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

The spouse of a 72-year-old female enrollee has requested services at a skilled nursing facility (SNF) level of care for treatment of the enrollees Parkinsons disease.   Findings:  The physician reviewer found that the patient sustained a right hip fracture. She underwent a prolonged rehabilitation process but was unable to maintain independence in regards to her self-care and mobility to a safe degree. She underwent another extensive period of inpatient rehabilitation during the said time frame related to her chronic debility and progressive Parkinsons disease. While physical therapy and exercise are appropriate in the management of Parkinson's disease-related gait disorder (Ceravolo,), there should be a transition from an initial supervised period to an independent period where the patient takes on the responsibility of maintaining activity levels (Morris, et al). The patient in this case underwent a period of supervised therapy and was transitioned to a restorative nursing program.  Notably, she had been discharged from skilled therapies due to a plateau in progress.  The remainder of her stay during the said dates is not documented to have involved or required skilled therapy or skilled nursing interventions.  The patient was medically stable and followed by a physician on a routine basis as an outpatient.  There were no complex wounds requiring ongoing inpatient care. There were no ongoing skilled therapy needs. Additionally, there was no documentation of significant functional progress that was the result of additional skilled therapy interventions. As of the date in question and forward, the patient was receiving custodial level services for supporting her self-care, activities of daily living and mobility. Thus, the inpatient care in question was custodial in nature and not medically necessary.
Appeal type: Medical Necessity
Decision: Upheld

The patient is a 36-year-old female who has painful varicose veins. She has tried compression stockings without relief. She indicates she is a teacher who is required to stand on her feet most of the day. She has requested authorization and coverage for vein stripping. The Health Plan indicates the patient does not meet criteria for vein stripping and therefore, has determined that the requested procedure is not medically necessary for the patients medical condition.The patient has painful varicose veins but no documented greater saphenous vein (GSV) reflux. The guidelines of Milliman Care state that varicose vein surgery will not be authorized without GSV reflux. These guidelines are medically reasonable and appropriate and within the standard of care for treatment of patients such as this patient.  Therefore, the vein stripping is not medically warranted for treatment of this patients varicose veins. As such, I have determined that the requested procedure is not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld
Appeal type: Medical Necessity
Decision: Upheld

A 60-year-old female enrollee has requested for cataract revision surgery for treatment of her post status cataract surgery. Findings:  The physician reviewer found that the medical records do not indicate a disease or deformity that would necessitate surgery.  All told, the submitted medical records fail to establish the medical necessity of the requested cataract revision surgery.
Appeal type: Medical Necessity
Decision: Upheld

A 35-year-old male enrollee has requested for an anterior cruciate ligament (ACL) knee brace and add-ons for treatment of her status post left knee ACL reconstruction. Findings:  The physician reviewer found that the mainstay of therapy following ACL reconstruction is physiotherapy with a focus on recovery of strength, range of motion and agility. When relevant, this is often followed by a gradual return to sports activities, starting with basic agility and sports-specific drills, then part-time and full-time competition. If swelling develops or there is a loss in the patients range of motion, activities are reduced until the swelling subsides and range of motion is restored (Shelbourne and Klotz). A neoprene sleeve can also be used as an option for additional support (Birmingham, et al.). Despite some early recommendations for functional ACL bracing post-operatively (Marans, et al.), subsequent literature has not established its efficacy. No evidence has been provided that the systematic use of postoperative ACL braces has an effect on patients pain, range of motion, graft stability, or protection from subsequent injury (Wright and Fetzer). Additionally, Andersson, et al. also concluded that the use of a postoperative knee brace does not affect the clinical outcome after ACL reconstruction. Overall, there is insufficient, reliable evidence in the peer reviewed medical literature that would support the medical necessity of the requested equipment for this patient.
Appeal type: Medical Necessity
Decision: Overturned

