Persius/imr-appeals huggingface dataset:
A 38-year-old female enrollee has requested an MRI scan of the breast for her history of Lynch syndrome/HNPCC and metastatic colorectal cancer to the liver.  Findings:  Two physician reviewers found that Lynch syndrome (hereditary non-polyposis colorectal cancer) is characterized by the development of colorectal cancer, endometrial cancer and various other cancers.  Protocols for surveillance in Lynch syndrome include colonoscopy, gynecological examinations, which may include regular ultrasounds and biopsies, and abdominal ultrasound screening.  The American College of Radiology has recognized the increased sensitivity of MRI for high-risk patients.  Clinical situations in which breast MRI may be warranted include patients with BRCA mutations, patients who are untested but who have a first-degree relative with BRCA mutations and patients with a lifetime risk of breast cancer of 20 to 25% or greater as defined by BRCAPRO or other models that are largely dependent on family history. This patient does meet established criteria for breast MRI.  Although the provider states that there is a lifetime risk of breast cancer of approximately 20%, this cannot be established based upon any given model.  All told, the requested MRI of the breast is not likely to be superior over other methods of evaluation.
The parent of a 15-year-old female enrollee has requested Genotropin growth hormone therapy for treatment of the enrollees idiopathic short stature.  Findings:  The physician reviewer found that the patient has normal growth factors and pituitary function on laboratory testing.  IGF-1 and IGFBP-3 levels were normal, and serum chemistries were normal.  She has no complaints or symptoms of pituitary insufficiency and no history of pituitary abnormality.  There is no evidence of growth hormone deficiency.  All told, in this patients case, the requested Genotropin growth hormone therapy is not medically indicated.
A 54-year-old male enrollee has requested a motorized wheelchair (power-operated vehicle) for treatment of his idiopathic transverse myelitis, suspected multiple sclerosis.  Findings:  The physician reviewer found that the submitted documentation does not substantiate the presence of impairments that would preclude the patient from accomplishing his mobility-related activities of daily living within the home with the aid of a manual wheelchair.  The records do not document any neurological or musculoskeletal impairment or pathology affecting the upper limbs.  He does not have a documented cardiovascular or pulmonary condition that is severe enough to preclude the use of a manual wheelchair to accomplish his mobility-related activities of daily living.  The power mobility device form signed by the patients primary care physician on the said date specifically endorses that the patient has sufficient upper limb function to propel an optimally configured manual wheelchair in the home through the course of a typical day.  With respect to falls, there is no evidence in the present case that would support that there would be a significant additional risk of falling when comparing a manual versus a power wheelchair.  All told, the requested motorized wheelchair (power-operated vehicle) is not medically necessary this patient.
A 44-year-old male enrollee has requested a DelRoyal T600 Digital hot/cold therapy system with blanket for treatment of his vertebral fractures. Findings:  Three physician reviewers found that the patient was prescribed the DeRoyal T600 Digital hot/cold therapy system with blanket for treatment of his low back pain. A literature search revealed no studies demonstrating or even assessing the efficacy of a heating/cooling system for the treatment of low back pain. As such, this therapy should be considered experimental at this time absent additional clinical trials demonstrating the equivalence or superiority of the device when compared to standard alternatives.
A 25-year-old female enrollee has requested an MRI of the whole body, leg or foot for evaluation of her foot pain. Findings:  The physician reviewer found that with the exception of x-rays, imaging has not been done.  Whole body MRI is not medically indicated for this patient since there is no history of malignancy. Whole body MRI, although not widely available, is generally reserved for the detection of skeletal metastases as well as other organ involvement.  This patient has a history of a foot neuroma.  Due to the fact that imaging of her feet has not been done despite symptoms which have persisted for over one year, bilateral MRI of the feet is medically indicated for the evaluation of this patient.  All told, in this patients case, evaluation with bilateral MRI of the feet is medically appropriate given her symptoms.
A 23-year-old male enrollee has requested inpatient psychiatric hospitalization for treatment of his medical condition.  Findings:  The physician reviewer found that this patient clearly exhibited suicidal ideation throughout his stay and lacked a strong support system outside the hospital setting.  The inpatient hospitalization was consistent with standards of medical practice in the community and his care could not be provided safely on an outpatient basis. Inpatient hospitalization was therefore medically necessary for this patient.
A 48-year-old female enrollee has requested iron infusions for treatment of her chronic anemia. Findings:  The physician reviewer found that this patients records are devoid of any current clinic notes which document anemia with an etiology of iron deficiency. Further, there is inadequate documentation of the patients failure to improve her iron stores with oral supplementation. The patient has a serum ferritin from last year of 13 ng/mL, which is low and suggestive of iron deficiency. More recently, her blood work from this year shows low iron saturation values which are low in the single digits and again suggestive of iron deficiency. However, the records do not clearly justify treatment at this time since there is insufficient documentation of an anemia work up or failure of oral supplements. In addition, the patients recent hemoglobin has not been provided for review. For these reasons, the requested therapy has not been demonstrated to be medically necessary for management of this patients condition.
