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

Nature of Statutory Criteria/Case Summary:  An enrollee has requested a blood test for evaluation of her medical condition.  Findings:  Three physician reviewers found that the patient presents with significant coronary risk and an episode of chest discomfort.  In this circumstance, guidelines for the management of cardiac risk and dyslipidemia have been established, are periodically updated by expert committees and are endorsed by several national organizations.  These guidelines currently do not recommend routine performance of specialized tests in the context of assessing coronary risk (Greenland, et al; Stone, et al). Treatment change or addition based on the results of screening with these specialized tests has not been shown to improve cardiac outcome incremental to that achievable by treatment based on standard risk factor profiling and basic lipid analysis. Thus, the services at issue were not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.  Final Result: Three 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. Credentials/Qualifications:  All three reviewers are board certified in internal medicine with sub-specialty certification in cardiovascular disease and are actively practicing. All three reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for three trigger point injections. Findings:  The physician reviewer found that the efficacy of trigger points is well documented in the literature if the points are clearly identified and injected or dry needled. The interrater reliability for identifying myofascial trigger points is an important consideration. Documentation of the clinical aspects of myofascial trigger points also includes the taut band, local twitch response, and referred pain patterns. In this case, the patient has fibromyalgia and has had hip surgery and shoulder surgery which have left her with constant pain. The patient has had physical therapy in the past and describes it as less than effective. She had medication trials with tramadol and ibuprofen and also uses cannabis for pain. While the progress notes describe the location of the trigger points, they do not detail the taut muscular band and pattern of radiation. The description of the trigger points and the pattern of radiation are not documented. Under these circumstances, the present request for three trigger point injections is not medically necessary to treat the patients medical condition at this time.Final Result: The reviewer determined that the requested services 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 subspecialty 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 authorization and coverage for Euflexxa injections. There is adequate evidence that intraarticular hyaluronic acid injections reduce pain and increase function in knee osteoarthritis, and the benefits are long-lasting as compared with intraarticular corticosteroids. Researchers conducted a systematic review of overlapping meta-analyses comparing viscosupplementation with other non-operative treatment modalities for knee osteoarthritis. The authors reported that the current highest level of evidence suggests that intraarticular hyaluronic acid is a viable option for patients with knee osteoarthritis which results in improvements in knee pain and function that can persist for up to 26 weeks. Viscosupplementation has a good safety profile, and its use should be considered in patients with knee osteoarthritis. All told, the requested Euflexxa injections are supported as medically necessary for treatment of this patients knee osteoarthritis. 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 female enrollee requested BRAC Analysis Large Rearrangement (BART) genetic testing (CPT code 81213) for medical evaluation of the enrollee, who has a family history of breast cancer.  Findings:  The physician reviewer found that the records do not document that the patient meets accepted guidelines for BRCA testing.  Therefore, the genetic testing was not medically indicated for the evaluation of this patient.
Appeal type: Experimental/Investigational
Decision: Overturned

 The enrollee requested reimbursement for the gene test, Prothrombin G20210A (Factor II) mutation testing. The enrollee has a past medical history of a right acoustic neuroma, that was surgically resected. She has a history of migraines, which worsened after pregnancy. The enrollee previously utilized hormonal therapy for her migraines. A magnetic resonance venography (MRV) of the head showed filling defects in the right sigmoid sinus, concerning for thrombosis. Her neurologist recommended further evaluation in the neurointerventional radiology clinic. Hypercoagulable labs were drawn and the treatment plan included an angiogram and lumbar puncture to determine the severity and amount of clot/clots in her brain. However, her physician believed if the enrollee had a clotting disorder, these invasive tests, which carry risk of death, would be potentially unnecessary. The enrollee could avoid these tests and be placed on blood thinners to treat the clots.    Hypercoagulable states can be defined as a group of inherited or acquired conditions associated with a predisposition to venous thrombosis, arterial thrombosis, or both. Venous thromboembolism (VTE) disease is the most common clinical manifestation resulting from hypercoagulable states. There are no tests for a number of inherited conditions and there are no accepted guidelines as to what constitutes indications for such testing. Based on the medical literature, cerebral venous thrombosis is a rare thrombotic condition commonly associated with the presence of thrombophilia, and prothrombin G20210A is one of the most common thrombophilias associated with venous thrombosis. The physician reviewer found that  enrollee with unprovoked VTE and low bleeding risk is planning to stop anticoagulation, providers should test for thrombophilia if the test results would change this decision. In this case, the treatment plan included a decision as to whether or not to proceed with the more invasive testing, including angiogram and lumbar puncture depending on the result of the hypercoagulable test (whether or not enrollee has positive mutation on the Prothrombin G20210A). Considering this unusual site for venous thromboembolism, the enrollee is at a higher risk for serious complications than if it were a deep venous thrombosis of the legs. Thus, it is important for the enrollee and provider to have adequate clinical information to weigh the risks and benefits, and for the enrollee to provide informed consent for further management. The enrollees clinical situation is very suggestive of a genetic component, based on age and the unusual location of clotting. If a genetic condition is diagnosed, treatment decisions may be made accordingly. Final Result: Two of the three reviewers determined that the requested service was likely to have been more beneficial than any available standard therapy for treatment of the enrollees medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld

