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 magnetic resonance imaging (MRI) of the neck. Findings:  The physician reviewer found that the physician reviewer found the submitted documentation fails to demonstrate the medical necessity of the requested services. This patient has no documented red flags to warrant immediate MRI evaluation.  There were no neurological deficits documented in the provided records. The medical necessity of MRI cannot be established without the presence of an acute change in symptoms, including neurological deficit, which can be ascribed to a specific dermatome absent a six-week trial of conservative management. The current medical evidence does not support the requested services in this patients case. All told, the requested MRI of the neck is not medically necessary for the evaluation of this patient. Final Result: The reviewer determined that the requested services are not medically necessary for evaluation of the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is board certified in diagnostic radiology 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 44-year-old female enrollee has requested a power-operated vehicle (POV) for her mobility.  Findings:  The physician reviewer found that The records provided are not supportive of the patients need for a POV. There is no evidence of a condition or illness that would prevent the use of a standard heavy-duty wheelchair for mobility. The patient appears to have full use of her upper extremities and is fully capable of propelling a manual wheelchair. There is no indication of a need for a POV for mobility-related activities of daily living.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a 15-year-old female enrollee has requested inpatient psychiatric hospitalization for treatment of the enrollees behavioral health issues. Findings:  The physician reviewer found that given the patients ongoing documented symptoms described of mood disturbance, impaired judgment, irritability, isolation, guardedness and given the patients rapid decompensation as an outpatient, she was at high risk for recurrence and serious injury to self or others outside of an intense 24-hour treatment setting. Hospitalization from the said dates was medically necessary. The services provided were consistent with community standards of care, Child and Adolescent Level of Care Utilization System (CALOCUS) level of care guidelines and American Academy of Child and Adolescent Psychiatry (AACAP) practice parameters.
Appeal type: Medical Necessity
Decision: Overturned

A 47-year-old female enrollee has requested a laparoscopic gastric bypass procedure for treatment of morbid obesity.  Findings:  The physician reviewer found that this patient clearly meets the criteria set by the National Institutes of Health for surgical treatment of obesity with a BMI of 38.5 and a weight-bearing joint injury that will likely be ameliorated or eliminated by bariatric surgery.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Orthovisc injections in both knees. 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 lasting benefit from prior viscosupplementation, which was documented to last over six months. Furthermore, the patients osteoarthritis is not severe enough to warrant bilateral total knee arthroplasties. Given these findings, the requested Orthovisc injections in both knees are 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: Medical Necessity
Decision: Upheld

A 60-year-old female enrollee requested Oxycontin 60 mg tablets SR 12 hour for medical treatment of the enrollees fibromyalgia and myofascial pain.  Findings:  The physician reviewer found that the request for Oxycontin 60 mg tablets SR 12 hour is not medically necessary.  The current standard of care for chronic pain is treatment in a multidisciplinary practice to include physical therapy, massage therapy, behavioral therapy, and injections to help reduce pain (Fishman). Baron and McDonald reported that high dose and short acting opiates might contribute to pain sensitization via opioid-induced hyperalgesia, decreasing patient pain threshold and potentially masking resolution of a preexisting pain condition. In this retrospective study, the majority of patients undergoing detoxification of high dose opiates for chronic pain reported a significant decrease in pain at the end of the study, further supporting the theory of opioid-induced hyperalgesia. In addition, long-term opiates are more likely to cause adverse outcomes. Ballantyne and Mao reported that prolonged use of high dose opiates might induce tolerance, and abnormal pain sensitivity.
Appeal type: Experimental/Investigational
Decision: Overturned

A 52-year-old male enrollee has requested Humira for the treatment of his pityriasis rubra pilaris (PRP). Findings:  Two physician reviewers found that there is no medication approved by the FDA for treating PRP and there is no standard treatment for this condition. The patient is suffering with pain, discomfort, edema and congestive heart failure due to generalized erythroderma, which is a significant factor in his disease process. Cellulites and sepsis may also occur with severe PRP. Perhaps the most frequently used therapy is oral retinoids, which the patient is taking. There have been case reports describing beneficial results with anti-TNF drugs for PRP. This patients disease is severe, there is literature support for treatment with Humira, and the patient appears to be responding. Continued treatment with Humira is the best alternative at this juncture.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for EsophyX transoral incisionless fundoplication (TIF) surgery (CPT 43210). This patient presents with a history of GERD. The provider noted that the patient has failed standard treatment with proton pump inhibitor (PPI) medications. The provider has recommended the EsophyX TIF procedure. The efficacy of TIF has been studied in randomized controlled trials (Trad). However, the conclusions are contradictory (Witteman, et al.). The 2013 American College of Gastroenterology (ACG) guidelines for treatment of GERD report that the usage of current endoscopic therapy or TIF cannot be recommended as an alternative to medical or traditional surgical therapy (Katz, et al.). Auyang and colleagues found that further studies are required to define optimal techniques and most appropriate patient selection criteria, and to further evaluate device and technique safety. Guidelines from the American Society for Gastrointestinal Endoscopy (ASGE) do not recommend endoscopic procedures for patients with complicated GERD, which the guideline defines as dysphagia or Barretts esophagus and report that the long-term follow-up data for TIF are limited. Therefore, the requested EsophyX TIF surgery (CPT 43210) is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Findings:  Three of the three physician reviewers found the requested EsophyX TIF surgery (CPT 43210) 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 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 reviewers 1, 2, and 3 are board certified in internal medicine with subspecialty 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: Experimental/Investigational
Decision: Overturned

