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

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested authorization and coverage for Nutropin AQ Nuspin. The reviewer found that Short stature is defined by a height at below the third percentiles, or two standard deviations or more below the mean for children of that sex and chronologic age. The patient is plotted at the 14th percentiles for his height on the growth chart, and is therefore not considered short. The patients reported skeletal age is congruent with his chronological age. Based on this information, his predicted adult final height is going to be around 5 feet 8.2 inches, which is normal in the society (above 5 feet 4 inches) and within 2 inches from genetic target height. Under these circumstances, Nutropin AQ Nuspin is not medically necessary for the patients medical condition.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 pediatrics 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.Findings:  The physician reviewer found that
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for 60 minute physical therapy sessions for treatment of his low back pain and radiculopathy.  Findings: The physician reviewer found that per the clinical practice guidelines for the management of chronic musculoskeletal low back pain, the focus of treatment should be patient education, self-care, common analgesics, independent exercise and remaining active.  The benefit of prolonged formal therapy services is not established in the medical literature for this patients condition.  There is no proven marginal benefit of passive modalities such as massage/manual therapy and modalities provided in a formal setting on a prolonged basis on pain, health or functional outcomes over self-massage and topical treatments, such as ice or heat applied independently. There are no documented exercises that the patient was doing in therapy that could not be done independently or substituted with independent exercise.  Exercises such as planks do not require supervision on a prolonged basis. Overall, although the patient has ongoing symptoms, there is no expectation of a marginally significant difference in clinical course or outcomes with the requested physical therapy over an independent program. All told, the requested 60 minute physical therapy sessions are not medically necessary for the treatment of 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 physical medicine and rehabilitation and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/ Case Summary:  The patient with osteoarthritis of the left knee tried steroid injections, lifestyle changes, Motrin, Celebrex, a brace, ice, heat, natural remedies, stretching, acupuncture, chiropractic care and bee therapy.  Hyaluronan injections to the knee were requested. Based on the current medical studies, hyaluronic acid is no longer recommended for patients with symptomatic osteoarthritis. There was not enough improvement noted to support it use.Final Result: The reviewer determined that the service at issue was not medically necessary for treatment of the patients condition.  Therefore, the health plans denial was upheld.Credentials/Qualifications: The physician reviewer is board certified in Orthopedic Surgery and is actively practicing.
Appeal type: Experimental/Investigational
Decision: Upheld

A 42-year-old male enrollee has requested a spinal cord stimulator for the treatment of his lower back pain. Findings:  Three physician reviewers found that spinal cord stimulation is well accepted treatment for several pain syndromes. Long-term studies have validated its use. Kumar and colleagues published a case report with follow-up ranging from 6 months to 15 years. In that study, 58% of implanted patients, after careful trial selection, experienced continuous pain relief. Kumar and colleagues also documented satisfactory outcomes in a 10-year follow-up. Finally, North and colleagues have published multiple studies comparing the outcomes of spinal cord stimulation versus re-operation.  The authors noted spinal cord stimulation is more effective than reoperation as a treatment for persistent radicular pain after lumbosacral spine surgery. While spinal cord stimulation is a superior modality in this setting, the submitted evidence does not demonstrate this patient has undergone a psychological evaluation. Such evaluation is indicated prior to the procedure. Therefore, a psychological evaluation should be performed prior to this trialing in order to rule out underlying psychopathology that may compromise the potential success of this treatment.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Plegridy Pen for treatment of the enrollees relapsing multiple sclerosis. Findings:  The physician reviewer found that this patient has longstanding multiple sclerosis with mild disability and recent increase in disease activity. She discontinued one disease modifying therapy six years previously due to interferon side effects. It has now been recommended she use Plegridy, which is a pegylated interferon, every two weeks. As this is an interferon that is nearly identical to Rebif, it would be expected that the patient would have similar side effects. It has been the experience of many providers that Plegridy actually has more interferon related side effects than all of the other interferons. Plegridy offers no clear advantages over other interferons except for its biweekly dosing schedule. It is thus reasonable to use Avonex which is on the formulary and has efficacy and side effect profiles similar to Plegridy including low incidence of neutralizing antibodies, except it does not have injection site reactions due to its intramuscular route of administration. Currently, there is a lack of evidence that Plegridy has higher efficacy than the standard available therapies. 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 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

A 47-year-old male enrollee requested authorization and coverage of synvisc injections for the treatment of hepatitis C, rheumatoid arthritis and degenerative joint disease in both knees.  The Health Plan denied the enrollees request indicating that the requested treatment is not medically necessary.One physician reviewer performed a medical necessity Independent Medical Review.  The physician reviewer upheld the health plans denial on the basis that the requested services are not medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld

