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

Nature of Statutory Criteria/Case Summary: The patient has been diagnosed with osteoarthritis of both knees. The patient reported bilateral knee pain. Physical examination findings included tenderness over the right knee medial joint line. Patellar grind tests were positive in bilateral knees. The patient has previously been treated with cortisone injections and physical therapy, with minimal improvement. The provider noted that the previous hyaluronic acid injections provided good results for the patient. The patient has requested authorization and coverage for Hyaluronan (Euflexxa) injections (J7323) in both knees. The Health Plan denied the request and reported that the requested services are not medically necessary for the treatment of this patient. At issue in this case is whether Hyaluronan (Euflexxa) injections (J7323) in both knees are medically necessary for the treatment of the patients medical condition. Review of the current medical literature pertaining to viscosupplementation reveals mixed results. Although viscosupplementation may relieve knee pain in some patients with osteoarthritis, it is unknown which patients 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. Considering the foregoing, viscosupplementation can only be recommended for patients with a history of lasting benefit from prior injections and in carefully selected cases when everything else has been tried and the options are limited. In this case, the patient has a history of good response to prior viscosupplementation injections. Furthermore, the patients options are limited. The patient has tried and failed other conservative treatments, with the alternative being a total knee arthroplasty. The medical evidence supports the requested services in this clinical setting. Therefore, Hyaluronan (Euflexxa) injections (J7323) 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: Upheld

The parent of a 15-year-old female enrollee has requested  for Yaz birth control medication for treatment of her menorrhagia.  Findings:  The physician reviewer found that oral contraceptives can be used for treatment of menstrual irregularities and menorrhagia. They have been shown to be useful in the treatment of acne. There are multiple preparations available that have been shown to be effective. There is no evidence that the patient has contraindications to other forms of oral contraceptives and there is no indication that alternative, Apri, would not be an adequate alternative.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary:  An enrollee has requested authorization and coverage for stereotactic body radiation therapy (SBRT) for treatment of the enrollees prostate cancer. Findings:  The physician reviewers found that SBRT for prostate cancer is an emerging technology. At the present time, SBRT of prostate is being evaluated in phase I-II trials. While SBRT is a promising technology, it is considered experimental/investigational in this clinical setting due to insufficient data in the literature supporting its use. Until the clinical outcomes (local control, survival, toxicity) relative to intensity modulated radiation therapy (IMRT) with or without brachytherapy are known from these trials, SBRT is not considered standard of care for localized prostate cancer. There is very limited published data on the long term efficacy and safety of SBRT for prostate cancer when compared to standard fractionated IMRT or brachytherapy. A few available articles on SBRT treatment of prostate cancer are from single institution studies with a small number of patients and short follow up. They are mostly technical feasibility studies and do not provide data on the long term efficacy and safety. Until the results from the current trials can demonstrate long term efficacy of SBRT for early stage prostate cancer, SBRT cannot be considered as a standard of care. For these reasons, SBRT is not likely to be more effective than any conventional modality for treatment of this patient. Final Result: Two of three reviewers determined that the requested services are 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 number one, two, and three are board certified in radiation oncology and 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: Experimental/Investigational
Decision: Overturned

A 37-year-old male enrollee has requested transcatheter closure of a patent foramen ovale (PFO).  Findings:  Two physician reviewers found that the requested services are likely to be more effective for the patient than other available options. Based on the information provided, the patient would benefit from transcatheter closure of PFO. While the literature is mixed with regard to superiority of PFO closure versus anticoagulation, the data is trending towards improved outcomes with PFO closure. Given the patients young age, it is reasonable and likely to be more beneficial to close the PFO rather than taking anticoagulations for many years. All told, the requested transcatheter closure of a PFO is likely to be more beneficial for treatment of the patients medical condition than any other modalities.
Appeal type: Medical Necessity
Decision: Upheld

