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

A male enrollee requested the continuous passive motion (CPM) machine for medical treatment of his status post right total knee arthroplasty.  Findings:  The physician reviewer found that there is evidence in the medical literature that CPM may not significantly influence range of motion gain. Herbold and colleagues compared CPM use with non-CPM use and determined that the application of CPM may not significantly influence ROM gain. In addition, Mau-Moeller and colleagues indicated sling therapy has a clinically relevant beneficial short-term effect compared to CPM. Based on the clinical documentation submitted for review and the peer reviewed literature, the CPM machine is not medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Epclusa for 12 weeks for treatment of the enrollees hepatitis C. 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. This applies regardless of fibrosis stage, and advanced fibrosis is not required for treatment. Per the guidelines, Epclusa is recommended as first-line therapy for treatment-naive, genotype 2 patients. A delay in treatment may result in decreased survival. For these reasons, Epclusa for 12 weeks is medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested medication regimen is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in internal medicine with sub-specialty certification in gastroenterology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for Oncotype Dx Prostate Cancer Assay genetic testing. Findings:  Three physician reviewers found there are three major therapeutic approaches to the management of apparently localized prostate cancer. These include radical prostatectomy, radiation therapy, or active surveillance with no specific treatment given. Recommendations are made as to these options based on risk stratification. The individuals prostate cancer is evaluated with a combination of clinical features, prostate-specific antigen and pathologic findings. Based on the records, this patient is in the favorable intermediate risk group. The treatment recommendation for this group is not as clear as in the other groups. Oncotype Dx Prostate Cancer Assay genetic testing is a 17-gene panel that may assist in predicting risk of recurrence after treatment of a patients prostate cancer. Increasingly, it is being used in localized cancer to guide initial treatment. There is sufficient support for the services at issue in this patients case. Therefore, the Oncotype Dx Prostate Cancer Assay genetic testing performed on 3/28/17 was likely to have been of greater benefit than other methods of evaluating this patient. Final Result: The reviewers determined that the services at issue were 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 and 3 are board certified in internal medicine with sub-specialty certification in medical oncology 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 a virtual colonoscopy based on family history and patient age.  The health plan denied the enrollees request indicating that a virtual colonoscopy 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 virtual colonoscopy is not medically necessary.
Appeal type: Medical Necessity
Decision: Overturned

A 63-year-old male has requested Boost nutritional supplement six times per day (#186 per month) for treatment of chronic dysphagia secondary to nasopharyngeal cancer.  Findings:  The physician reviewer found that based on review of the available records, this patient has a complex surgical history which has resulted in permanent oropharyngeal dysphagia. His options for nutrition are limited. One option is to place a gastric tube, which is invasive and is associated with some risk. The other option is to provide a pureed diet, which is rarely a successful long-term solution. It is reasonable for the patient to receive Boost at a quantity to meet his nutritional needs, which includes six cans of Boost per day. Given this patients documented oropharyngeal or esophageal dysphagia, the requested Boost nutritional supplement six times per day (#186 per month), is supported as medically necessary for treatment of his medical condition.
Appeal type: Medical Necessity
Decision: Overturned

A 33-year-old female enrollee has requested continued acute inpatient rehabilitation for post subarachnoid hemorrhage treatment. Findings:  The physician reviewer found that a view of the record indicates the patient had multiple deficits involving cognition, communication, swallowing, head and trunk control and bilateral upper and lower extremity strength and movement. She has been receiving intensive, comprehensive neuro-rehabilitation with a multiple disciplinary approach. It appears from the record the patient has been participating in daily rehabilitation therapies and she has demonstrated steady small gains in communication, recall, right UE mobility and tolerance of oral feedings. She has also been decannulated.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the Orthovisc vials purchased and injected in the left knee.Current medical literature pertaining to viscosupplementation reveals mixed results. Evidence from eight systematic reviews and six randomized controlled trials indicates that 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. The current evidence is limited, and guidelines from organizations such as the American Academy of Orthopedic Surgeons indicate that the evidence is not conclusive. As such, the Academy does not currently support viscosupplementation as standard treatment for osteoarthritis of the knees. 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, there is a history of lasting relief from prior injections. Furthermore, the patients options are limited. The patient has tried and failed other conservative treatments as well as arthroscopic surgery, with the alternative being a total knee arthroplasty. Under these circumstances, the Orthovisc vials purchased and injected into the left knee 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 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

