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

Nature of Statutory Criteria/ Case Summary:  The enrollee is requesting authorization and coverage for Supartz injections to bilateral knees. The enrollee has osteoarthritis of bilateral knees. At a follow-up visit, she reported worsening, ongoing pain. The enrollee indicated her knee buckles, she has pain at the posterior aspect of the knee, and she reported throbbing pain with swelling. She reported the last Supartz injections provided relief for over six months. Her physician recommended another round of viscosupplementation injections, because they have helped her in the past. The enrollee indicates her physician wishes to defer knee replacement surgery because of her young age and good health status. She reports the Supartz injections have kept her knees from getting worse and they last much longer than cortisone injections. Prior injections have yielded positive pain relief results; keeping this enrollee active. Literature describes osteoarthritis as a common condition, which results in pain, reduced mobility, and decreased function. Corticosteroids have been a mainstay of osteoarthritis treatment; providing short-term pain improvement. A large number of recent studies have demonstrated hyaluronic acid (Supartz) is a viable treatment option; showing longer-term improvement in both pain and function. Literature indicates a single injection of hyaluronic acid (Supartz) is safe and effective for six months for treatment of knee osteoarthritis.Final Result: The reviewer determined that the requested service is medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The physician 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 similar medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for the wound therapy pump vacuum and wound dressing sets/equipment. Findings:  The physician reviewer found that in the medical literature, a study noted that negative pressure wound therapy (NPWT) following greater saphenous vein (GSV) harvest is safe, well tolerated and improves postoperative recovery with prolonged impact on mobility at six weeks. Another study reported that the VAC can effectively reduce postoperative complications, such as lymphedema, incision infection, wound dehiscence, and skin flap necrosis in CABG patients who underwent great saphenous veins harvesting. Overall, there is adequate data in the scientific data supporting NPWT for surgical dehiscence. For these reasons, the wound therapy pump vacuum and wound dressing sets/equipment were 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 equipment at issue was 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 reviewer number one is board certified in family practice 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.Physician reviewer number two is board certified in surgery with sub-specialty certification in vascular 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.Physician reviewer number three is board certified in internal medicine with sub-specialty certification in infectious disease 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 22-year-old female enrollee requested the Medtronics MiniMed with Enlite for medical treatment of her type I diabetes. Findings:  The physician reviewer found that based on the current medical literature, clinical studies, and evidence that insulin pump therapy with continuous glucose monitoring is beneficial for adult patients with diabetes type 1, the requested insulin pump therapy with continuous glucose monitoring is medically necessary. The patients control will be better, with less risk of hypoglycemia, and she will experience improved quality of life. All told, the requested Medtronics MiniMed with Enlite continuous glucose monitoring system is medically necessary for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement and prospective authorization and coverage for intravenous ketamine infusions. Cohen and colleagues report, Evidence supports the use of ketamine for chronic pain, but the level of evidence varies by condition and dose range. Most studies evaluating the efficacy of ketamine were small and uncontrolled and were either unblinded or ineffectively blinded. The authors further note that for CRPS, There is moderate evidence supporting ketamine infusions to provide improvements in pain for up to 12 weeks, and that, In terms of duration of benefit, patient expectations and satisfaction should be considered, but based on the cumulative risks and costs of treatment, greater than three weeks following a single outpatient infusion and greater than six weeks following an inpatient or series of infusions are a reasonable designation. The authors recommended that, A consecutive series of infusions should not be administered by rote, but rather tailored to patient response. Considering the risks of long-term ketamine treatment, limiting these to no more than six to twelve treatments per year is reasonable. In a systematic review of 14 studies on the use of ketamine infusion therapy for the treatment of CRPS, Chitneni and colleagues found that in 13 of the studies, ketamine infusion resulted in a decrease in pain scores and relief of symptoms. The authors concluded, Patients who received ketamine infusion for treatment-resistant CRPS self-reported adequate pain relief with treatment. This suggests that ketamine infusion may be a useful form of treatment for patients with no significant pain relief with other conservative measures. In this case, the patient has a diagnosis of CRPS that has been refractory to standard treatments, including non-pharmacological approaches and medication management with multiple different drug classes. The records note successful prior treatment with ketamine infusions, leading to improvements in pain levels and functionality. Given that current medical literature suggests that ketamine infusions may be a useful form of treatment for patients with treatment-resistant CRPS without significant pain relief with other conservative measures, the services at issue were and are medically indicated. Therefore, intravenous ketamine infusions were and are medically necessary for the treatment of this patientFinal Result: The reviewer determined that the services at issue were and 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 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

A 39-year-old male enrollee has requested for the medication Enbrel for treatment of his  psoriasis.    Findings:  The physician reviewer found that this patient has psoriasis that is becoming aggressive and spreading in a short period of time.  He has only 20% BSA involvement to date, but his disease is active and increasing in distribution. He has failed several topical therapies and UVB phototherapy.  The patient most recently failed an adequate course of Soriatane.  Methotrexate is not a good option for this relatively young patient due to its long-term risks of hepatotoxicity.  Also, cyclosporin has multiple side effects and patients frequently flare when the medication is discontinued.  As the patient failed a trial of Soriatane, the next appropriate therapy would be a biological therapy.  Enbrel is very effective and has a very safe side effect profile.
Appeal type: Medical Necessity
Decision: Overturned

