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

A 44-year-old male enrollee has requested osteochondral knee allograft for treatment of his knee pain. Findings:  Two physician reviewers found that the requested services are likely to be more effective for this patient than other available options. In this case, the patient is young with large osteochondral lesion of lateral tibial plateau. This is an isolated osteochondral lesion. Femoral lesion is relatively minor with no subchondral involvement. Thus, the patients knee pathology is not a kissing lesion. In addition, the patient has a well-aligned and stable knee with no joint space narrowing. Finally, osteochondral knee allografting allows the patient to delay knee replacement until he reaches the appropriate age, as knee replacement is not preferred treatment for patients at his age. Therefore, the requested services are likely to be more beneficial than any standard treatments for this particular patient.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary:    An enrollee has requested breast augmentation and vascular surgery pre-operative consultation/clearance for treatment of her gender dysphoria. Findings:  The physician reviewer found that based on her response to hormone therapy, the patient presents with sufficient breast development to be considered consistent with adult female anatomy. Thus, breast augmentation surgery would be considered aesthetic and not medically necessary. As such, the requested vascular surgery pre-operative consultation/clearance is also not medical necessity for treatment of the patients medical condition. With regard to the whether the requested services are considered reconstructive in nature, the submitted documentation reveals the patient has relatively normal female breast development. The patient has been treated with hormone therapy and the submitted photographs document the presence of visible breast tissue. As such, the patient does not present with an abnormal structure of the body. Thus, the requested breast augmentation is not reconstructive in nature for treatment of the patients gender dysphoria. Final Result: The reviewer determined that the requested services are not medically necessary for treatment of the patients medical condition or reconstructive in nature. Therefore, the Health Plans denial should be upheld.  Credentials/Qualifications: The reviewer is board certified in plastic 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 42-year-old female enrollee has requested cryoablation (cryosurgical ablation) of the breast for treatment of her right breast mass. Findings:  Two physician reviewers found that review of the submitted documentation and relevant literature fails to support the requested services in this clinical setting. Cryoablation is not considered a standard medical therapy. Although there is some support in the medical literature showing the efficacy of this treatment with respect to partial or complete resolution of the mass, there is a lack of published evidence that this treatment is as effective or superior to the current standard treatments which include observation or surgical excision. In addition, there is still the likelihood that after the cryoablative therapy the patient may be left with a small, residual mass. All told, the request for cryoablation (cryosurgical ablation) of the breast is not likely to be more beneficial than other modalities for the treatment of the patients medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for bilateral occipital nerve block procedure with ultrasound guidance (CPT 64405 x 2, 64450 x 2, and 01992). According to the International Classification of Headache Disorders, occipital neuralgia is associated with unilateral or bilateral paroxysmal, shooting, or stabbing pain in the posterior part of the scalp, following the distribution of the greater occipital nerve and/or the lesser occipital nerve. In this case, the patients symptoms and physical examination findings are consistent with occipital neuralgia. Her pain has been refractory to medical management. However, she underwent treatment with bilateral occipital nerve blockade with ultrasound guidance with improvement of pain and reduction of use of pain medications. Treatment with use of bilateral occipital nerve blockade with ultrasound guidance in this clinical setting is consistent with the current medical literature. Authors concluded that occipital nerve block is a safe, technically simple, and effective method that carries a minimal risk of side effects and can be applied for patients that do not achieve desired pain relief using conventional pain management methods. All told, the requested bilateral occipital nerve block procedure with ultrasound guidance (CPT 64405 x 2, 64450 x 2, and 01992) is 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 bilateral occipital nerve block procedure with ultrasound guidance (CPT 64405 x 2, 64450 x 2, and 01992) is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the requested services are likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: Physician reviewers 1, 2, and 3 are board certified in neurology and are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

A female enrollee requested authorization and coverage of a deluxe commode transfer chair for assistance with her Parkinsons disease. The Health Plan has denied this request.One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer upheld the Health Plans denial on the basis that the requested equipment is not medically necessary at this time.
Appeal type: Medical Necessity
Decision: Upheld