A 22-year-old female enrollee has requested for protective coating for her prosthesis for treatment of her status post below knee amputation. Findings:  The physician reviewer found that endoskeletal prostheses use foam coverings to provide bulk to the prosthesis (akin to muscle and fat on a biological limb) and protective outer coverings to protect the foam and internal componentry (akin to biological skin).  The protective outer covering in question is a basic component required for use of the prosthesis in conditions where exposure to moisture is expected.  This component is medically necessary for this patient for her use in routine activities of daily living and community activities.  All told, the requested protective coating is medically indicated in this patients case.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for internal medicine with subspecialty certification in cardiovascular disease. The peer-reviewed medical literature has not demonstrated that genetic testing for management of cardiovascular disorders is more beneficial than routine risk analysis and testing. MTHFR testing lacks support to be used as a reliable guide for management of this patients hypertension. Therefore, the requested MTHFR gene analysis and common variants are likely not more beneficial for evaluation of the patients medical condition than any standard therapy available.Findings:  Three physician reviewers found the requested MTHFR gene analysis common variants is not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the requested MTHFR gene analysis common variants is 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: 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: Upheld

A 42-year-old female has requested laparoscopic adjustable gastric banding for treatment of her obesity.  Findings:  The physician reviewer found that based upon the patients most recently documented BMI of 32.8, she does not currently meet the criteria set forth by nationally accepted guidelines for weight loss surgery. According to the National Institutes of Health Consensus Guidelines, an individual must have a BMI of at least 35 along with significant co-morbidities to be considered an appropriate candidate for bariatric surgery. In this case, the patient lost a significant amount of weight following her surgical consultation in February 2012 and no longer appears to have a BMI of 35 or above. Given the patients sustained weight loss, the risks of bariatric surgery outweigh the potential benefits of surgery at this time. It is likely an individual in this patients circumstances will be able to achieve adequate weight loss using conservative weight loss methods such as diet and exercise.
Appeal type: Medical Necessity
Decision: Upheld

A 26-year-old female enrollee has requested physical therapy for treatment of her low back pain. Findings:  The physician reviewer found that the submitted clinical evidence demonstrates that this patient has already received extensive PT. The patients current documented functional deficits do not demonstrate that the patient is precluded from performing activities of daily living. There is no evidence-based rationale to support further PT in this setting. Moreover, although Pilates-based and aquatic programs have been proposed, there is no evidence that the inclusion of these techniques would be clinically superior to the PT that the patient previously received (Long, et al. and Sertpoyraz, et al.). All told, the submitted documentation does not demonstrate that the proposed therapy is warranted from a medical standpoint.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement and prospective authorization and coverage for Supartz injections. 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 is status post lateral meniscus transplantation and articular cartilage paste grafting of the lateral tibial plateau, and status post chondroplasty of the lateral femoral condyle. Magnetic resonance imaging (MRI) showed grade III chondromalacia of the medial femoral condyle and grade IV chondromalacia of the posterior medial tibial plateau. The provider reported that Supartz was administered to supplement the synovial fluid in the osteoarthritic knee and to help the elastoviscosity in the joint, thereby alleviating the symptoms. In this clinical setting, the options were limited, and a corticosteroid injection was not an option as it would have harmed the transplanted tissue. Given the patients limited options and based on the current medical literature, the services at issue were and are medically indicated. Therefore, Supartz injections were and are medically necessary for the treatment of this patient.Final 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 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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Otezla. The submitted documentation fails to demonstrate the medical necessity of the requested medication. This patient has tried and failed other therapies.  She has had a trial of therapy with Otezla, with some improvement. There is no documented reason indicating why the patient cannot use the other preferred agents, including contraindications, adverse effects or intolerances. Therefore, Otezla 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 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: Overturned