The patient has requested authorization and coverage for Stelara 90 mg every four weeks. Current medical literature supports the requested dose escalation of Stelara in this case. The patient has active disease symptoms. A large randomized controlled trial demonstrated safety and efficacy for induction and maintenance of remission in patients with moderate-to-severe Crohns disease that was resistant to anti-tumor necrosis factor (TNF) therapy, which this patient has failed. The mechanism of Stelara is different from anti-TNF medications. One study showed Stelara dosing at 90 mg every four weeks can address inadequate disease control, and a large proportion of patients have been able to maintain response with dose escalation to 90 mg every four weeks. Multiple studies have shown that a majority of patients in whom Stelara dosing every eight weeks failed to control symptoms responded to dosing every four weeks. The American Gastroenterological Association (AGA) guidelines for the management of Crohns disease state that when response to a biologic medication is lost in the setting of a low drug level and lack of anti-drug antibodies, the drug dosage should be increased. In this case, the patient has failed multiple conventional and biologic alternatives, as well as Stelara every eight weeks. She responds to Stelara, but routinely loses response at four weeks after injection in the setting of a low Stelara level. Continuation of the current dose may result in complications. For these reasons, Stelara 90 mg every four weeks is 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 overturned. Credentials/Qualifications: The reviewer is board certified in internal medicine with subspecialty 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 55-year-old female enrollee has requested Nuvigil, 250 mg per day for treatment of her excessive daytime somnolence related to narcolepsy with cataplexy. Findings:  The physician reviewer found that Nuvigil cannot be considered medically necessary in this case because a diagnosis of narcolepsy has not been confirmed and cannot be confirmed without the completion of a sleep study. Although the treating provider is concerned about the discontinuation of the patients medications, it is accepted practice for such medications to be discontinued in order to complete a valid sleep study. In the absence of confirmatory evidence of a diagnosis of narcolepsy, the medical necessity of Nuvigil is not established.
Appeal type: Medical Necessity
Decision: Upheld

The patients parent has requested authorization and coverage for orthodontia/braces. In this clinical setting, the records note a submitted handicapping labio-lingual deviation (HLD) score of 27, which was recalculated by the Dental Plan as 19 and 16. The difference in scoring was in the area of measurement of anterior crowding, which is scored only if the crowding exceeds 3.5 mm in either arch. As the submitted documentation did not include intraoral photographs and only poor-quality model records, the presence or absence of anterior crowding cannot be affirmed. However, two scorers independently assessed an HLD score under the threshold of 26. Given the HLD score computed below the required threshold and a lack of orthodontic records supporting a severe malocclusion requiring intervention, the requested services are not medically indicated. Therefore, orthodontia/braces are not necessary to prevent disease and promote oral health or restore oral structures to health and function in this patient.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for weekly Benlysta 200 mg injections. Findings:  The physician reviewer found that submitted documentation supports the medical necessity of the requested medication. A SELENA-SLEDAI (systemic lupus erythematosus disease activity index) score of 13 is noted in the medical records. She has failed to respond to other standard drugs for SLE treatment, such as hydroxychloroquine. Furie and colleagues performed a phase III, multicenter, randomized, placebo-controlled trial of antinuclear antibody-positive or anti-double-stranded DNA-positive SLE patients with SELENA-SLEDAI scores greater than or equal to 6. This trial included a large number of patients with musculoskeletal symptoms due to SLE, as experienced by this patient. The authors noted that Benlysta was efficacious in controlling SLE symptoms as indicated by statistically significant improvements in SLE responder index scores compared to placebo by 76 weeks. Navarra and colleagues performed a randomized placebo controlled trial that evaluated the safety and efficacy of Benlysta in patients with SLE. A majority of study participants had musculoskeletal disease, as in this patients case. Benlysta use was found to be associated with improved SLE symptoms when compared to placebo by 52 weeks. Therefore, weekly Benlysta 200 mg injections are medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested medication is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in internal medicine with sub-specialty certification in rheumatology 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 60-year-old female enrollee has requested for steroid injections for treatment of her moderate to severe spinal stenosis.  Findings:  The physician reviewer found that the medical literature relevant to this determination includes a prospective randomized study on transforaminal epidural steroid injections in lumbosacral radiculopathy (Vad, et al). The authors concluded that fluoroscopically guided transforaminal epidural injections serve as an important tool in the non-surgical management of patients with lumbosacral radiculopathy secondary to a herniated nucleus pulposus. With regard to the frequency and timing of treatment, Novak and Nemeth performed a literature review of the current evidence-based guidelines. The researchers concluded that there does not appear to be any evidence to support the current common practice of a series of injections. However, it is appropriate to perform no more than four epidural steroid injections in one year, at least six weeks apart, if the first injection provides adequate pain relief. In addition, Arden and colleagues WEST Study consisted of a multicentre randomized controlled trial of epidural steroid injections for treatment of sciatica in terms of effectiveness and predictors of response. The authors found that epidural steroid injections offered transient benefits in symptoms at three-weeks in patients with sciatica, but no sustained benefits in terms of pain, function, or need for surgery, were reported.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patients parent has requested authorization and coverage for renal-bladder ultrasound on an Acuson imaging machine and annual renal-bladder ultrasound on the same Acuson imaging machine. This patient presents with bilateral hydronephrosis. The records indicate that the patients condition showed improvement in the right degree of dilatation on last imaging. The dilation is mild enough to be followed annually to monitor for changes that might be indicative of increasing obstruction. The patients renal-bladder ultrasound scans have been performed on an Acuson machine. The patients provider has recommended repeat imaging with use of the same machine and follow-up with the same provider, who has been treating the patient for the past six years. Based on the available medical literature, it is appropriate for this patient to receive an annual ultrasound on a machine of current resolution that utilizes similar technique in order to be comparable to prior scans. In addition, the patient requires continuous monitoring by a pediatric urologist for examinations to assure appropriate care. However, the records provided for review do not support an indication for repeat imaging with the same machine or provider to accurately monitor his hydronephrosis. Therefore, the requested renal-bladder ultrasound on an Acuson imaging machine and annual renal-bladder ultrasound on the same Acuson imaging machine are not medically necessary for this patient. 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 urology with subspecialty certification in pediatric urology 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 30-year-old female enrollee has requested for Rocephin for treatment of her Lyme disease.   Findings:  Three physician reviewers found that there is insufficient evidence that this patient has, or has ever had Lyme disease. Based on the information that has been submitted, she has no recorded clinical history of a tick bite or rash which is consistent with this disease. The patient has no history of symptoms (cardiac, neurological or rheumatological) which would suggest that she has Lyme disease. Although there is a single positive IgM Western Blot recorded in the record, almost always, a positive IgM Western Blot without a positive IgG means a false positive.
Appeal type: Medical Necessity
Decision: Upheld

