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

A 58-year-old female enrollee has requested continued stay at acute rehabilitation level of care and continued antibiotic therapy at the acute rehabilitation level of care for treatment of her brain abscess. Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested services.  This patient had a stroke followed by brain abscess, for which extensive rehabilitative care was required for retraining and safety.  However, the current medical evidence does not support continued stay at acute rehabilitation level of care at this time.  Per the records, caregiver training has been completed.  The records indicate that the patient is medically stable and does not require treatment in the acute rehabilitation level of care setting.  Additionally, it is not medically necessary that the patient receive continued antibiotic therapy at the acute rehabilitation level of care.  Intravenous antibiotics can be given in the home or skilled nursing facility setting.  All told, continued stay at acute rehabilitation level of care and continued antibiotic therapy at the acute rehabilitation level of care are not medically indicated for the treatment of this patient.
Appeal type: Experimental/Investigational
Decision: Upheld

Findings:  The physician reviewer found that An enrollee has requested reimbursement for laboratory testing (4K prostate score). The records provided for review document that this patient presented with a history of rising prostate specific antigen (PSA) and a family history of prostate cancer in his father, and a low free PSA level. The patient underwent evaluation with 4Kscore testing. Given the patients rising PSA value, family history, and low free PSA level, a biopsy would have been recommended for further evaluation of this patients condition. Moreover, the current peer-reviewed medical literature does not support routine use of the 4Kscore test in the evaluation of patients in this clinical scenario. Saltman and colleagues concluded that more research is needed to determine the novel biomarker testing such as 4Kscore in the evaluation and treatment of patients with prostate cancer. Therefore, the laboratory testing (4K prostate score) was not likely to have been more beneficial for evaluation of the patients medical condition than any available standard therapy. Findings: Two of the three physician reviewers found the laboratory testing (4K prostate score) was not likely to have been more beneficial for evaluation of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the services at issue were not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary:  An enrollee requested Xiaflex for medical treatment of his Peyronies disease.   Findings:  Two physician reviewers found that Xiaflex has been shown to have modest efficacy in clinical trials and is U.S. Food and Drug Administration (FDA) approved for use in patients with Peyronies disease with at least 30 degrees of curvature and a palpable plaque. In addition, Xiaflex is the only FDA approved drug for Peyronies disease. This patient has failed conservative therapy, has a greater degree of dorsal penile curvature, and has a palpable penile plaque. All told, the requested Xiaflex is supported as likely to be more beneficial for treatment for treatment of this patients Peyronies disease.Final Result: Two reviewers determined that the requested medication is 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: Reviewers 1, 2, and 3 are board certified in urology and is 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 49-year-old female enrollee has requested a custom ACL knee brace for the treatment of her medical condition status post ACL repair surgery. Findings:  The physician reviewer found that while certain physicians use an off-the-shelf anterior cruciate ligament derotation brace postoperatively to try to decrease the risk of recurrent anterior cruciate ligament injury, the indication for a custom brace is a patient who cannot be fit with an off-the-shelf brace for some unusual anatomic reason.  In this case, there is no documentation of an unusual anatomic reason or an apparent trial of an off-the-shelf brace.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary:  An enrollee has requested Norco for treatment of his pain.  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested medication.  This patient has non-malignant chronic pain, which will often worsen or recur as a result of opioid rebound.  The current standard of care for chronic pain is treatment in a multidisciplinary pain management practice to include physical therapy, massage therapy, cognitive behavioral therapy, and injections to help reduce pain.  The current medical evidence does not support the requested medication in this clinical setting.  Baron and McDonald reported that high-dose 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.  High-dose and short-acting opiates may also cause adverse outcomes.  Ballantyne and Mao reported that prolonged use of opiates might induce tolerance, abnormal pain sensitivity, and hormonal effects. The aim of current guidelines is to protect patients from the adverse effects of opioid therapy.  All told, the requested medication Norco is not medically indicated 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 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

Nature of Statutory Criteria/Case Summary:   An enrollee has requested monitored anesthesia care (MAC) for treatment of his medical condition.   Findings:  The physician reviewer found that there is sufficient support in the medical literature for the services at issue in this clinical setting. According to Alharbi and colleagues, propofol used for sedation during colonoscopy has become increasingly popular and is attributable to its deep sedative effect, rapid onset of action, and short recovery time, resulting in greater patient and endoscopist satisfaction with the procedure while increasing the efficiency of endoscopy units. In addition, per the Centers for Medicare and Medicaid Services (CMS), anesthesia associated with colonoscopy is a covered benefit. Given the support in the peer-reviewed literature, the requested MAC services were medically necessary for evaluation of the patients medical condition. Final Result: The reviewer determined that the services at issue were medically necessary for evaluation of the patients medical condition. Therefore, the Health Plans denial should be overturned.  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: Upheld

