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

A 55-year-old male enrollee requested authorization and coverage of a Cox-II medication (Celebrex, Vioxx or Bextra). The Health Plan denied the request indicating that the requested medication is not medically necessary for treatment of the enrollees shoulder tendonitis.One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer overturned the Health Plans denial on the basis that the requested medication is medically necessary.
Appeal type: Experimental/Investigational
Decision: Upheld

A 43-year-old male enrollee has requested transcranial magnetic stimulation (TMS)for treatment of his major depression, recurrent. Findings:  Two physician reviewers found that there are no medical records available for review in this case.  There is also no mention as to whether the patient has tried any type of psychotherapy.  He has several psychiatric diagnoses listed in the records provided.  His medication trials have caused intolerable side effects.  The patient feels his psychiatric symptoms were not improved during the above medication trials. However, his psychiatrist noted that the patient did have some relief of his depression. It is difficult to tell if the trauma that caused his post-traumatic stress disorder may be causing many of his depressive symptoms.  It is also very likely that his medical problems and fibromyalgia may be causing or worsening his mood symptoms.  There is a lack of TMS studies that include patients that have as many comorbid conditions as this patient.  TMS has been shown to be effective in depression.  However, there is a lack of evidence indicating that it would benefit a patient with his history.  A vast majority of the studies done on TMS have excluded patients such as him due to the length of his depression alone. There are variable results available in the literature regarding TMS. This patient does not fit into the category of the vast majority of patients who have been successfully treated so far with TMS(Schutter).  Issues around duration of treatment effectiveness, type of stimulation, and use of this modality as a monotherapy versus an adjunct remain ill-defined. Further, medication-resistant patients often show small to moderate improvement and are more often vulnerable to relapse(Schutter). The fact that he and his psychiatrist disagree as to whether past medications were actually helpful to him indicates that he may be medication-resistant, even to numerous medications.  Therefore, there is little hard evidence that in his situation TMS would be more beneficial than standard therapies.
Appeal type: Urgent Care
Decision: Upheld