The parent of a 7-year-old male enrollee has requested 25 hours of applied behavioral analysis therapy per week for treatment of the enrollees autism.  Findings:  The physician reviewer found that upon reviewing the medical literature, there are numerous studies addressing the functional benefits of ABA therapy. When ABA therapy was first initiated, some providers recommended that 40 hours per week was indicated but this was later reduced to 20 hours per week as a result of the burden of the intensity that the therapy puts on families and service providers. Since that time, additional studies have been conducted looking at low intensity (less than 20 hours per week) and high intensity (more than 20 hours per week) to further assess the outcome relative to additional hours of treatment. In addition, studies have been conducted to address the need for intensive behavior therapy versus standardized care. Overall, the scientific data is supportive of the utility of behavioral therapy and suggest that patients who receive this treatment show a statistical improvement in cognitive, language and adaptive behavior skills when compared to patients who were untreated. However, Spreckley and Boyds meta analysis of the literature found that appropriately powered clinical trials with broader outcomes are still needed to fully establish the role of ABA in managing young patients with ASD. The authors cited a study by Roberts, et al. which determined that for best results, a minimum of 20 hours per week of intervention over 2 years, taking into account of each patients strengths and weaknesses and family circumstances, is essential for young patients with ASD to make gainsWhile there is no literature specifically addressing the utility of 25 hours per week of ABA therapy, there is support for high intensity therapy of at least 20 hours per week. Therefore, based on the clinical documentation provided as well as review of the relevant scientific evidence, there is adequate support for 20 hours of ABA therapy per week for this patient.
A 56-year-old female enrollee has requested radiofrequency ablation/neurolysis of the sacroiliac joint and lumbar spine (including CPT codes 64622 and 64640) for treatment of her degenerative disc disease and sacroiliac joint dysfunction.  Findings:  Three physician reviewers found that this patient reported significant pain relief from the right sacroiliac (SI) joint injection, which is a clinical indication that she will benefit from the requested procedures. The available peer reviewed medical literature suggests that radiofrequency (RF) ablation of the SI joint is no longer investigational. Further, Ferrante and colleagues concluded that RF denervation has been shown to be efficacious for about six months of pain relief when used in patients with a successful SI joint injection. As this patient reported 100% pain relief with the SI joint injection and 50% or more relief at 6-week follow-up, she is an appropriate candidate for the proposed treatment.
A 60-year-old female enrollee has requested for chiropractic treatments for treatment of her cervical spondylosis and brachial neuritis.  Findings:  The physician reviewer found that the literature supports the effectiveness of manual therapy and spinal manipulative therapy for the management of chronic neck pain (Hurwitz, et al.). In addition, Wolsko and colleagues concluded that chiropractic techniques are commonly applied for the treatment of neck pain, and have been rated very helpful by patients. Moreover, Bronfort and colleagues reported positive outcomes with spinal manipulative therapy and mobilization for the management of low back pain.
The parent of a 14-year-old male enrollee has requested growth hormone (GH) therapy (Nutropin AQ) for the treatment of the enrollees growth hormone deficiency. Findings:  The physician reviewer found that this patients projected adult height could approximate six feet according to the Greulich and Pyle Hand Atlas Table. However, the patients endocrinologists letter indicates an annual growth velocity of 1.2 cm, which is subnormal. The stimulation testing showed subnormal GH responses. The records indicate the patient is overweight. Relative obesity is also associated with blunted GH responses, especially in a patient who is insulin-resistant. Based on the evidence provided, this is a patient who has markedly delayed puberty who appears to be destined to reach a normal adult height (given the heights of his parents). The objective documentation does not does not provide confirmatory evidence of the stated low growth rate of 1.2 cm per year. In this case, there is no documented evidence over time of an abnormally low growth rate; a valid growth rate requires height measurements of six to twelve months in duration, and not over a lesser period of time. The submitted records in this patients case do not support the medical necessity of Nutropin AQ.
The parent of a 15-year-old male enrollee has requested for subtalar arthroereisis surgery for treatment of the enrollees bilateral pes planus. Findings:  Two physician reviewers found that Subtalar arthroereisis has proven efficacy in the treatment of pediatric flatfoot with overpronation syndrome. One of the major benefits of the procedure is that it is minimally invasive and reversible. A study by Forg and colleagues reported on the use of the Smith subtalar arthroereisis implant (STA-peg) to correct severe collapsing pes valgoplanus in children. Twenty-one patients with a total of 40 STA-peg procedures were evaluated subjectively and objectively. The average age at the time of surgery was 9.7 years (4 to 16 years). The follow-up period averaged 36 months (12 to 90 months). The authors concluded that subjective, objective, and radiographic results were positive and the complication rate was low.