A 43-year-old female enrollee requested authorization and coverage of participation in a phase I clinical trial of intraperitoneal Y-90 chimeric antibody and Gemcitabine chemotherapy. The Health Plan denied the request indicating that the requested therapy is considered experimental for treatment of the enrollees appendiceal adenocarcinoma.Three physician reviewers performed a medical necessity Independent Medical Review. Two physician reviewers concluded that the requested therapy is not likely to be more beneficial for the treatment of the enrollee medical condition than any available standard therapy. One physician reviewer concluded that the requested therapy 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 therapy is not likely to be more beneficial for the treatment of the enrollee's medical condition than any available standard therapy, the Health Plans denial has been upheld.
Appeal type: Medical Necessity
Decision: Overturned

A 49-year-year-old female has requested laparoscopic duodenal switch (DS) bariatric surgery in lieu of vertical sleeve gastrectomy (VSG) without completion of the Options Program 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 51.7 and co-morbidities that will likely be ameliorated or eliminated by bariatric surgery. With regard to the Options Program, there is no scientific evidence demonstrating that structured diet or exercise plans have been successful in the treatment of the morbidly obese. In fact, the Swedish obesity study identified that even though there may be reduction or resolution of some symptoms with diet and exercise, surgery has the longest and best long-term outcome for the morbidly obese. In addition, recent studies indicate that bariatric surgery is associated with decreased over all mortality for the morbidly obese. If a psychological evaluation has not occurred, one should be conducted to ensure the patient is an appropriate candidate for surgical weight loss. The patient has a need for long-term treatment with NSAIDs making the Roux-en-Y gastric bypass (RYGB) procedure a less tenable option. Laparoscopic gastric banding is not likely to be as effective as other surgical alternatives. The VSG procedure is a component of the biliopancreatic diversion with duodenal switch procedure (BPD/DS). VSG is an appropriate first step and may facilitate adequate weight loss for the enrollee. VSG is a less risky procedure than the full BPD/DS and moderate weight loss will be achieved without severe side effects such as dumping syndrome or malnutrition. If weight loss is not adequate (< 40% of excess body weight) and/or comorbidities do not improve, a staged conversion to BPD/DS is possible and would be indicated if treatment with NSAIDs continues.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested Harvoni for 12 weeks for treatment of her chronic hepatitis C virus genotype 1b.  Findings:  The physician reviewer found that according to the most recent joint guidelines issued by the American Association for the Study of Liver Diseases (AASLD) and the Infectious Diseases Society of America (IDSA), all patients with chronic hepatitis C should be treated except those with limited life expectancy due to non-liver-related conditions. This applies regardless of fibrosis stage or viral load. Per the AASLD and IDSA guidelines, noncirrhotic genotype 1 patients who have failed therapy with interferon and ribavirin should be re-treated with Harvoni for 12 weeks. These recommendations are based on multiple randomized clinical trials, and the medication is U.S. Food and Drug Administration (FDA) approved for all patients with chronic hepatitis C genotype 1 regardless of fibrosis stage. The AASLD/IDSA guidelines also cite data showing increased survival with earlier treatment. For these reasons, the requested treatment with Harvoni for 12 weeks is supported as medically necessary for the treatment of this patients hepatitis C infection. Final Result: The reviewer determined that the requested medication is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in internal medicine with sub-specialty certification in gastroenterology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