A 48-year-old female enrollee has requested acute inpatient psychiatric services for treatment of her major depressive disorder, severe without psychotic features and borderline personality disorder. Findings:  The physician reviewer found that the submitted documentation supports the medical necessity of a portion of the services at issue.  This patient evidenced profound recurrent affective and characterological pathology that created a symptom complex which was difficult to treat.  Per the records, the patient was improving and engaged in active treatment.  She was tolerating her medications and sleeping well.  However, a second generation antipsychotic was added to the medication regimen, while there were conflicting reports of suicidality in the medical record.  In sum, the patient was demonstrating a chronic pattern of behavior that necessitated comprehensive specialty services, and facilitating a smooth discharge to the most appropriate setting was necessary.  Discharging this patient on the date indicated would have more than likely resulted in undue morbidity.  Per the medical records, discharge to the partial hospital program would have been medically appropriate.  All told, acute inpatient psychiatric services were medically necessary for 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 high frequency chest wall oscillation unit (InCourage Airway Clearance System). Findings:  Two of the three physician reviewers found bronchiectasis is a syndrome of chronic cough and daily sputum production associated with airway dilatation and bronchial wall thickening that is associated with multiple conditions. Treatment includes the use of antibiotics to treat or prevent infections, regular use of airway clearance techniques and inhaled medications, including bronchodilators. There are many forms of chest physiotherapy to decrease obstructing respiratory secretions, including aerobic exercise, autogenic drainage, postural drainage and percussion methods. Of note, the long-term improvement in clinical outcome has not been shown.  High-frequency chest wall oscillation is not considered a first-line method for airway clearance. The evidence shows that it is not as effective as other airway clearance techniques.  There has not been a significant difference in lung function shown with patients using high-frequency chest wall oscillation versus other methods for chest percussion therapy. In this case, the requested high frequency chest wall oscillation unit (InCourage Airway Clearance System) is not likely to be of greater benefit than other treatment options. Final Result: The reviewers determined that the requested device is 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 and 2 are board certified in in internal medicine with sub-specialty certification in pulmonary disease and are actively practicing. Physician reviewer 3 is board certified in internal medicine 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: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for hyaluronan injections to the left knee. Findings:  The physician reviewer found that the requested services are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.An exhaustive review of the current medical literature pertaining to the viscosupplementation reveals mixed results. Although viscosupplementation may relieve knee pain in some individuals with osteoarthritis, it is not known as to which individuals will benefit. Different studies have tried mixing hyaluronic acid with corticosteroids, platelet-rich plasma, and other agents to make it more effective. The current medical evidence does not support viscosupplementation as standard treatment for osteoarthritis of the knees. 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 enrollee significantly benefited from prior injections, with symptom improvement for 11 months. The enrollee's options are limited, with the alternative being a total knee arthroplasty. There is sufficient support for the requested services in this clinical setting. Therefore, hyaluronan injections to the left knee are medically necessary for the treatment of this enrollee. Final Result: The reviewer determined that the requested services are medically necessary for treatment of the enrollees 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 48-year-old female enrollee has requested a Continuous Passive Motion (CPM) machine for the treatment of her knee (status-post surgery). Findings:  The physician reviewer found that there is a paucity of well-controlled studies in the peer-reviewed medical literature showing improved clinical outcomes from use of a CPM machine following any type of knee surgery. The literature does not clearly support the role of CPM after knee trauma surgery and does not sufficiently demonstrate that CPM improves long-term outcomes when compared to standard post-operative therapy measures. More outcomes data is needed to demonstrate the efficacy of CPM use in cases such as this patients case.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary:   The parent of an enrollee has requested the Early Start Denver Model applied behavioral analysis (ABA) therapy for treatment of the enrollees medical condition. Findings:  Two physician reviewers found that the Early Start Denver Model is medically necessary for treatment of the patients medical condition. There is evidence in the peer-reviewed literature that supports the Early Start Denver Model as effective for autism. A study by researchers concluded that participants in the Early Start Denver Model group showed significantly higher gains in developmental rate and receptive language. The Early Start Denver Model group has relationship building services built into this model. In this case, the patients current ABA therapy is providing progress. However, the parent feels that the patients progress can improve with a different model. At this point, it is medically reasonable to try a new model to see how much more the patient could learn because the window of the most gains is during this patients age range. Given the above, the requested services are medically necessary for treatment of the patients medical condition.  Final Result: Two 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: One reviewer is board certified in child neurology and is actively practicing. One reviewer is board certified in pediatrics and child neurology and is actively practicing.  One reviewer is board certified in pediatrics with sub-specialty certification in developmental-behavioral pediatrics 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: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested Revlimid for treatment of his medical condition. Findings: Three physician reviewers found that the current medical evidence supports the requested medication in this patients case.  In the study by Fowler and colleagues, 50 patients with follicular lymphoma were treated with Rituxan and Revlimid. Of the evaluable patients, 87% had a complete response and 11% had a partial response. Toxicity was quite manageable. Thus, this combination must be considered highly active.  The study by Leonard and colleagues also demonstrated good activity with this combination, even in those with prior therapy.  