A 58-year-old female enrollee has requested radiofrequency ablation (neurolysis) for the treatment of her chronic low back pain. Findings:  Two physician reviewers found that for this particular patient, repeat lumbar facet radiofrequency ablation (neurolysis) is likely to be more beneficial for the treatment of her chronic low back pain than any other standard therapy. Gofeld and colleagues performed a 10-year prospective clinical audit of lumbar radiofrequency denervation. They concluded that proper patient selection and anatomically correct radiofrequency denervation of the lumbar zygapophyseal joints provide long-term pain relief in a routine clinical setting. This patient is a good candidate for this procedure. She reported a reduction in her pain and increased mobility following lumbar medial branch blocks and previously performed lumbar facet radiofrequency. Geurts and colleagues concluded that there is moderate evidence that radiofrequency lumbar facet denervation is more effective for chronic low back pain than placebo. Van Kleef and colleagues performed a randomized trial of radiofrequency lumbar facet denervation for chronic low back pain and concluded that radiofrequency zygapophyseal joint denervation results in a significant alleviation of pain and functional disability in a select group of patients with chronic back pain. The study also disputed other studies with modest outcomes in which invalidated techniques for radiofrequency lumbar facet denervation were used. To summarize, the van Kleef study reports good outcomes for lumbar facet denervation as long as the patients are appropriately selected and the proper technique is used. This patients clinical symptoms and physical findings point to lumbosacral facet pain. In addition, there are no clinical signs for lumbar radicular pain. All told, this patient is an appropriate candidate for radiofrequency ablation (neurolysis).
Appeal type: Medical Necessity
Decision: Overturned

A 55-year-old female enrollee has requested a three-month course of Sovaldi 400mg tablets, Pegasys Pro Click 180mcg/0.5mL solution and Ribapak 600mg tablets for treatment of her hepatitis C. Findings:  The physician reviewer found that the submitted documentation demonstrates the medical necessity of the requested medication combination.  The current medical evidence supports the requested medication combination in this clinical setting.  Sovaldi has been included in nationally-accepted joint treatment guidelines of the American Association for the Study of Liver Diseases and the Infectious Diseases Society of America (AASLD/IDSA).  Per the medical records, this patient has no contraindications to interferon-based treatment.  Allowing for the development of advanced fibrosis prior to initiating the proposed treatment regimen is likely to reduce the efficacy of the proposed treatment and lower the patients chance of virologic response.  All told, the requested three-month course of Sovaldi 400mg tablets, Pegasys Pro Click 180mcg/0.5mL solution and Ribapak 600mg tablets is medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a six-month-old male enrollee has requested authorization and coverage for an extensive development assessment.  Findings:  The physician reviewer found that infants born prematurely and those born with extremely low birth weight are at risk for a number of difficulties.  These difficulties include nutrition and growth problems, cerebral palsy and other motor difficulties, neurodevelopmental disabilities, behavioral problems, and sensory impairments.  These individuals have more language delay, visual-perceptual problems, and problems with attention and behavior.  As noted by Merenstein and Gardner, parents of neonatal intensive care unit infants should be offered comprehensive, coordinated, developmentally based, family-oriented follow-up for their child through infancy and childhood.   Spittle and colleagues conducted a review of the effectiveness of early developmental intervention post discharge from hospital for preterm infants.  The authors concluded that early intervention programs for preterm infants have a positive influence on cognitive outcomes in the short-term and medium-term. Early developmental follow-up is the standard of care in many centers.  In this patients case, the requested extensive development assessment is medically indicated.
Appeal type: Experimental/Investigational
Decision: Upheld