A 64-year-old female enrollee has requested an ultrasound, foot and ankle strapping, and electrical stimulation for the treatment of her feet. Findings:  The physician reviewer found that the literature demonstrates that there is no evidence to support the efficacy of the modalities used in improving clinical outcomes for this patients diagnoses. The literature noted that these modalities have not demonstrated proven efficacy, while noting that most studies are limited for these modalities. Thus, these modalities are of questionable benefit for this patients condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for ketamine infusion services.Researchers performed a meta-analysis study to examine the efficacy of ketamine in the treatment of complex regional pain syndrome (CRPS). They selected randomized clinical trials or cohort studies for meta-analyses, with the primary outcome being pain relief. Their findings suggested that ketamine infusion can provide clinically effective pain relief in short term for less than three months. Researchers conducted a retrospective review to ascertain if the use of subanesthetic inpatient infusions of ketamine provide meaningful improvements in pain scores, and thus, quality of life, in patients suffering from CRPS. They concluded that limited subanesthetic inpatient infusions of ketamine may offer a promising therapeutic option in the treatment of appropriately selected patients with intractable CRPS. In this case, records suggest that the patient has a brachial plexopathy due to the thoracic outlet syndrome that in turn has led to this CRPS condition. The patient has severe chronic pain and CRPS type 2, which usually involves a damaged nerve, with widespread disease throughout the patient's body. Records indicate that the patient had in the past had several months of pain relief with ketamine infusions. Ketamine infusions are a method of chronic pain management for individuals such as the patient. Given the patients CRPS diagnosis and her history of good relief from ketamine infusions, ketamine infusion services were medically necessary for the patient. Accordingly, the ketamine infusion services at issue were medically necessary to treat the patients medical condition.Final Result: The reviewer determined that the services at issue were medically necessary to treat the patient's medical condition. Therefore, the Health Plans denial should be overturned.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: Upheld

The patient is a 68-year-old male who had a cerebral vascular accident (CVA) in 1995.  He currently weighs 450 pounds and has problems with sleep apnea, osteoarthritis and poor balance. The patient has been using a standard hospital bed and claims that the bed requires frequent mechanical repairs and does not provide adequate support. The patients request for authorization and coverage of a bariatric hospital bed was denied by the Health Plan based upon a determination that the equipment is not medically necessary.There is no information in the medical record provided indicating the medical need for a hospital bed. There is no documented evidence that the patient requires special positioning or frequent repositioning which necessitate the features of a bariatric hospital bed.  It appears that this bed has been requested for the patients convenience.  Therefore, I have determined the requested equipment is not medically necessary for the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned

The patient is a 31-year-old female with a two-year history of vulvar pain. She has consulted with her primary care physician as well as several OB/GYNs. She was screened for multiple vaginal infections and unsuccessfully treated. In an effort to address the possibility of neurogenic pain, the patient had been given a trial of Elavil, which she was unable to tolerate. The patients chronic pain had escalated to the point where she was having difficulty walking or sitting for any period of time and she was contemplating applying for disability since she was not able to continue working in her current state.At that point the patient was referred by her gynecologist to a pelvic pain specialist who diagnosed her with subcutaneous panniculosis and pelvic floor musculoskeletal hypersensitivity. The patient was started on a course of physical therapy and subsequently reported marked improvement of her pain.The treatment of chronic pelvic pain/vulvodynia is difficult and is often beyond the scope of a general gynecologist as is demonstrated in this case. After consulting with a number of physicians and trying all of the conventional therapies, the patient did not experience any improvement in her pain and was referred to a pelvic pain specialist.  This provider made a diagnosis of subcutaneous panniculosis with pelvic floor musculoskeletal hypersensitivity and recommended physical therapy (PT) and biofeedback.The use of PT for the treatment of chronic pelvic pain is not without precedent. The March 2004 ACOG Practice Bulletin cites observational studies that suggest various PT modalities are effective, e.g., manual treatment of trigger points in the pelvic floor resulted in improvement in pain in 65-70% of cases. In addition, there has been extensive publication on this subject in the urological literature. Given the extent of the patients disability, the failure of conventional treatments, and the lack of alternative services offered by the Health Plan, physical therapy with a pelvic pain specialist is medically reasonable and appropriate for treatment of this patients vulvodynia. Based upon the information set forth above, I have determined that the requested therapy is medically necessary for treatment of the patients medical condition. The Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Upheld

A 32-year-old male enrollee has requested continuous passive motion (CPM) machine for treatment of his post-operative torn anterior cruciate ligament (ACL) of his the left knee.   Findings:  The physician reviewer found that in the medical literature, Richmond and colleagues reported on their comparison of 4-day versus 14-day use of CPM in the post-operative care of 20 patients following ACL reconstruction surgery with patellar bone autograft. At 42-day follow-up, the patients with measurements of ROM and other parameters confirmed that there were no statistically significant differences in those patients using the CPM for the 4-day period versus those using the CPM for the 14-day period. In addition, Gaspar and colleagues documented a significantly greater flexion extension ROM at time of discharge from the hospital, but reported that by 6-month follow-up, the differences were negligible. Consistent with the lack of scientific data supporting improved health outcomes with the use of CPM for post-operative care of patients after ACL surgery, the use of CPM in this patient was not medically necessary or beneficial. This decision is based upon a lack of evidence in the controlled studies and case reports. There is no evidence in this patient of any complications such as arthrofibrosis, which might provide an indication for the use of CPM. As such, the equipment at issue was not medically necessary for treatment of this patient following ACL reconstruction surgery, and therefore the denial was appropriate.
Appeal type: Experimental/Investigational
Decision: Upheld