In sum, Revlimid is likely to be more effective than other treatment options.Final Result: Three 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:  All three physician reviewers are board certified in internal medicine with sub-specialty certification in medical oncology 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 57-year-old female enrollee has requested for a DynaSplint device for treatment of her plantar fasciitis.  Findings:  The physician reviewer found that the use of the DynaSplint for the treatment of plantar fasciitis is not supported by the medical literature. There is no evidence to suggest that it is likely to be more effective for this patient than a properly adjusted night splint. Given the lack of data supporting the efficacy of the DynaSplint for plantar fasciitis, the medical necessity of the device has not been established.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Prometheus Anser IFX testing. Findings:  Three physician reviewers found the presence of antibodies alone does not necessarily result in reactions to infliximab or loss of response to infliximab, nor have threshold levels been established. Furthermore, studies have found that anti-infliximab antibodies can be transient, and disappear over time, with many patients who have these antibodies maintaining their response. The current medical literature reports contradictory outcomes and lacks high-quality controlled studies to define drug level or antibody level thresholds requiring action, compare clinical strategies (such as dose increase or change in medication) based on those thresholds, and then definitively establish that use of this testing improves outcome. For these reasons, the superior effectiveness of Prometheus Anser IFX testing has not been established. Final Result: The reviewers determined that the requested services are 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.Credentials/Qualifications: Physician reviewers 1, 2 and 3 are board certified in internal medicine with sub-specialty 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: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for night splint/ankle foot orthotic (AFO) (code L4397). The records provided for review document that this patient presents with bilateral foot pain. Foot pain and heel pain are common, especially in obese patients. Conservative nonsurgical treatment is recommended and has been demonstrated to be effective for most patients with foot and heel pain. Goff and Crawford noted that, Initially, patient-directed treatments consisting of rest, activity modification, ice, massage, oral analgesics, and stretching techniques can be tried for several weeks. If heel pain persists, then physician-prescribed treatments such as physical therapy modalities, foot orthotics, night splinting, and corticosteroid injections should be considered. In this case, initial treatment of foot pain should be patient-directed consisting of activity modification, ice, stretching techniques, analgesic medications such as acetaminophen or nonsteroidal anti-inflammatory drugs (NSAIDs), and weight loss. The records provided for review do not document that the patient has failed treatment with first-line therapies to support an indication for the requested night splint/AFO. Therefore, the requested night splint/AFO (code L4397) is not medically necessary for treatment of this patient. Final Result: The reviewer determined that the requested device 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 orthopedic surgery with subspecialty certification in sports 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: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the Cartiva implant (synthetic cartilage implant). Based on current medical literature, the Cartiva implant was not likely to provide this patient with a superior health outcome when compared to standard treatment modalities. Standard implants and joint fusion has been shown to provide positive health outcomes in this clinical setting. By comparison, the Cartiva implant has not been demonstrated in randomized controlled clinical trials to be safe and effective at long-term follow-up. All told, the Cartiva implant (synthetic cartilage implant) was not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.One reviewer found that the Cartiva implant (synthetic cartilage implant) was likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: Two of the three reviewers determined that the services at issue were 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:  One reviewer is board certified in podiatry and is actively practicing. One Reviewer is board certified in podiatry and is actively practicing.  One Reviewer is board certified in podiatry 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: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for TiLite titanium wheelchair (or a wheelchair comparable to the same model she has been using). Findings:  The physician reviewer found that the patient has a history of spina bifida and is a long term wheelchair user. The patient has developed a gluteal pressure ulcer attributed to the fit of the wheelchair and back angle. There is no new injury or change in this patients neurological condition. Accordingly, the pressure ulcer can be attributed to her current seating system. The patient requires a replacement wheelchair as her current chair cannot be adjusted in terms of its back angle. A 90 degree back would be expected to distribute seating pressures evenly over the weight-bearing surface and limit shear forces. A repair of her current wheelchair would not resolve this patients pressure ulcers. For these reasons, the TiLite titanium wheelchair (or a wheelchair comparable to the same model she has been using) is medically necessary for the treatment of this patients medical condition. 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.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

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for occipital nerve block therapy and prospective authorization and coverage for continued occipital nerve block therapy. Findings:  Two of the three physician reviewers found that neuralgia is a type of neuropathic pain. Attacks can either be spontaneous or provoked by direct stimulation or palpation of other trigger point zones. Occipital neuralgia can specifically refer to pain or headache in the occipital region in the greater, lesser, or third occipital nerve areas which can also be accompanied by dysesthesia or decreased sensation in the nerve distribution. This patient has been diagnosed with occipital neuralgia on examination. Another key element to the diagnosis is response to occipital nerve blocks, which is also reported in the documentation provided. The treatment of choice for occipital neuralgia is a local occipital nerve block due to its ability to relieve pain and act as a diagnostic marker. There is sufficient support for the services at issue in this clinical setting. Therefore, the service at issue were and are likely to be of greater benefit than other treatment options. Final Result: The reviewers determined that the services at issue were and 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.