An enrollee has requested hyperbaric oxygen (HBO) therapy. The submitted documentation does not support the medical necessity of the requested services. The patient has had long-standing progressive hearing loss and tinnitus. The evidence for HBO therapy has been limited to small case series from Europe and Asia, with very little evidence from well-controlled studies in the United States. The evidence for HBO therapy is based on its possible effect on sensorineural hearing loss, as referenced by colleagues. However, this evidence points to the necessity of very early (less than 14 days from onset of hearing loss or tinnitus) intervention with hyperbaric oxygen, as noted by colleagues. In this case, HBO therapy has been requested years after the patients CVA and would be undertaken months after the patients audiogram. Given its current limited evidence based support in the medical literature, and the fact that HBO therapy would be distant in time from the onset of hearing loss or tinnitus, the requested HBO therapy is not medically necessary to treat the patients medical condition.Final Result: The reviewer determined that the requested therapy 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 otolaryngology 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: The patient has requested authorization and coverage for intravenous immune globulin 2 g/kg initial dose, and then 1 g/kg monthly. Findings:  The physician reviewer found that Wynford-Thomas and colleagues describe myelin oligodendrocyte glycoprotein (MOG)  antibody associated disease as an inflammatory demyelinating condition of the central nervous system characterized by a monophasic or relapsing course of neurological dysfunction, which does not meet the typical criteria for multiple sclerosis or other known neuroinflammatory conditions and occurs in the presence of serum MOG antibodies detected using specific cell-based assays, with a relapsing course reported in 44% to 83% of patients that more commonly involves the optic nerve. The authors further note that while randomized control trials are limited, observational open-label experience suggests a role for high-dose steroids and plasma exchange in the treatment of acute attacks, and for immunosuppressive therapies, such as steroids, oral immunosuppressants, intravenous immune globulins and rituximab as maintenance treatment. Current medical literature supports the association of intravenous immune globulin with a reduction in MOG antibody associated disease relapse rates. Ramanathan and colleagues report that long-term treatments with prednisolone, intravenous immune globulins, rituximab, mycophenolate mofetil, methotrexate or azathioprine have all been reported to reduce the annualized relapse rate in MOG antibody associated disease. In a large retrospective multicenter study of 70 patients with MOG antibody associated disease, Chen and colleagues conclude that maintenance immunotherapy reduces recurrent central nervous system demyelinating attacks, with the lowest annualized relapse rate being associated with maintenance intravenous immune globulin therapy. In this case, the patient has MOG antibody associated disease. In this clinical setting, given that intravenous immune globulin therapy is associated with a reduction in relapse rates and is recommended as a maintenance therapy for MOG antibody associated disease, the requested service is medically indicated. Therefore, intravenous immune globulin 2 g/kg initial dose, and then 1 g/kg monthly, is medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested service 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: Upheld

The patient is a 15-year-old male adolescent with previously diagnosed obsessive-compulsive disorder (OCD) and disruptive disorder  not otherwise specified, the former beginning when the patient was age seven. The patient has since been treated with Paxil, Topamax, and Buspar. He was admitted to residential treatment on 12/1/04 due to escalating aggressive behavior at home as well as brief experimentation with marijuana. The aggression has consisted of arguing with his mother, and later breaking her windshield with a golf club and punching some holes in the walls. The patient noted his mother as having provoked him. The patient also noted having witnessed a good deal of violence between his mother and father over the years, including his mother slapping his father in the face, thereafter grabbing the patient, putting him in the car, and leaving with him. Though his OCD affected the patient with compulsive rituals in the past (e.g., repeated hand washings and showers with prominent concerns about contamination), he denied having had such for about the past four years. The patient reported his current OCD symptoms involve obsessive thoughts, which he is simply unable to stop thinking about - such as the idea of wanting some new clothes. He has tried to engage his mother in such discussions and when she has refused he has become angry. He has had no recent checking or contamination symptoms.Review of the submitted treatment notes indicates the patient has sometimes been irritable and passive-aggressive. Paxil was maintained at 50mg CR a day, and Topamax and Buspar were discontinued in favor of supplemental Geodon. At issue is whether residential treatment services are medically necessary for treatment of the patients behavioral health problems.Though the patient has a history of OCD, the condition appears to have been relatively well controlled by the time the patient was admitted to residential treatment. The patient was admitted for aggressive behavior, not refractory OCD. The aggression appears to be localized to his interaction with his mother. Based upon the submitted treatment notes, it appears the patients mother is given to much anger and aggressive behavior. It does not appear that this family has had any sort of family therapy along the way. Though the family believes the patients problems stem from his OCD, this is clearly not the case. It appears there are entangled family dynamics that have fostered the patients aggression. As such, residential treatment is not the first-line approach to treatment and is not the standard of care in this situation. There is no indication that residential treatment is medically warranted for treatment of this patient or is likely to be of benefit. Based upon the information set forth above, I have determined that the requested services are not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for dental anesthesia for treatment of the enrollees dental treatment. Findings:  The physician reviewer found that the request for dental anesthesia service is medically necessary for treatment of the patients medical condition. In general, intravenous sedation or general anesthesia is indicated for patients with acute situational anxiety due to immature cognitive functioning or for patients who are uncooperative due to physical or mental compromising conditions. In this case, the patient has moderate autism and intellectual disability. Due to the patients developmental disabilities, the patient has an extreme fear of dentistry which precludes conventional care. Given the patients documented impairment the requested dental anesthesia is medically necessary for treatment of the patients medical condition. Final Result: The reviewer determined that the requested service 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 dentistry 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.