A 59-year-old female enrollee has requested cervical discography for evaluation of her neck pain and headaches. Findings:  Three physician reviewers found that the medical literature indicates that cervical discography is of equivocal help in terms of identifying a pain generator and predicting results from surgery. However, in this case, the patients history of chronic neck pain as well as associated fibromyalgia and multilevel degenerative findings on MRI are key factors. Regardless of the outcome of the multilevel discogram, this patient would be a poor candidate for cervical surgery.  Confirming a pain generator is particularly challenging given the comorbid diagnoses of fibromyalgia and chronic pain. For these reasons, the medical literature does not demonstrate that discography was indicated in this case, as it would not have been likely to alter the treatment plan
A 59-year-old male enrollee has requested intensity modulated radiation therapy for treatment of his recurrent prostate cancer. Findings:  The physician reviewer found that the medical literature does not support the clinical benefit of the administration of radiation to grossly positive lymph node metastatic disease after treatment with chemotherapy and hormone ablation. Radiation, specifically IMRT, for the treatment of metastatic adenocarcinoma in retroperitoneal lymph nodes is of unproven efficacy and not medically necessary in this setting. The standard of care remains chemotherapy or hormone ablation. For this patient, with metastatic disease, the requested local treatment is not likely to provide positive results and remains unproven in the medical literature.
A 43-year-old female enrollee has requested bariatric surgery including laparoscopic banding and revision of previous gastric restrictive procedure for the treatment of her morbid obesity. Findings:  The physician reviewer found that this patients records do not document a complication of the Roux-en-Y gastric bypass procedure. In addition, the patient admits to emotional eating since the Roux-en-Y procedure and a laparoscopic gastric band placed over the bypass will not necessarily prevent such cravings. Given the patients small pouch and lack of documented follow-up, aggressive dietary and behavioral counseling with exercise would be the next appropriate step in this setting. At this time, there is a paucity of studies regarding the long-term (greater than two years) outcome of patients who have undergone revision of previous gastric bypass. Thus, the proposed procedure remains of questionable efficacy and is indicated to remedy an anatomical failure of the previous surgery. In this case, anatomical failure is not demonstrated by the records provided.
A 59-year-old female enrollee has requested a follow-up visit with her gastroenterologist for the treatment of her chronic hepatitis B. Findings:  The physician reviewer found that This patient has chronic, active hepatitis B and is being treated with entecavir. Her hepatitis B viral load was negative in April 2009. Most primary care physicians are not familiar with the guidelines for the treatment of hepatitis B. The expertise and experience of gastroenterologists and hepatologists are needed for monitoring patients with hepatitis B. These specialists are familiar with antiviral therapy for hepatitis B, including the efficacy, resistance profile and stopping rules. These specialists also have the required expertise for monitoring for viral breakthrough and surveillance for hepatocellular carcinoma. Follow-up care with the patients gastroenterologist is medically appropriate and indicated.
A 28-year-old male enrollee has requested substance abuse inpatient care and acute detoxification for the treatment of his polysubstance dependence. Findings:  The physician reviewer found that the submitted clinical documentation does not demonstrate the medical necessity for continued acute inpatient/detoxification treatment. There is no report of a physical examination or vital signs documenting that the patient was unstable from a medical standpoint as of the last authorized date of service. In addition, although the records provide limited details regarding the detoxification protocol, it appears the patient had received five days of detoxification services. By the end of the period at issue, the patient reported feeling physical improvement. Thus, the submitted evidence does not establish that the patient was experiencing significant withdrawal symptoms during the period in question such that continued acute inpatient/detoxification services were required.
A 58-year-old female has requested speech therapy for the treatment of her habit cough. Findings:  The physician reviewer found that this patient has a chronic cough that had failed to be diagnosed and treated through prior extensive evaluation. Although her main complaint is the chronic cough, her history and examination show evidence of vocal straining with use of the false cords for phonation. Endoscopy showed significant plica ventricularis, which is a laryngeal function disorder caused by phonation of the ventricular folds (false folds) rather than the true vocal folds. The patients condition traditionally is responsive to speech therapy.  Given the patients laryngeal dysfunction, speech therapy is medically indicated and appropriate.
A 19-year-old female enrollee has requested acute inpatient psychiatric treatment for the treatment of her behavioral health problems. Findings:  The physician reviewer found that during her stay, several psychotropic medication adjustments were required. The overall medical documentation supports the level of care provided. The patient remained at risk for self harm, she was also highly anxious with nightmares and insomnia. The services provided are consistent with the recommendations of the American Psychiatric Association (APA), the level of care guidelines published by the American Academy of Child and Adolescent Psychiatry (AACAP) and the Association of Community Psychiatrists.
