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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Euflexxa injections in the left knee. There is sufficient support for the requested services in this clinical setting. The records document mild osteoarthritis of both knees. The right knee was symptomatic in the past and responded to viscosupplementation, with resolution of the pain. The left knee has been symptomatic despite corticosteroid injections. An exhaustive review of the medical literature pertaining to viscosupplementation reveals mixed results. Although viscosupplementation may relieve knee pain in some individuals with osteoarthritis, it is not known which individuals will benefit. Different studies have tried mixing hyaluronic acid with corticosteroids, platelet rich plasma and other agents to make it more effective. Viscosupplementation can only be recommended for patients with a history of lasting benefit from prior injections and in carefully selected cases where the options are limited. In this case, the patient had an excellent response to viscosupplementation of the right knee in the past. Furthermore, she has not responded to recent corticosteroid injections to her left knee. This patients options are limited, with the alternative being a total knee arthroplasty. Therefore, Euflexxa injections in the left knee are medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested services are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in orthopedic surgeyr 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: The enrollee has requested reimbursement for the genetic testing performed.Findings:  The physician reviewer found that while a FNA biopsy of a suspicious thyroid nodule is typically an accurate means of assessing whether the nodule is benign or malignant, approximately 15% of FNA biopsy results are considered to be indeterminate. Until recently, the only way to establish whether the nodule was in fact thyroid cancer was via surgical excision even though the majority turn out to be benign. Afirma utilizes a gene expression classifier in order to help determine the likelihood of malignancy of nodules with indeterminate cytology on FNA biopsy, thereby decreasing the need for unnecessary surgeries . All told, the genetic testing performed was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Final Result: Two of the three  reviewers determined that the testing at issue was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: Physician reviewers are board certified in internal medicine with sub-specialty certification in endocrinology, diabetes and metabolism 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

The enrollee requested coverage for proton beam radiotherapy. The patient had symptoms of urinary frequency, urinary intermittency, and nocturia. The treating physician recommended proton beam radiotherapy as the best available treatment option for the patient. Proton beam radiotherapy has not been shown to be superior to intensity modulated radiation therapy for prostate cancer. The current literature shows that when considering metrics of higher doses delivered to the adjacent normal structures, the superiority of proton beam radiotherapy is less clear and some studies show a slight disadvantage with proton beam radiotherapy.Final Result: The reviewer determined that the requested medication is not medically necessary for the treatment of the enrollees medical condition.Credentials/Qualifications: The physician reviewer is board certified in radiation oncology 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: Medical Necessity
Decision: Upheld

A 21-year-old female has requested approval for 90 days of residential chemical dependency treatment or admission to residential chemical dependency treatment for treatment of her chemical dependency.   Findings:  The physician reviewer found that based on review of the available records, this patient presents without an acute medical or psychiatric condition. She has been successfully treated in an outpatient setting in the past. In addition, she completed a 30 day rehabilitation program but did not comply with her outpatient care recommendation to live in a sober house. She now agreed to a residential program to avoid further legal difficulties. The requested services are not medically based and are not supported by current placement criteria or practice guidelines from the American Psychiatric Association (APA) and American Society of Addiction Medicine (ASAM).
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: an enrollee has requested authorization and coverage for a 12 week extension of Sovaldi, Daklinza and ribavirin. Findings:  The physician reviewer found that according to 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 life expectancy less than 12 months due to non-liver-related conditions. However, this patient has started a 12-week course of Sovaldi, Daklinza, and ribavirin. The guidelines state that for treatment-naive and experienced patients with HCV genotype 3 infection in the allograft, including those with compensated cirrhosis: daily daclatasvir (60 mg) plus sofosbuvir (400 mg) with low initial dose of ribavirin (600 mg, increased as tolerated) for 12 weeks is a recommended regimen for patients with hepatitis C virus genotype 3 infection. This applies in this case as the patient is treatment-experienced and has cirrhosis in the allograft. This is based on a study of 77 liver transplant patients receiving Sovaldi with Daklinza (Fontana, et al). Regarding the request to extend therapy in the context of a positive viral load at week 4, the AASLD/IDSA guidelines do not recommend extending therapy on the basis of detectable viral load at any point, stating that the significance of a positive HCV RNA test result at week 4 that remains positive, but lower, at week 6 or week 8 is unknown. No recommendation to stop therapy or extend therapy can be provided at this time. Final Result: The reviewer determined that the requested medications 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 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: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for digital breast tomosynthesis performed. Findings:  The physician reviewer found that the patient who was asymptomatic with respect to her breasts.  On the date of dispute, the patient underwent a routine screening mammogram consisting of a synthetically reconstructed two dimensional views with three dimensional tomosynthesis study. In addition, the patient had an automated whole breast sonogram examination.  The current images were compared to a prior mammogram dated six years prior, and no interval changes were noted on the mammographic portion of the study.  There were no masses, areas of suspicious calcifications, or areas of architectural distortion on the mammogram.  However, the automated whole breast sonogram indicated a questionably increasing nodule in the left breast, for which additional imaging was recommended.  Her breasts were described as heterogeneously dense. The Health Plan has denied reimbursement for digital breast tomosynthesis performed on the date of dispute.  Per the Health Plan, the service at issue was investigational for the evaluation of this patient. Breast tomosynthesis is a technique that was developed several years ago as a problem solving adjunct to routine mammography.  Applying the same basic concept as computed tomography scanning, the logic is that by separating the various layers of breast tissue, one can better detect abnormalities. This has been shown to be most useful in the evaluation of dense breasts.  In this particular patient, there are two distinct reasonable indications for tomosynthesis. First, she has breast tissue that was noted as heterogeneously dense. It is specifically those patients who have dense breasts that can benefit most from tomosynthesis. Second, the presence of a questionably increasing nodule on the sonogram necessitates a degree of certainty that a biopsy is not necessary. The ability to separate out the overlapping structures enables the possibility of demonstrating or excluding an otherwise occult tumor. Therefore, digital breast tomosynthesis performed on the date of dispute was likely to have been of greater benefit than other methods of evaluating this patient.Final Result: The reviewers determined that the service at issue was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: Physician reviewers 1,2 & 3 are board certified in diagnostic radiology 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 55-year-old female enrollee requested authorization and coverage of continued intravenous antibiotic therapy. The Health Plan denied the request indicating that the requested therapy is not medically necessary for the treatment of the enrollees Lyme disease and Rocky Mountain spotted fever.One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer upheld the Health Plans denial on the basis that the requested therapy is not medically necessary.
Appeal type: Experimental/Investigational
Decision: Upheld