The patient is a 47-year-old female who was assaulted resulting in amputation of her right index finger at the middle phalanx. She complains of pain and swelling and that her function is impaired. She is seeking authorization for a prosthetic finger. The Health Plan has denied authorization for the requested prosthesis.The Health Plans denial is correct. A digital prosthesis is neither functional nor intended for treatment of stump pain. A digital prosthesis is indicated for aesthetic purposes. Because the requested prosthesis will neither benefit the patients stump pain nor improve function, I have determined the requested prosthesis is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a two-year, four-month-old male enrollee has requested speech therapy for treatment of the enrollees speech delay. Findings:  The physician reviewer found that according to the text by Carey and colleagues, they found that children involved in early intervention services with parental interaction and teaching showed stronger language skills than children who did not receive early intervention. Consistent with these findings, Law and colleagues extensive review of the literature reported on the positive effects of speech therapy intervention for children with expressive phonological and vocabulary difficulties. Given that children with documented speech delays treated with therapy show improvement when compared with their untreated peers, the requested speech therapy is clinically indicated for this patients expressive language delays. This patient was found to have expressive language delays during an evaluation, with later tests revealing progressively worsened delays. As this patients delays have persisted and actually increased, the requested speech therapy is medically necessary for management of his medical condition and should therefore be approved.
Appeal type: Medical Necessity
Decision: Upheld

A 64-year-old male enrollee has requested reimbursement for a magnetic resonance (MR) neurography. Findings:  The physician reviewer found that the available peer reviewed medical literature does not provide sufficient evidence regarding the sensitivity and specificity of MR neurography, as a diagnostic test. Filler, et al. reported that in patients with sciatica in whom standard diagnosis and treatment failed to effect improvement, MR neurography and interventional MRI led to re-diagnosis. The authors also indicated that MR neurography had a 93% specificity and 64% sensitivity in distinguishing patients with piriformis syndrome from those without piriformis syndrome who had similar symptoms (Filler, et al). In a critique of this paper, Tiel and Kline (2006) indicated that sensitivity and specificity are used in clinical studies to evaluate new methods in reference to a recognized gold standard. However, piriformis syndrome has not been submitted to this standard and the data presented by Filler, et al. may be misleading. In a 2008 paper by Tiel, the author stated that histological and physiologic confirmation is needed to support the findings by Filler and colleagues concerning the diagnosis of entrapment of the sciatic nerve by the piriformis muscle. There are no other available studies in the peer reviewed medical literature demonstrating the efficacy of MR neurography in the diagnosis of piriformis syndrome. Based on the paucity of evidence demonstrating the true sensitivity and specificity of MR neurography in the diagnosis of piriformis syndrome, MR neurography was not medically necessary for treatment of the patients medical condition.