A 52-year-old female enrollee has requested use of a CPM machine for the treatment of the enrollee, who is status post total knee arthroplasty. Findings:  The physician reviewer found that the addition of a CPM machine to the postoperative rehabilitation program following total knee arthroplasty has not been shown to offer significant advantages over physical therapy alone. Stiffness after knee replacement is uncommon, but can be disabling. The majority of studies show that the use of a CPM machine results in no statistical difference in terms of relieving stiffness over an extended period. A review of the peer-reviewed Level 1 and Level 2 studies in the current medical literature does not support the use of a CPM device in the home following total knee arthroplasty. There is no significant increase in range of motion in the long-term from the use of a CPM machine in this setting. Objective evidence that CPM results in improved clinical outcomes is lacking at this time.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for a colonoscopy. Findings:  The physician reviewer found that United States Preventive Services Task Force (USPSTF) recommendation for colorectal cancer screening states, The USPSTF did not specifically review the evidence on screening in populations at increased risk; however, other professional organizations recommend that patients with a family history of colorectal cancer (a first-degree relative with early-onset colorectal cancer or multiple first-degree relatives with the disease) be screened more frequently starting at a younger age, and with colonoscopy. The American Cancer Society (ACS) noted that people at increased or high risk of colorectal cancer might need to start screenings before age 45, or be screened more often, but stated that the ACS does not have screening guidelines specifically for people at increased or high risk of colorectal cancer. Wilkins and colleagues advise individuals who have a first-degree relative with colorectal cancer diagnosed before age 60 to start screening colonoscopies at 40 years of age or 10 years younger than the earliest diagnosis in their family, whichever comes first. In this case, the patient has a family history of colorectal cancer, with a first-degree relative diagnosed at age 38. Under current guidelines, a screening colonoscopy based on the patients family history of colon cancer is not medically indicated. There is no documentation of symptoms which would warrant a colonoscopy, such as bleeding, unintentional weight loss, or anemia. Therefore, a colonoscopy is not medically necessary for the evaluation of this patient.Final Result: The reviewer determined that the requested service 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 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

A 47-year-old female enrollee requested authorization and coverage of uvulopalatopharyngoplasty (UPPP) for the treatment of snoring.  The Health Plan denied the enrollees request indicating that the requested treatment is not medically necessary.One physician reviewer performed a medical necessity Independent Medical Review.  The physician reviewer upheld the health plans denial on the basis that the requested services are not medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld

A 58-year-old male has requested Holmium laser enucleation of the prostate (HoLEP) for treatment of benign prostatic hypertrophy.  Findings:  The physician reviewer found that the medical necessity of the requested services has not been established.  Holmium laser enucleation, transurethral resection of the prostate, and selective photovaporization with green light laser are all accepted treatment options in this clinical setting.  The laser procedures have the advantage of less bleeding and lower risk of hyponatremia/water overload as compared to transurethral resection of the prostate.  However, there is a lack of clinical data demonstrating the advantage of Holmium laser enucleation in this setting. The submitted clinical records do not demonstrate the medical necessity of the requested Holmium laser enucleation of the prostate (HoLEP) in this patients case.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Gelsyn-3 injection series in the right knee. Per the medical literature, although viscosupplementation may relieve knee pain in some individuals with osteoarthritis, it is not known as to which individuals will benefit. The current evidence is limited, and guidelines from organizations such as the American Academy of Orthopedic Surgeons indicate that the evidence is not conclusive. In light of the foregoing, viscosupplementation can only be recommended in individuals with a history of lasting benefit from prior injections, and in carefully selected cases where everything else has been tried, and the options are limited. In this case, the patient has tried and failed conservative therapies, including corticosteroid injections. Given the patients limited options, with the alternative being total knee arthroplasties, and based on the current medical literature, the requested services are medically indicated. Therefore, Gelsyn-3 injection series in the right knee are 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 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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for the medication Fioricet.The medical literature and submitted documentation do not support that the requested medication is medically necessary. Fioricet, the requested medication, contains a combination of acetaminophen, butalbital, and codeine. Butalbital-containing medications are associated with serious and undesirable side effects, and have been linked to the chronification of migraine and development of medication-overuse headaches. Additionally, there are multiple randomized controlled studies showing that relative to standard treatment with triptan and naproxen combination medications, butalbital-containing combination medications are less effective and often lead to transformation of migraines into chronic migraines. Use of sumatriptan and naproxen, in contrast to Fioricet, has been shown to be associated with less rescue medication use and a longer time before use of rescue medication compared with Fioricet. Thus, there is no strong medical data supporting Fioricet use over triptan and NSAID class of abortive medications and no evidence exists to vouch for Fioricet's strong effectiveness as an abortive migraine medication. In addition, the submitted documentation does not reflect that the patient has had recent treatment failure or intolerance to alternative abortive medications for migraines including other types of triptans besides sumatriptan, ibuprofen, dihydroergotamine (DHE), or other triptan/DHE class medications, which can be administered subcutaneously or intranasally. Under these circumstances, the requested medication Fioricet is not medically necessary for treatment of the patients medical condition.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 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.
Appeal type: Medical Necessity
Decision: Overturned

A thirty-six year-old female with multiple sclerosis and quadriplegia with severe spasticity is requesting reimbursement for the equipment for an Apex Lift.  Reviewers Findings:  The reviewing physician found that the Apex electric lift with sling is not a convenience item; it is clinically indicated to maintain the patients ability to transfer with assistance.  The reviewing physician found that the Health Plan denial should be overturned.
Appeal type: Experimental/Investigational
Decision: Upheld