A 60-year-old female enrollee has requested for use of a real time heart monitor for evaluation of her atrial fibrillation.  Findings:  Three physician reviewers found that guidelines from the American College of Cardiology (ACC) in 2006 regarding the recommended treatment of PAF. The decision to anticoagulate the patient with aspirin versus Coumadin is typically made by assessing her risk factors such as age, valvular disease or CAD. Real time telemetry has not been shown to change the assessment of the need for anticoagulation. Electrocardiogram monitoring has been recommended in the assessment episodes of asymptomatic PAF or to judge the adequacy of rate control. However, the guidelines do not, as of yet, recommend a real time component to the monitoring. Prolonged or frequent monitoring may be necessary to reveal episodes of asymptomatic atrial fibrillation (AF), which may be a cause of cryptogenic stroke. Ambulatory ECG (i.e., Holter) monitoring is also useful to judge the adequacy of rate control. This technology may provide valuable information to guide drug dosage for rate control or rhythm management.
A 64-year-old female enrollee has requested therapeutic activities for the treatment of her low back pain. Findings:  The physician reviewer found that there is insufficient evidence in the literature to support the benefit of the prescribed program of computer-assisted exercise over standard physical therapy for chronic low back pain. In contrast, standard physical therapy including strengthening and stretching exercise, modalities, and transition to a home exercise program is more consistent with standard clinical practice, and as the literature suggests, may result in greater improvement in symptoms. The evidence does not demonstrate that computer-assisted exercise results in any added benefit over standard physical therapy for the treatment of low back pain.
The parent of an eight-year-old male enrollee has requested speech therapy for the treatment of the enrollees Aspergers disorder. Findings:  The physician reviewer found that the medical documentation indicates that the patients language development appears normal. A formal assessment noted that the patient had a normal voice, good fluency and articulation with low average to borderline expressive and receptive language skills. The submitted clinical documentation does not demonstrate that the patient had deficits in speech and language which necessitated speech therapy.
The parent of a 5-year-old male enrollee has requested  for an ultra-light wheelchair for treatment of his cerebral palsy. Findings:  The physician reviewer found that this non-ambulatory patient will likely remain non-ambulatory and will require supportive wheelchairs throughout his lifetime. The  literature also shows that transportation load is non-variable and a constant, nearly daily need for children with cerebral palsy. The literature also notes that transportation safety depends on adequate restraints and support which would require an ultra-light wheelchair to have the supportive system recommended by the patients physical therapist.
A 55-year-old female enrollee has requested for a spinal cord stimulator trial for treatment of her back and hip pain status post laminotomies and foraminotomies with nerve root and spinal canal decompression.  Findings:  Two physician reviewers found that the proportion of patients with intractable pain successfully managed with spinal cord stimulation (SCS) remains disputed. They analyzed 27 consecutive patients with intractable pain treated with SCS using identical hardware (Itrel II System) by a single satisfactory diagnosis. A rigid selection protocol was used including: 1) satisfactory diagnosis of the pathologic process resulting in pain; 2) corrective surgical procedure was judged not feasible by surgeons experienced in the particular pathology, (i.e., vascular peripheral nerve, spine); 3) lack of satisfactory response to non-interventional pain management modalities by an interdisciplinary pain clinic; and 4) independent psychological evaluation, including a structured interview was performed by a psychologist specializing in chronic pain management. In the last eight cases, a battery of self-report tests designed to assess psychosocial and behavioral consequences of the chronic pain problem were administered as well. All cases were of nonmalignant pain, except for one patient. Thirteen cases were diagnosed with failed back surgery syndrome (FBSS), one older patient with lumbosacral radiculopathy who refused decompression, one patient with cervical radiculopathy and Klippel-Feil syndrome, six with reflex sympathetic dystrophy (RSD), two with peripheral vascular ischemic disease, one with post-thoracotomy pain syndrome, one with leg pain following resection of angiolipoma, one with traumatic superficial peroneal neuropathy, and one with Pancoast's tumor. All patients underwent a three day trial screening with Pisces-Quad/Resume epidural leads connected to a temporary external stimulator. An Itrel II System pulse-generator was internalized in each of the 24 patients who had successful trials (3 cervical and 21 thoracic-lumbar). There was no morbidity. Pain reduction was sustained in 22 out of the 24 patients who continued to use the stimulator. The same number would choose to receive an electrical stimulator again. Normalization or improvement in Quantitative Sudomotor Axon Reflex Test (Q-SART) and Thermography were documented in the patients with RSD. They concluded that rigid selection protocol can maximize the proportion of patients with intractable pain who are successfully treated with SCS. Strict neurosurgical technique eliminates infection risk. Hardware selection minimizes incidence of malfunction.