A 53-year-old female enrollee requested authorization and coverage for compounded medication.  The health plan has denied this request indicating that the requested compounded medication is not medically necessary for treatment of the enrollee's cronic pain.One physician reviewer performed a medical necessity Independent Medical Review.  The physician reviewer upheld the health plans denial on the basis that the requested medication is not medically necessary.
Appeal type: Experimental/Investigational
Decision: Overturned

A 61-year-old male enrollee requested  intensity modulated radiation therapy (IMRT) for medical treatment of his pancreatic cancer.   Findings:  Two physician reviewers found that IMRT was and is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. There is abundant single institution data to suggest that IMRT for pancreatic cancer yields improved plans versus conventional radiation with respect to normal tissue sparing (Landry, et al). IMRT for pancreatic cancer in select cases, such as in this case is clinically indicated as a superior treatment.  Given the dosimetric justification provided for review, the IMRT provided was and is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.
Appeal type: Medical Necessity
Decision: Upheld

A 56-year-old female enrollee requested authorization and coverage of an upper GI series. The Health Plan denied the request indicating that the requested services are not medically necessary for evaluation of the enrollees abdominal pain.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.
Appeal type: Experimental/Investigational
Decision: Upheld

A 62-year-old male enrollee requested authorization and coverage of hyperthermia with adjunctive low-dose radiation therapy.  The Health Plan denied the request indicating that the requested therapy is considered experimental for treatment of the enrollees metastatic chondrosarcoma.Three physician reviewers performed an experimental/investigational Independent Medical Review. All three physician reviewers concluded that the requested therapy is not likely to be more beneficial for treatment of the enrollee's medical condition than any available standard therapy. Because all three physician reviewers concluded that the requested therapy 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 overturned.
Appeal type: Urgent Care
Decision: Upheld