A 52-year-old male enrollee has requested proton beam therapy (PBT) for treatment of his malignant neoplasm of the prostate.  Findings:  Three physician reviewers found that the issue of whether proton therapy for prostate cancer affords any advantage over intensity modulated radiation therapy (IMRT) remains controversial. Most reports, including the article from Vargas and colleagues systematic review, assert that patients treated with proton therapy fare comparably to patients treated with IMRT. Further, the authors found that proton therapy yields improved normal tissue sparing as compared to IMRT. Of note is that other accepted technologies such as image guided radiation therapy (IGRT), with daily computed tomography (CT), imaging of fiducials or ultrasound, coupled with IMRT, also reduce normal tissue dosing and were technologies that were not investigated in that analysis. With the limited data, it is possible that proton therapy is actually disadvantageous as the depth of proton delivery is more susceptible to changes in tissue density. Thus, despite the fact that proton therapy for treatment of prostate cancer is not experimental, other treatment approaches including IMRT with or without IGRT have been proven to be highly effective and well tolerated. All told, there are insufficient compelling data to suggest that proton therapy is superior to or more beneficial than IMRT for management of this patients condition.
Appeal type: Medical Necessity
Decision: Upheld

A 58-year-old female enrollee, with long-standing fibromyalgia, has requested authorizaton for the compounded medication guaifenesin.Findings:  The physician reviewer found that there is no peer-reviewed literature to support the beneficial use of guaifenesin in the treatment of fibromyalgia. This agent is touted as being useful in fibromyalgia based on anecdotal and testimonial reports. The use of guaifenesin in fibromyalgia has not produced results better than placebo; one occasionally sees an initial apparent benefit that is eventually lost over time. As a result, guaifenesin is not an accepted therapy for fibromyalgia among rheumatologists.
Appeal type: Medical Necessity
Decision: Upheld

The representative of a 91-year-old female enrollee has requested skilled nursing facility services for the treatment of the enrollees fractured pelvis. Findings:  The physician reviewer found that this patient had a minimal fracture and needed custodial care and pain relief during the period in question. Her severity of illness did not meet skilled nursing facility level of care. Her therapy did not require a skilled level of nursing or rehabilitative care.
Appeal type: Experimental/Investigational
Decision: Upheld

A 57-year-old female enrollee has requested electrical stimulation therapy for treatment of her degenerative disc disease.  Findings:  Three physician reviewers found that overall, there is insufficient medical literature supporting the use of electrical stimulation for management of neck and shoulder pain despite its use in practice. There is a lack of high-grade clinical trials published in the medical literature demonstrating that electrical stimulation therapy confers a clinically or statistically significant sustained functional effect above that which would be achieved with conventional therapy in this setting. More research is needed to further evaluate and substantiate the claims that electrical stimulation is an effective modality for this condition. The electrical stimulation therapy provided on the date in question was not likely to be more beneficial for treatment of the patients medical condition than standard treatments including medication, epidural injections and physical therapy.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Ozempic 0.25/0.5 mg dose pen. The records provided for review document that this patient has a history of obesity. The patient reports that they engaged in an exercise program in his 20s to help manage his weight. The patients provider has recommended treatment with Ozempic. Gadde and colleagues noted that while lifestyle modification is recommended as the cornerstone of obesity management, many patients do not achieve long-lasting benefits due to difficulty with adherence as well as physiological and neurohormonal adaptation of the body in response to weight loss. There are multiple pharmacologic therapies available for weight management. Wegovy and Ozempic are equivalent members of a class of medications known as glucagon-like peptide-1 (GLP-1) analogs. As noted in the medical literature, GLP-1 analogs have been shown to improve glycemic control, reduce body weight and decrease cardiovascular risk (Knudsen and Lau). Studies have demonstrated Ozempics ability to promote weight loss via reduced appetite and energy intake and delayed gastric emptying (Cornell). For these reasons, the requested medication Ozempic 0.25/0.5 mg dose pen 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 endocrinology, diabetes, and metabolism and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for advanced lipoprotein testing. Findings:  Three physician reviewers found that the medical evidence has not established the superior efficacy of the services at issue in this clinical setting. Per the submitted documentation, this patients HDL cholesterol is elevated, which suggests a lower risk for cardiovascular disease. The use of advanced lipoprotein testing for risk stratification remains of limited and questionable value in most clinical situations. Based on the clinical data provided, advanced lipoprotein testing is not recommended or indicated by current risk stratification guidelines. Thus, advanced lipoprotein testing provided was not likely to have been more effective than other methods of evaluating this patient. Final Result: 3 of 3 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 physician reviewers are board certified in internal medicine with sub-specialty 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.