A 56-year-old female enrollee has requested Vicodin for her pain management. Findings: The physician reviewer found that the requested Vicodin would be contradictory to safe and effective pain management techniques. The higher dose of acetaminophen contained in Vicodin increases the risk for hepatotoxicity and death. Additionally, current standard of care for chronic pain is treatment in a multidisciplinary practice to include physical therapy, behavioral therapy, and injections to help reduce pain. Opiates are considered adjunctive to this therapy, and at the point at which they are required, controlled release narcotics with close monitoring by a certified physician is recommended.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/ Case Summary:  The enrollee requested coverage for Hybrid Maze procedure, atrial fibrillation. The enrollee has a history of atrial fibrillation for the past five years. He had a transient ischemic attack (TIA) which resulted in right-sided weakness and speech problems that lasted half an hour. At this time he was found to have atrial fibrillation. He underwent cryoablation and subsequently developed atrial fibrillation again and underwent cardioversion. He has had recurrence of atrial fibrillation and is short of breath, dizzy and unable to tolerate physical exertion. He is exhausted all the time.  His condition is getting progressively worse and he has exhausted all avenues of conservative medical management. His cardiothoracic surgeon advised the hybrid maze procedure to treat the enrollees persistent atrial fibrillation. According to recent published literature the use of the Hybrid Maze procedure offers improved clinical benefit for reduction in recurrent atrial fibrillation, when compared to widely-used catheter-based endocardial ablation procedures. Given this enrollee has already failed an attempt at rhythm control with a prior catheter-based ablation, and has a history of significant symptoms, a surgical based approach, such as the Hybrid Maze procedure is appropriate and offers improved clinical efficacy and freedom from atrial fibrillation compared to endovascular catheter-based procedures. Conventional treatments for controlling this enrollees atrial fibrillation have been ineffective. Literature supports the Hybrid Maze procedure can be a successful alternative to catheter ablation and open surgical procedures in enrollees who have been unresponsive to other treatments. This enrollee is symptomatic despite medical therapy, ablation and multiple direct current cardioversions. The literature cited shows that it is reasonable to consider this procedure in a symptomatic enrollee who has failed other commonly used procedures. Literature also indicates that it is more likely to be beneficial than cardioversion and ablation; which have failed. Final Result: Two of the three reviewers determined that the requested services are not likely to be more beneficial than any available standard therapy for treatment of the enrollees medical condition. Therefore, the health plans denial is upheld.Credentials/Qualifications: Two reviewers are board certified in Cardiovascular Disease and one reviewer is board certified in Thoracic and Cardiac Surgery 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: Experimental/Investigational
Decision: Upheld

A 57-year-old female enrollee has requested coverage for nucleoplasty percutaneous disc removal for treatment of her low back pain.  Findings:  Two physician reviewers found that the patient'sprovider states that she has not experienced relief of her symptoms with injections, physical therapy, or medication management and was not deemed a surgical candidate when evaluated by neurosurgery. The provider states the patient is a candidate for nucleoplasty with percutaneous disc decompression (CPT code 62287) given her lumbar discogram which was positive at L5-S1 for concordant pain. The provider indicates that nucleoplasty is an effective therapy for chronic discogenic back pain which results in significant reductions in levels of disability and capacity for work as well as decreased analgesic consumption. The peer reviewed systematic review from Gerges and colleagues discussed the effectiveness of the nucleoplasty procedure. Although the authors noted that nucleoplasty is a potentially effective minimally invasive treatment for patients with symptomatic disc herniation that has been refractory to conservative therapy, they concluded that, prospective randomized controlled trials with higher quality of evidence are necessary to confirm efficacy and risks and to determine ideal patient selection for this procedure. Consistent with these findings, there is insufficient evidence to establish nucleoplasty is superior to available standard therapies and therefore its use is not likely to provide this patient with improved health outcome beyond that expected with standard therapies.
Appeal type: Urgent Care
Decision: Overturned

A 51-year-old female enrollee has requested for emergency services on an emergent basis. Findings:  The physician reviewer found that this patient had been suffering a cough for two days, she did report chest pain as well as shortness of breath. Indeed, records note her to be in mild distress and she was immediately treated with inhaled bronchodilator therapy as well as intravenous steroids.  According to the documents provided, this patients symptoms of shortness of breath and chest discomfort met the prudent layperson criteria for an emergency. A prudent layperson with an average knowledge of medicine would reasonably expect the absence of emergency care to jeopardize her health.
Appeal type: Medical Necessity
Decision: Overturned

A 32-year-old female enrollee requested authorization and coverage of gastric bypass surgery. The Health Plan denied the request indicating that the requested procedure is not medically necessary for the treatment of the enrollees morbid obesity.One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer overturned the Health Plans denial on the basis that the requested procedure is medically necessary depending upon the results of a psychological evaluation.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: A female enrollee has requested authorization and coverage for Praluent for the treatment of the enrollees hypercholesterolemia. Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested medication. This patient has genetically proven familial hyperlipidemia and elevated LDL level to 164 mg/dl while on Juxtapid. Juxtapid is an oral inhibitor of the microsomal triglyceride transport protein (MTP), and this medication has not been studied in combination with proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitors such as Praluent. This patient meets usual accepted criteria for the use of Praluent as monotherapy or in combination with a statin or ezetimibe since studies have demonstrated safety and efficacy in this regard. However, the medical necessity of Praluent in conjunction with Juxtapid has not been established since PCSK9 inhibitors have not been studied in conjunction with this medication. All told, Praluent is not medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested medication is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in in internal medicine with sub-specialty certification in cardiovascular 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: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for wearable cardioverter defibrillator (DME K0606) provided by Zoll LifeVest. This patient sustained a recent MI and underwent acute revascularization with coronary stenting. His subsequent ejection fraction was less than 35% and his medical management was being optimized. Chung and colleagues noted that the risk for sudden cardiac death appears to be highest in the first 30 days after MI in patients with left ventricular dysfunction or heart failure. This patients ejection fraction may have been transiently low and may have improved over time due to recovery of stunned myocardium from the MI, treatment with medications, or revascularization surgery. If the patient did achieve an ejection fraction greater than 35%, then he would not be a candidate for a permanent implantable defibrillator. A wearable LifeVest cardioverter defibrillator was appropriate to provide temporary protection from early sudden death due to arrhythmia during this interim period. In motivated patients who can manage the device, there is data that a wearable LifeVest cardioverter defibrillator can provide temporary protection from possible lethal ventricular arrhythmias in this patient population during this interim waiting period. All told, the wearable cardioverter defibrillator (DME K0606) provided by Zoll LifeVest was likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Findings:  Two of the three physician reviewers found the wearable cardioverter defibrillator (DME K0606) provided by Zoll LifeVest was likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Final Result: The reviewers determined that the services at issue were 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 internal medicine with subspecialty certification in cardiovascular disease 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: Overturned

