-4 levels along with advanced spondylosis from L1-2 through L4-5 and mild spondylosis at L5-S1. However, there is a lack of documentation of findings supportive of the spinal vertebral bodies as being the overwhelming primary generators of the patients chronic persistent pain. There was also plausible occasional nerve root generated/painful radiculitis evident. There is a paucity of current studies demonstrating that the Intracept procedure is likely to be more beneficial for this patient than standard available treatment modalities. Therefore, the requested Intracept spine procedure is not 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 Intracept spine procedure is not 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 reviewers 1, 2 and 3 are board certified in orthopedic surgery 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 Ozempic 1 mg/dose pen. Ozempic is a member of  the glucagon-like peptide 1 (GLP-1) analogues, a new class of drugs used in the treatment of type 2 diabetes that mimic the endogenous hormone GLP-1.  The use of this class of medications may result in improvements in glycemic control, progressive weight loss, low incidence of hypoglycemia and potential improvement of cardiovascular risk factors. Ozempic is the newest agent of the GLP-1 analogues.  While it appears to be quite effective for glycemic control, as well as for promoting weight loss, it is currently only approved by the U.S. Food and Drug Administration (FDA) for patients with a history of type 2 diabetes. Therefore, Ozempic 1 mg/dose pen is not medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested medication is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is board certified internal medicine with sub-specialty certification in endocrinology, diabetes and metabolism 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 54-year-old female enrollee has requested coverage for Synvisc injections for treatment of her osteoarthritis. Findings:  The physician reviewer found that the patient is relatively young and has a severe condition in her right knee. She has not responded to anti-inflammatory medications. Based on the fact the patient has osteoarthritis, persistent knee pain and has failed treatment with oral medications, a series of Synvisc injections is the best treatment alternative at this time. This treatment should not be precluded for lack of a failed steroid injection. Synvisc therapy can reasonably be expected to alleviate her pain and postpone the need for surgical intervention.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Afrezza. The submitted documentation supports the medical necessity of the requested medication. This patient has variable post meal glucose control, including hypoglycemia after meals. Afrezza is a rapid acting insulin with a quick onset of action. This medication can help decrease hyperglycemia as well as avoid hypoglycemia. This patient has severe glycemic fluctuations and requires additional prandial insulin shots. The patients provider has recommended Afrezza insulin in addition to the current insulin regimen, which is a combination of basal insulin and a prandial insulin. Afrezza is medically indicated in this clinical setting and is likely to improve the patients glycemic control. Therefore, Afrezza is medically necessary for the 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 internal medicine with sub-specialty certification in endocrinology, diabetes and metabolism 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: Urgent Care
Decision: Overturned

A 33-year-old male enrollee has requested emergency services for treatment of his throat pain.  Findings:  The physician reviewer found that a prudent layperson would have sought immediate medical attention on the date in question. The patient had severe throat pain, after a bout of documented tonsillitis/pharyngitis, has, in the differential diagnosis the potential to be a case of peritonsillar abscess or retropharyngeal abscess, both of which are life-threatening complications of tonsillitis/pharyngitis. Moreover, the determining factor in this case is the degree of pain that the patient was in, the fact that he had severe pain (9 out of 10) constitutes grounds for a prudent layperson to have thought this to be an emergency medical condition and to have sought immediate medical attention in an emergency department. The patients symptoms on the date in question met prudent layperson criteria for emergency care.
Appeal type: Medical Necessity
Decision: Overturned

The patient is a 52-year-old male who underwent surgical resection of a recurrent acoustic neuroma in 2001. Subsequent postoperative MRI scans showed residual tumor within the right cerebellopontine angle. The most recent MRI from September 2004 showed a stable appearance of the residual right acoustic neuroma. The patients current request for a surveillance scan was denied by the Health Plan based upon a determination that the MRI is not medically necessary.Close medical monitoring with serial MRI studies of a patient with recurrent acoustic neuroma and two previous surgeries is medically reasonable. The Milliman criteria for follow up of an acoustic neuroma cited by the Health Plan applies to patients who have either undergone radiosurgery or have not had surgery at all. This patient does not fall into either of these categories. While there is no fixed interval for surveillance MRI for patients such as this one, Dr. Timothy Hain advocates for three to six MRI scans over a period of five years. As 2006 marks five years following the patients last surgery, it is medically appropriate to perform an MRI scan at this time. Therefore, I have determined the requested diagnostic procedure is medically necessary for evaluation of the patients medical condition. The Health Plans denial should be overturned.
Appeal type: Experimental/Investigational
Decision: Overturned

A 53-year-old female enrollee has requested authorization and coverage for a high frequency chest wall oscillation air pulse generator system for treatment of the enrollees bronchiectasis without acute exacerbation.  Findings:  Two physician reviewers found that the patient has a history of bronchiectasis, asthma, gastroesophageal reflux disease (GERD), thick sputum production, and frequent episodes of bronchitis (4 or more times per year) treated with antibiotics and corticosteroids. The patient has been using the high frequency chest wall oscillation (HFCWO) air pulse generator system (Vest) for over two years with reduced bronchitis exacerbations. The provider has requested authorization for the HFCWO Vest airway clearance system which the Health Plan has denied as investigational. The peer-reviewed medical literature includes some data supporting the effectiveness of the requested device in patients with non-cystic fibrosis bronchiectasis. Specifically, the literature suggests that the Vest HFCWO helps to move sputum out of bronchiectatic airways when other methods fail. The Centers for Medicare and Medicaid Services (CMS) generalized the indications for the HFCWO air pulse generator system systems for bronchiectasis caused either by cystic fibrosis, or other causes in November of 2003. CMS requires a patient with severe disease to have failed conventional treatments including chest physical therapy and postural drainage. The Vest should continue to move sputum out of the patients lower airways, and prevent infection, hospitalization, recurrent bronchitis, and reduce drug resistant organisms. Therefore, the Vest airway clearance system is likely to be more beneficial than repeated attempts at conservative therapy in managing this patients non-cystic fibrosis bronchiectasis.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested Harvoni for treatment of his hepatitis C.  Findings:  The physician reviewer found that according to the most recent joint guidelines issued by the American Association for the Study of Liver Diseases and the Infectious Diseases Society of America, all patients with chronic hepatitis C should be treated except those with limited life expectancy due to non-liver-related conditions. This applies regardless of fibrosis stage or viral load.  The guidelines recommend that treatment-naive genotype 1 patients should be treated with Harvoni for 12 weeks.  These guideline recommendations are based on multiple randomized clinical trials, and the medication is U.S. Food and Drug Administration (FDA) approved for all patients with chronic hepatitis C, genotype 1 regardless of fibrosis stage.  The requested treatment with Harvoni is supported as medically necessary for the treatment of this patients hepatitis C infection.  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 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