A 32-year-old female enrollee has requested for emergency services required on an emergent basis. Findings:  The physician reviewer found that this patient had an exacerbation of a pre-existing problem that did not produce a fever, fluid loss through vomiting or diarrhea, or pain documented as being sufficiently severe to be worrisome for placing the patients health in serious jeopardy. Nothing in the patients labs or imaging were concerning and the patient remained hemodynamically stable throughout her stay.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Lidocaine patch 5%. Findings:  The physician reviewer found that a review conducted by Moisset and colleagues evaluated the available pharmacological and non-pharmacological treatments for neuropathic pain. The authors concluded that, The recommendation for the use of topical lidocaine in peripheral neuropathic pain is weak (moderate quality of evidence but excellent safety profile). Per the U.S. Food and Drug Administration (FDA), the lidocaine patch has been approved for patients with a diagnosis of post-herpetic neuralgia. In this case, the patient has chronic thoracic spine pain after sustaining a spinal cord infarct during a procedure to repair a ventral dural tear of the thoracic spine that was causing cerebral spinal fluid leaks. The patient has undergone a multimodal treatment plan that has included neuromodulating agents such as pregabalin, tizanidine, and Cymbalta. The patient reports that lidocaine patches applied locally to the thoracic spine have been effective at alleviating his pain. However, the current medical literature does not support the use of the lidocaine patch for musculoskeletal pain. The records do not support a diagnosis of post-herpetic neuralgia. Moreover, there is a paucity of evidence regarding the efficacy of the lidocaine patches for the treatment of this patients pain emanating from the spinal cord due to myelomalacia. All told, the requested Lidocaine patch 5% is not medically necessary for 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 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: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested Copaxone for treatment of his multiple sclerosis. Findings: The physician reviewer found that Copaxone (glatiramer acetate) is medically necessary for treatment of the patients medical condition. Copaxone is U.S. Food and Drug Administration (FDA) approved for relapsing forms of MS. Copaxone has been studied against placebo and was found to be safe and effective. Given that Copaxone FDA approved for relapsing forms of MS and the support in the peer-reviewed literature, the requested medication is medically necessary.  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 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 39-year-old male enrollee has requested knee surgery (osteochondral grafting/transplant) for treatment of his osteochondral injury to the anteromedial tibial plateau.  Findings:  The physician reviewer found that the Orthopaedic Knowledge Update (OKU) states that osteochondral grafting fills osteochondral defects with cartilage and bone either derived from an autologous site or through the use of allograft donor bone. The advantage of osteochondral allograft is that there is no donor site morbidity and that there is little rejection and little risk of either viral or bacterial agents being transferred to the patient and structural and mechanical properties of the transferred tissue can match the tissue properties in the adjacent anatomical structures. It is medically necessary for this 39-year-old patient to undergo the requested treatment of osteochondral knee allograft for the lateral tibial plateau lesion. This patients young age and traumatic nature of the lesion support the requested intervention. Prior documentation at the time of microfracture through direct arthroscopic inspection noted satisfactory cartilage surrounding the lesion without the presence of a kissing lesion. Further, the patient has no varus or valgus malalignment, which indicate the lesion is primarily post-traumatic and not degenerative. The patient has already undergone treatment with microfracture and joint arthroplasty would require revision considering the patients young age. All told, the requested knee surgery (osteochondral grafting/transplant) is medically necessary for treatment of this patients medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The enrollee has requested authorization and coverage for Orthovisc injections for both knees.Findings:  The two out of three physician reviewers found that the requested services are likely to be more beneficial for treatment of the enrollees medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned. Evidence from systematic reviews and randomized controlled trials indicate that although viscosupplementation may relieve knee pain in some enrollees with osteoarthritis, data has not established which enrollees will benefit. Guidelines from studies indicate that the data on the safety and efficacy of viscosupplementation remain inconclusive. As such, the guidelines do not currently recommend viscosupplementation as standard treatment for osteoarthritis of the knees. Viscosupplementation is reserved for enrollees with a history of lasting benefit from prior injections and in cases where the remaining options are limited. This enrollee presents with a history of osteoarthritis of both knees. The enrollee complains of bilateral knee pain, left greater than right, associated with functional limitations. Physical examination and imaging studies show end-stage osteoarthritis of both knees. The enrollee has exhausted conservative treatment including nonsteroidal anti-inflammatory drugs (NSAIDs), physical therapy, and corticosteroid injections. As the remaining alternative is a total knee arthroplasty, Orthovisc injections for both knees are likely to be more beneficial for treatment of the enrollees medical condition than any available standard therapy.Final Result: Reviewers determined that the requested services are likely to be more beneficial for treatment of the enrollees medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications:  One reviewer is board certified in orthopedic surgery and is actively practicing. One reviewer is board certified in orthopedic surgery and is actively practicing.  One reviewer is board certified in orthopedic surgery and is 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: Upheld

The patient is a 49-year-old female who was injured while riding on public transportation.  She has undergone a wide variety of treatments for neck and back pain including cervical fusion approximately two years ago.  She is requesting coverage for intradiscal electrothermal therapy (IDET).IDET remains a controversial treatment for degenerative disc disease. A review of the medical literature revealed there was little to no efficacy associated with the procedure. The clinical value of IDET remains questionable, and it is not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for lumbar spinal fusion surgery. The Health Plan has denied this request indicating that the requested procedure is not medically necessary for treatment of the enrollees central posterior annular tear.At issue in this case is whether the requested lumbar spinal fusion surgery is medically necessary for treatment of the patients medical condition.The patient is diagnosed with chronic low back pain with no dermatomal/myotomal symptoms or findings of a lumbar radiculopathy (Ropper AH et al). The patient has no symptoms of neurogenic claudication and there is no documentation of failed conservative management in the past three to six months. There is no documented cognitive behavioral therapy for the nicotine addiction. There is no evidence of spondylolisthesis instability. There is no correlation of imaging for a clinical condition, and no localizing features of pain or signs/symptoms to implicate the L4-5 or the L5-S1 level as the pain generator.The Milliman Care guidelines criteria for lumbar fusion for each level require: low back pain with radiculopathy that has not responded for three to six months of conservative management including documented physical therapy, injections, NSAIDS/analgesics, home exercise program, imaging correlates with clinical findings, completion of a cognitive behavioral rehabilitation program, documentation of being nicotine free for at least 6 weeks, tumor/infection/trauma, progressive nerve compression with acute neurologic deficit. The patient does not meet any of the criteria for a two level L4-5/L5-S1 spinal fusion; therefore, the proposed surgery is not medically necessary. Final Result: The reviewer determined that the requested procedure 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 neurological 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.