A 45-year-old male enrollee requested authorization and coverage of a GlucoWatch. The Health Plan denied the request indicating that the requested equipment is considered investigational for treatment of the enrollees nocturnal hypoglycemia. Three physician reviewers performed an experimental/investigational Independent Medical Review. Two of the three physician reviewers concluded that the requested equipment is not likely to be more beneficial for treatment of the enrollee's medical condition than any available standard therapy. One of the three physician reviewers concluded that the requested equipment 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 equipment 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 upheld.
Appeal type: Medical Necessity
Decision: Upheld

The patient is a 59-year-old female with primary progressive multiple sclerosis diagnosed in December 2004. She is requesting authorization for a power-operated vehicle (POV). The patient walks with a cane, although the only documented exam from her primary neurologist indicates she had a normal gait in November 2004. The submitted documentation demonstrates the patient is ambulatory with a cane and independent in her home. The Health Plan has denied authorization and coverage for a POV on the basis it is not medically necessary.The Health Plans denial should be upheld. Review of the submitted documentation does not demonstrate a POV is medically necessary. The patient is ambulatory with a cane. In addition, the patient is independent in her home. Thus, the patient does not meet nationally accepted medical necessity criteria for authorization of a POV. Accordingly, I have determined a POV is not medically necessary to assist with the patients mobility problems. Therefore, the Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Synvisc One injections in both knees. Per the medical literature, although viscosupplementation may relieve knee pain in some individuals with osteoarthritis, it is not known as to which individuals will benefit. The current evidence is limited, and guidelines from organizations such as the American Academy of Orthopedic Surgeons indicate that the evidence is not conclusive. In light of the foregoing, viscosupplementation can only be recommended in individuals with a history of lasting benefit from prior injections, and in carefully selected cases where everything else has been tried, and the options are limited. In this case, the patient has severe osteoarthritis of both knees with chronic pain. The patient has tried and failed other conservative treatments, including bilateral intra-articular corticosteroid injections, icing, and nonsteroidal anti-inflammatory drugs, with the alternative being a total knee arthroplasty. Given the patients limited options and based on the current medical literature, the requested services are medically indicated. Therefore, Synvisc One injections in both knees are medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested services are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in orthopedic surgery and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary:  An enrollee has requested whole body integumentary photography (mole mapping) for evaluation of her atypical nevi.  Findings:  The physician reviewer found that this patients clinical presentation of pigmented lesions is suggestive of the atypical nevus syndrome. Patients with this condition have a higher risk for developing melanoma. Various imaging methods are available that can be used in patients to evaluate pigmented lesions suspicious for malignant transformation to melanoma. Biopsy can be problematic because of the need to excise the entire lesion in order to avoid a sample error, and possible complications of this interventional procedure. Effective approaches to early melanoma detection should identify and evaluate both changing and new nevi. Therefore, the whole body photography is a standard of care approach to early diagnosis of melanoma in such patients. Consistent with these findings, whole body integumentary photography (mole mapping) was medically necessary.  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 dermatology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Norco. On determining when to initiate or continue opioids for chronic pain, Dowell and colleagues report, Nonpharmacologic therapy and nonopioid pharmacologic therapy are preferred for chronic pain. Clinicians should consider opioid therapy only if expected benefits for both pain and function are anticipated to outweigh risks to the patient. If opioids are used, they should be combined with nonpharmacologic therapy and nonopioid pharmacologic therapy, as appropriate.  