Findings:  The physician reviewer found that The patient has requested authorization and coverage for Dexcom G6 continuous glucose sensor and transmitter. Olczuk and Priefer note that self-monitoring of glucose allows patients with diabetes mellitus to take control of their disease and thus directly affect the outcomes related to it. The authors further note that continuous glucose monitor (CGM) systems have recently been refined and improved for home use. Zheng and colleagues report that CGM systems may be clinically valuable due to their accuracy and convenience and may promote glycemic and weight control, helping to reduce the risk of hypoglycemia and hyperglycemia. Given that current medical literature supports the safety and accuracy of CGM systems, such as the Dexcom G6, for home monitoring of glucose levels, the requested equipment is medically indicated. Therefore, Dexcom G6 continuous glucose sensor and transmitter are medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested equipment is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Overturned

The patient is a 64-year-old female with diabetes who is currently on dialysis. The patient has experienced decreased mobility and ability to ambulate.  She was admitted to a skilled nursing facility (SNF) on 5/12/04. The submitted notes indicate the patient does well with physical therapy on days when she does not have dialysis but is too fatigued on days when she has dialysis to fully participate in physical therapy. A request has been made for continued SNF services. The Health Plan has denied the request on the basis that SNF services were not medically necessary after 6/13/04.The submitted records indicate the patient progressed from maximum assistance with bed mobility to standby assistance in a period of one month. Additionally, there is evidence the patient progressed from moderate assistance with ambulation to contact guard assistance within one month. Thus, the submitted medical records demonstrate the patients condition was improving with therapy. Furthermore, though it was noted the patient had trouble with physical therapy on days she had dialysis, there is no evidence that an attempt was made to schedule the patients physical therapy sessions in the morning followed by dialysis in the afternoon. Given the patients documented progress additional SNF services are medically appropriate and indicated.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested breast tomosynthesis for evaluation of her medical condition.  Findings:  Two physician reviewers found that breast tomosynthesis was likely to be more beneficial for this patient than any available standard modalities. Medical studies have shown that the addition of three dimensional (3D) digital breast tomosynthesis (DBT) reduces false positive results and increases cancer detection when compared to two dimensional full field digital mammography alone. Three dimensional DBT allows better characterization of possible masses, spiculation, and architectural distortion. In sum, there is sufficient evidence supporting the use of tomosynthesis for this patients routine breast cancer screening. Final Result: Two reviewers determined that the services at issue were 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: The patient has requested authorization and coverage for Genesight genetic testing, ketamine infusions, and ketamine nasal spray. The Health Plan denied the requests and reported that the requested services and medications are not medically necessary for the evaluation and treatment of this patient. At issue in this case is whether Genesight genetic testing, ketamine infusions, and ketamine nasal spray are medically necessary for the treatment of the patients medical condition. The Health Quality Ontario study noted that there is uncertainty about the use of the Genesight psychotropic pharmacogenomic genetic panel to guide medication selection. It was associated with improvements in some patient outcomes, but not others. Murrough and colleagues reported that ketamine infusions were associated with a rapid antidepressant effect in treatment resistant depression that was predictive of a sustained effect. Naidoo and colleagues reported intraperitoneal ketamine administration resulted in favorable concentrations in the brain and plasma. However, intranasal ketamine administration demonstrated moderately low drug levels post administration. In this case, the patient has been diagnosed with major depressive disorder and anxiety. Per the records, this patient reported a depressed mood, loss of interest/pleasure, fatigue, and thoughts of death/self-harm. The medical evidence supports ketamine infusions in this clinical setting. Therefore, ketamine infusions are medically necessary for the treatment of this patient. Genesight genetic testing and intranasal ketamine are not medically necessary for the evaluation and treatment of this patient. Final Result: The reviewer determined that the requested services are partially medically necessary for evaluation and treatment of the patients medical condition. Therefore, the Health Plans denial should be partially 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

A fifty year-old female who was diagnosed with cholangiocarcinoma is requesting authorization for thermoradiation therapy, hyperthermia and low-dose radiationReviewers Findings:  The reviewing physician found that there is insufficient rigorous evidence in the literature to support thermoradiation therapy, hyperthermia and low-dose radiation for this or any other indication.  The reviewing physician found that the Health Plan denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld

A 55-year-old female enrollee requested authorization and coverage of acupuncture treatments. The Health Plan denied the request indicating that the requested therapy is not medically necessary for treatment of the enrollees right shoulder pain.One acupuncture reviewer performed a medical necessity Independent Medical Review. The acupuncture reviewer upheld the Health Plans denial on the basis that the requested therapy is not medically necessary.