A 41-year-old male enrollee has requested for artificial intervertebral disc replacement for treatment of his multiple-level degenerative disc disease in the cervical spine. Findings:  Two physician reviewers found that there is no evidence that disc replacement reliably, reproducibly, and over long periods of time fulfills the three primary aims of clinical efficacy, continued motion, and fewer adjacent segment degenerative problems. Total disc replacement has been associated with a high rate of reoperations, and the potential problems that may occur with longer follow-up have not been fully documented. Anterior cervical discectomy and fusion are considered to be the gold standard for treatment of symptomatic degenerative disc disease within the cervical spine. However, fusion may result in progressive degeneration of the adjacent segments. Therefore, disc arthroplasty has been introduced. Among these, artificial disc replacement seems to be promising. However, segmental motion should be preserved. This is very difficult to judge and has not yet been proven.  No truly blinded studies have been done to establish efficacy, and the results are short-term at best.  Until this is a proven therapy, it cannot be considered to be equivalent or better than standard therapies.
Appeal type: Medical Necessity
Decision: Overturned

A 44-year-old female enrollee has requested repeat Supartz injections for the treatment of her left knee osteoarthritis and pain. Findings:  The physician reviewer found that in this patients case the only alternative to viscosupplementation may be total joint arthroplasty. Based on her physical finding of anterior cruciate ligament deficiency and her x-ray report of tri-compartmental degenerative change, she is not a candidate for less extensive reconstruction surgery such as osteotomy or uni-compartmental arthroplasty. Total knee arthroplasty in a young patient such as this patient would commit her to at least 1-2 future revisional procedures, assuming she has no co-morbid conditions that would decrease her life expectancy. A third course of viscosupplementation in this patient is medically necessary to maximize non-operative management and further postpone a bridge burning procedure such as total knee arthroplasty.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary:  An enrollee has requested authorization and coverage for fentanyl patch at 150 micrograms or 125 micrograms. The submitted documentation fails to demonstrate the medical necessity of the requested medication dosages. This patient is on high-dose fentanyl and Ambien. This drug combination carries significant risk. Additionally, clinical practice guidelines advise against maintaining patients on greater than 50 mg of morphine equivalent per day. Researchers studied the long-term use of opiates in polyneuropathy and found little benefit and major adverse outcomes. A slow taper as suggested by her provider is medically reasonable and necessary. Therefore, fentanyl patch at 150 micrograms or 125 micrograms is not medically necessary for the treatment of this patient. Final Result: The reviewer determined that requested medication dosages are not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is board certified in anesthesiology with sub-specialty certification in pain medicine and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a six-year-old male enrollee has requested authorization and coverage for a one hour session of speech therapy, two days per week, for 12 weeks. Findings:  The physician reviewer found that the submitted medical records demonstrate the medical necessity of the requested services in this patients case.  As noted by Nelson and colleagues, speech and language development is considered by experts to be a useful indicator of a childs overall development and cognitive ability and is related to school success.  The authors noted that identification of children at risk for developmental delay or related problems may lead to intervention services and family assistance at a young age when chances for improvement are best.  Speech and language delay must be taken seriously in young children, because the long-term consequences may be substantial. According to Law and colleagues, approximately 6% of children have speech and language difficulties.  The authors noted that children whose difficulties persist into primary school may have long-term problems concerning literacy, socialization, behavior, and school attainment.  Per Bernhardt and Major, early phonological and metaphonological intervention can promote normalization of speech development and normal acquisition of literacy skills for some children with a history of severe phonological impairment. This patient has a severe articulation disorder which is negatively impacting his ability to communicate in a functional and age-appropriate manner.  Studies have shown that speech and language therapy can result in significant improvement in this clinical setting.  The current medical evidence supports the requested services in this patients case.  All told, a one hour session of speech therapy, two days per week, for 12 weeks is medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for bilateral Orthovisc injections series at the frequency of once per week for three consecutive weeks. Findings:  The physician reviewer found that the evidence based literature supports the use of repeat series of viscosupplementation injections for the treatment of pain in patients with osteoarthritis of the knee. The study concluded that repeated cycles of intra-articular sodium hyaluronate treatment to delay time to total knee replacement in patients with knee osteoarthritis which failed conservative treatment was found efficacious during a 54-month follow-up period. In this case, the patient has been diagnosed with bilateral knee osteoarthritis. The patient has undergone two prior viscosupplementation series with marked pain reduction, improvement in functional ability and ability to avoid surgery. The patient has failed to respond to other conservative treatment including anti-inflammatory medications, activity modification, and corticosteroid injections. Therefore, the requested bilateral Orthovisc injections series at the frequency of once per week for three consecutive weeks are medically necessary for treatment of the patients bilateral knee osteoarthritis. Final Result: The reviewers 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: 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.