The parent of a six-year-old female enrollee has requested neuropsychological testing for evaluation of the enrollees autism.  Findings:  The physician reviewer found that the relevant medical literature suggests that a neuropsychological assessment is indicated whenever a child has a known or suspected medical or neurologic condition that can be expected to have an impact on the developing brain. Specifically, ASD is a neurodevelopmental disorder for which neuropsychological studies have yielded profiles ranging from wholly intact to severe impairment. Simpler abilities including basic attention, elementary motor, simple memory, and formal language may be intact or enhanced with ASD. Higher-order cognitive abilities, or those requiring integrative processing, are often disproportionately impaired in ASD. Thus, neuropsychological testing is the basis for determining an estimate of the general level of functioning, assessing the integrity of specific behavioral functions, and evaluating functions. Further, it also helps to determine the services and supports needed from specialists. For these reasons, the neuropsychological testing performed on the date in question was medically indicated and necessary for proper evaluation of this patients medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld

A forty-eight year-old male with degenerative disc disease of the lumbar spine with radiculopathy is requesting authorization for IDET at the C3-4 and C4-5 levels.Reviewers Findings:  The three reviewing physicians found that although some of the early results with IDET are promising, it is not yet a reasonable alternative to conventional treatment such as fusion.  The reviewing physicians found that the Health Plan denial should be upheld.
Appeal type: Urgent Care
Decision: Upheld

A 20-year-old male enrollee has requested for emergency services for treatment of his ear pain.  Findings:  The physician reviewer found that the patients symptoms did not meet prudent layperson criteria for emergency care. A prudent layperson with an average knowledge of medicine and 8/10 ear pain for two days, similar to previous episodes of ear wax blockage, would not reasonably expect the absence of emergency care to jeopardize their health. The patients symptoms could have been safely evaluated on a non-emergent basis.
Appeal type: Experimental/Investigational
Decision: Overturned

A 30-year-old female enrollee requested authorization and coverage of radiofrequency ablation. The Health Plan denied the request indicating that the requested therapy is considered experimental for the treatment of the enrollees cervical facet syndrome.Three physician reviewers performed a medical necessity Independent Medical Review. Two physician reviewers concluded that the requested therapy is likely to be more beneficial for the treatment of the enrollee's medical condition than any available standard therapy. One physician reviewer concluded that the requested therapy is not likely to be more beneficial for the treatment of the enrollee's medical condition than any available standard therapy. Because two of the three physician reviewers concluded that the requested therapy is likely to be more beneficial for the treatment of the enrollee's medical condition than any available standard therapy, the Health Plans denial has been overturned.
Appeal type: Medical Necessity
Decision: Upheld

A female enrollee requested an electric mobility device for medical treatment of her medical condition. Findings:  The physician reviewer found that in this patients case, an assessment revealed that the patient had no significant gait impairments while walking more than 250 feet at a time, including outdoors.  There are no documented musculoskeletal or cardiovascular impairments that would preclude the use of a gait implement such as a walker for accomplishing her mobility-related activities of daily living.  Physical activity, moreover, is generally appropriate for general musculoskeletal health and for chronic pain syndromes such as fibromyalgia.  All told, the requested electric mobility device is not medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: A patient has requested authorization and coverage for a Monovisc injection in the right knee. An exhaustive review of the current medical literature pertaining to viscosupplementation reveals mixed results. Evidence from eight systematic reviews and six randomized controlled trials indicates that although viscosupplementation may relieve knee pain in some individuals with osteoarthritis, it is not known as to which individuals will benefit. Different studies have tried mixing hyaluronic acid with corticosteroids, platelet-rich plasma, and other agents to make it more effective. 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 enrollee has failed NSAIDs, arthroscopic surgery, and physical therapy. The right knee remains swollen and painful. The osteoarthritis is considered mild, and the patient is not a candidate for joint replacement surgery. There is sufficient support for the requested service in this clinical setting. Therefore, the requested Monovisc injection in the right knee is medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested service is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in 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.