A 64-year-old female enrollee has requested spinal decompression for treatment of her low back pain.  Findings:  Three physician reviewers found that in this patients case, the superior efficacy of the services at issue has not been established.  The current medical evidence does not support spinal decompression therapy in this clinical setting.  There is a lack of support in the medical literature for the services at issue.  There is no demonstrated benefit of traction above standard care.  All told, spinal decompression performed on the dates indicated and future spinal decompression therapy was not and is not likely to be more efficacious than other treatment modalities.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Sensipar, or in the alternative, cinacalcet hydrochloride (HCL) 30 mg tablets. The signs and symptoms of primary hyperparathyroidism (PHPT) can be due to hypercalcemia, especially when the serum calcium is greater than 12 mg/dL, or if there is a rapid increase in serum calcium (Bilezikian). The symptoms of PHPT are more likely related to its key target organs. The treatment for symptomatic PHPT is parathyroidectomy (Marcocci and Cetani). In patients who are not considered candidates for surgery, but have a serum calcium greater than 1 mg/dL above normal or are symptomatic, pharmacological treatment may be indicated. Cinacalcet is a calcimimetic agent that can accomplish this goal by virtue of its property to bind to the calcium-sensing receptor. Cinacalcet is of benefit in patients with intractable primary hyperparathyroidism (Schwarz, et al.). This patient has intractable primary hyperparathyroidism with symptoms of organ involvement. She is unable to undergo parathyroidectomy, as she has had two prior surgeries and an adenoma was not localized on imaging. Based on the available documentation, the patient meets the U.S. Food and Drug Administration (FDA) approved indications for treatment with cinacalcet HCL. Moreover, the patient reports that she started treatment with the generic formulation, cinacalcet, and would like to continue treatment. The provider states that the patients history of broken femurs, new renal stone and significantly elevated blood levels support treatment with the generic formulation of Sensipar, cinacalcet HCL. For these reasons, cinacalcet HCL 30 mg tablets are 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 subspecialty certification in diabetes, endocrinology 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

Nature of Statutory Criteria/Case Summary:An enrollee has requested authorization and coverage for Avastin 743 mg The Health Plan has denied this request indicating that the requested medication is not medically necessary for treatment of the enrollee who has a history of cervical carcinoma.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 in internal medicine with sub-specialty certification in medical oncology 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

The patient has requested authorization and coverage for corneal collagen cross-linking procedure. Medical studies on cross-linking measure prior documented disease progression in order to scientifically determine whether the treatment is effective. Researchers found that corneal collagen cross-linking is a safe and effective method for halting the deterioration of keratoconus, while slightly improving visual function. Researchers found long-term stability of keratoconus after cross-linking without relevant side effects. In this case, given the patients vision loss, examination findings, and the natural progression of keratoconus, cross-linking is medically indicated. Therefore, the requested corneal collagen cross-linking procedure is medically necessary for the treatment of this patient.
Appeal type: Experimental/Investigational
Decision: Upheld

A 43-year-old female enrollee requested authorization and coverage of endoluminal radiofrequency ablation. The Health Plan denied the request indicating that the requested procedure is considered investigational for treatment of the enrollees varicose veins. Three physician reviewers performed an experimental/investigational Independent Medical Review. Two of the three physician reviewers concluded that the requested procedure is not likely to be more beneficial for treatment of the enrollee's medical condition than any available standard therapy. One of the three physician reviewers concluded that the requested procedure is likely to be more beneficial for treatment of the enrollee's medical condition than any available standard therapy. Because two of the three physician reviewers concluded that the requested procedure is not likely to be more beneficial for treatment of the enrollee's medical condition than any available standard therapy, the Health Plans denial has been upheld.
Appeal type: Medical Necessity
Decision: Upheld

A 52-year-old female enrollee requested bariatric surgery for medical treatment of her morbid obesity.  Findings:  The physician reviewer found that this patient underwent a psychological assessment which noted contraindications for the requested procedure.  The most common psychiatric reasons for surgical delay or exclusion are poorly controlled or significant psychopathology and lack of understanding about risks and postoperative requirements of the surgery.  The goal of these evaluations is to address potential psychiatric issues that can lead to poorer outcomes or more psychiatric dysfunction following surgery.  The current medical evidence does not support the requested services in this clinical setting, given the contraindications to surgery noted on psychological assessment.  All told, the requested bariatric surgery is not medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for inpatient hospitalization services. The management of patients with traumatic brain injury (TBI) is primarily contingent on the presence of intracranial hemorrhage. Traumatic intracranial hemorrhage is determined by cranial computed tomography (CT) imaging. In general, patients with traumatic brain injury but without traumatic intracranial hemorrhage are discharged from the emergency department, while patients with traumatic intracranial hemorrhage are admitted to the hospital for further management (Vos, et al.). The standard management of patients with TBI with evidence of intracranial hemorrhage includes admission to the hospital, neurosurgical consultation and evaluation with a repeat head CT scan six to 24 hours after the initial study to evaluate for progression (Cooper, et al.). The disposition of patients with a normal mental status examination and traumatic intracranial hemorrhage that does not require immediate neurosurgical intervention may include admission to the intensive care unit (ICU), admission to hospital in non-ICU setting, or monitoring in the emergency department observation unit. One study across a consortium of trauma centers by Nishijima and colleagues identified wide variability in ICU use within a cohort of similarly injured patients with traumatic intracranial hemorrhage. The authors found that a large portion of patients with traumatic intracranial hemorrhage who are admitted to the ICU never required critical care intervention, which suggests a need to improve the use of the ICU for patients with traumatic intracranial hemorrhage. In this case, the patient presented with head trauma after a fall, and she was found to have a subarachnoid hemorrhage. Based on the current medical literature, the patient was appropriately admitted to the hospital for monitoring. For these reasons, the inpatient hospitalization services were medically necessary for this patient. Final Result: The reviewer determined that the services at issue were 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 neurology 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.