A 39-year-old female enrollee requested authorization and coverage of gastric bypass surgery. The Health Plan denied the request indicating that the requested procedure is not medically necessary for treatment of the enrollees morbid obesity.One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer overturned the Health Plans denial on the basis that the requested procedure is medically necessary.
Appeal type: Experimental/Investigational
Decision: Upheld

A 36-year-old male enrollee has requested total disc arthroplasty (CPT code 22856) artificial disc replacement for treatment of his neck pain. Findings:  Three physician reviewers found that further investigations in the form of large, prospective, randomized trials are needed to determine the long-term benefits of artificial cervical disc replacement. Although there are well-controlled, prospective studies showing comparable short-term results of cervical spine arthroplasty and anterior decompression and fusion, there are insufficient long-term randomized controlled trials demonstrating the safety and efficacy of the requested procedure.  All told, the superior efficacy of total disc arthroplasty (CPT code 22856) artificial disc replacement has not been established.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary:   The parent of an enrollee has requested inpatient psychiatric hospitalization services for treatment of the enrollees behavioral health conditions. Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the services at issue.  During the dates of service in dispute, the patient was not a threat to herself or others.  She was not violent or aggressive, and she was medically stable.  Her medication management did not require inpatient monitoring.  She was cooperative and compliant.  She had improved and no longer required 24-hour monitoring.  There was no evidence that returning her to her home environment would lead to decompensation.  She still needed treatment for medication management and psychological and family treatment.  However, this treatment could be provided at a lower level of care such as intensive outpatient or outpatient.  All told, inpatient psychiatric hospitalization services, during the dates of service in dispute, were not medically indicated for the treatment of this patient.  Final Result: The reviewer determined that the services at issue were 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 psychiatry 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 an office visit with a cancer specialist. The National Comprehensive Cancer Network (NCCN) guidelines on prostate cancer recommend yearly prostate-specific antigen (PSA) screening for five years after undergoing definitive therapy. In this case, the patient is approximately five years out from having completed definitive therapy for treatment of prostate cancer. His PSA levels are under 0.1 ng/mL and checked regularly by the same provider following the patients thrombocytosis. In this clinical setting, given that the patient is receiving appropriate follow-up care under NCCN guidelines, the requested service is not medically indicated. Therefore, an office visit with a cancer specialist is not medically necessary for the evaluation of this patient.Final Result: The reviewer determined that the requested service is not medically necessary for evaluation 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 certifications in medical oncology and hematology 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

The patients parent has requested reimbursement for a second unit of deep sedation coded. Medical literature noted that the appropriate setting for sedation should be determined as there is an increased risk outside the hospital setting. Researchers found that the risk of adverse anesthesia complications is not increased when choosing between moderate and deep sedation/general anesthesia for adolescent patients undergoing third molar extraction. According to the records provided for review, the dental surgery was performed with deep sedation. The use of deep sedation for the procedure was appropriate given the removal of impacted teeth, while the previous procedure on involved removal of teeth numbers 1, 16, 17, and 32, which were not impacted. Deep sedation was provided to ensure that the patient did not move during the procedure and was consistent with the recommendations in the medical literature. All told, the second unit of deep sedation was medically necessary for treatment of this patient.
Appeal type: Medical Necessity
Decision: Overturned

A 24-year-old female enrollee has requested acute inpatient psychiatric services for treatment of her alcohol dependence and major depression. Findings:  The physician reviewer found that the patient clearly met the established criteria for continued acute inpatient psychiatric care. She underwent a prolonged detoxification process and was acutely ill with depression and anxiety. Her anxiety escalated to panic when discharge was imminent. The patient underwent ECT for treatment of her depression with plans to continue this intervention on an outpatient basis. Multiple medications were prescribed for depression, anxiety, mood stabilization and relapse prevention and dosages were titrated throughout her stay.