The Federation of State Medical Boards (FSMB) strongly recommends prescribers use, Opioid therapy for chronic pain that is not cancer-related, or part of palliative care or end-of-life care, only when non-opioid and non-pharmacological options have not been effective. In this case, the patient has chronic low back pain, as a result of twisting his back, without signs or symptoms of neurological deficit or weakness. A follow up lumbar MRI detected an old stable compression fracture at L1 and evidence of ungraded facet joint disease at the other levels, without sign of high grade canal or foraminal stenosis at the other lumbar levels. Treatment included medication management with nonsteroidal anti-inflammatory drugs and non-pharmacological treatments such as exercise, physical therapy, and trigger point injections of the latissimus dorsi. The patient has been prescribed a short course of Norco 5-325 mg without follow up prescriptions or documentation that chronic opioid therapy was indicated. In this case, objective imaging did not find evidence of cord or nerve compression and physical examination did not reveal evidence of disability or impairment. The treating provider did not document that chronic opioid therapy is medically necessary to treat musculoskeletal pain thought to be from a pulled muscle. Given that clinical guidelines do not recommend opioid therapy for musculoskeletal pain as first line therapy and that nonpharmacological treatments are preferred, the requested medication is not medically indicated. Based on the available medical records for review and the national guidelines and literature reviews, the request for Norco is not medically necessary.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: The patient has requested authorization and coverage for Synvisc One injection in the right knee (HCPCS Code J7325). Evidence from systematic reviews and randomized controlled trials indicate that although viscosupplementation may relieve knee pain in some patients with osteoarthritis, data has not established which patients will benefit. Guidelines from the American Academy of Orthopedic Surgeons (AAOS) indicate that the data on safety and efficacy of viscosupplementation remain inconclusive. As such, the AAOS does not currently recommend viscosupplementation as routine treatment for osteoarthritis of the knees. Viscosupplementation is reserved for patients with a history of lasting benefit from prior injections and in cases where the remaining options are limited. In this case, the patients remaining treatment options are limited. The patient has tried and failed conservative treatments including aspiration and injection with steroids, and physical therapy, with the alternative being a total knee arthroplasty. Given these findings, the requested Synvisc One injection in the right knee (HCPCS Code J7325) is medically necessary for treatment of this patient. Final Result: The reviewer determined that the requested services are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in orthopedic surgery and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned

 A male enrollee requested an implantable cardioverter defibrillator for medical treatment of his medical condition.  Findings:  Three physician reviewers found that the services at issue were likely to have been superior over other treatment options.  The medical records noted left ventricular dysfunction and a recent ejection fraction of 30 to 35%.  The current medical evidence supports an implantable cardioverter defibrillator in this clinical setting.  Given this patients history, the device at issue was indicated for primary prevention of sudden cardiac death.  All told, an implantable cardioverter defibrillator was likely to have been of greater benefit than other treatment modalities.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a two-year-old male enrollee has requested authorization and coverage for speech therapy at the frequency of two sessions per week for one hour per session.  The Health Plan has denied this request indicating that the requested therapy is not medically necessary for treatment of the enrollees expressive language disorder.  Findings:  The physician reviewer found that this patient has an identified delay in expressive speech of greater than 50%. Additionally, there is an 18% to 32% delay in pragmatics.  Speech therapy is indicated with any delay greater than 25% (Feldman & Messick). Extensive review of the literature, including a meta-analysis by Law, et al., noted the positive effect of speech and language therapy interventions for children with expressive phonological and expressive vocabulary difficulty. Feldman & Messick also note that treatment for language disorders is predicated primarily on the childs language profile and level of communication skills. Children who participate in speech-language treatment show better improvement than those children who receive no treatment (Feldman & Messick). Gallagher, et al. evaluated speech and language interventions for 24 preschool children with specific language impairment and found statistically greater improvement with intensive direct speech and language therapy delivered by speech and language therapists over an eight-month period when compared to no intervention or nursery-based intervention. Therefore, speech therapy is medically necessary for this patient for two hourly sessions per week.