A 29-year-old female  has requested coverage for emergency services provided. Findings:  The physician reviewer found that the patient had a history of endometriosis and ovarian cysts and was status post left oophorectomy. She presented to the emergency room (ER) with a chief complaint of heavy menstrual bleeding for 11 days. Per the ER records, the patient was not in any pain (pain level was documented as 0 on a scale of 1 to 10) but did feel a bit dizzy.  Upon physical exam it was noted that the patient did not appear to be in any obvious distress, the abdomen was benign, and the pelvic exam was benign with minimal blood present. The patients vital signs were normal, she was not pregnant, and she was not anemic. She was diagnosed with dysfunctional vaginal bleeding. No treatment was rendered in the ER or at the time of discharge, and the patient was instructed to follow-up with her primary care provider the next day. The patient flew to Hungary the day after presenting to the ER where her symptoms continued. One week after having been seen in the ER, she was admitted to a hospital in Hungary where dilation and curettage (D&C) was performed. The diagnosis was metrorrhagia (dysfunctional vaginal bleeding). The D&C was effective in stopping the patients uterine bleeding. At issue in this case is whether a prudent layperson in the patients circumstances would have sought immediate medical attention on the date at issue. California law defines an emergency medical condition as a medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain) such that the absence of immediate medical attention could reasonably be expected to result in any of the following: (1) Placing the patients health in serious jeopardy; (2) Serious impairment to bodily functions; (3) Serious dysfunction of any bodily organ or part.Review of the submitted evidence demonstrates that the patient had prolonged menstrual bleeding diagnosed by her medical providers at both the ER and at the hospital in Hungary. The submitted medical records indicate that at the time she was seen in the ER she was not in pain, did not have a fever, and was not passing out. The patients husband reports that he and his wife were leaving on a trip to Hungary the next day and therefore they wanted a physician to check the patients condition prior to proceeding with their travel plans. The patients examination could have taken place in an alternate setting and did not require immediate medical attention in an emergency department. All told, a prudent layperson would not have thought this to be an emergency medical condition and would not have sought immediate medical attention on the date at issue.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Zilretta injections (every four months in both knees). The U.S. Food and Drug Administration approves the use of Zilretta, an extended-release synthetic corticosteroid, as an intra-articular injection for the management of osteoarthritis pain of the knee. Zilretta relieves the pain of osteoarthritis of the knees and improves function by means of its slow release into the synovium and articular cartilage of the knee, providing a longer lasting benefit and avoiding harmful effects on the articular cartilage and systemic effects such as elevation of the blood sugar level. Palik and colleagues note that repeat administration of triamcinolone acetonide extended-release may be similarly efficacious to an initial injection without having deleterious effects on cartilage or other aspects of joint structure. In this case, the patient has osteoarthritis of the bilateral knees, previously treated with viscosupplementation and Zilretta. The patient reported a preference for Zilretta based on the degree of pain relief. X-rays documented the presence of chondrocalcinosis, or calcium pyrophosphate deposition disease, which benefits from steroid injections. In this clinical setting, the requested services are medically indicated. Therefore, Zilretta injections (every four months 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: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary:  An enrollee has requested genetic testing for evaluation of her type A aortic dissection.  Findings:  Three physician reviewers found that genetic testing was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. In this case, the patient sustained an aortic dissection at a young age. The medical literature shows that mutations in genes causing aortopathy are found in a minority of patients who do not meet clinical criteria for Marfan syndrome. When mutations are identified in specific genes known to be associated with dissection and rupture at much smaller aortic sizes than typically associated with Marfan syndrome (MYLK, ACTA2, TGFBR1, TGFBR2), this justifies early pre-emptive surgical intervention to prevent dissection. Therefore, genetic testing results could impact medical management of this patient with resulting improvement in health outcome.  Final Result: Three 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:   One reviewer is board certified in cardiovascular disease and is actively practicing.  Two reviewers are board certified in clinical genetics and clinical biochemical genetics 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: Medical Necessity
Decision: Overturned

A 64-year-old female enrollee requested authorization and coverage of an MRI of her right breast for the treatment of breast pain  related to an implant placed post mastectomy in 1992. 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 overturned the health plans denial on the basis that the requestedMRI is medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: a parent of an enrollee has requested authorization and coverage for 40 hours per week of direct applied behavioral analysis (ABA) therapy, eight hours per month of supervision and six hours per month of parent training. Findings:  The physician reviewer found that according to the documentation submitted for review, the patient has problematic behaviors which include tantrums, aggression, and vocal scripting. The patient has difficulty matching pictures with objects and requires a significant amount of modeling and direction at school. Failure to master these skills puts the patient at an increased risk for injury, and makes it difficult to be successful in more generalized environments. The Behavior Analyst Certification Board states that typical comprehensive ABA programs range from 30 to 40 hours of treatment per week. Final Result: The reviewer determined that the requested services at issue 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 pediatrics with sub-specialty certification in developmental-behavioral 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.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for a tricycle (Liberty Trike, 750-watt folding scooter/tricycle). The documentation does not reveal that a tricycle (Liberty Trike, 750-watt folding scooter/tricycle) is medically necessary for this patient. The records do not include an objective evaluation of the patients gait, a musculoskeletal examination, or a neurologic examination that indicate the patient has a mobility related deficit requiring the requested tricycle. The provider does not report that the patient has a deficit that it is unable to be safely resolved with the use of an appropriately fitted cane or walker. Moreover, the records do not describe that the patient is unable to perform mobility related activities of daily living (MRADLs) without an assistive device, or that the patient is able to safely navigate the requested tricycle in the van in which he lives to complete MRADLs. For these reasons, the requested tricycle (Liberty Trike, 750-watt folding scooter/tricycle) is not medically necessary for this patient.Final Result: The reviewer determined that the requested device 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 physical medicine and rehabilitation with subspecialty certification in neuromuscular 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: Experimental/Investigational
Decision: Upheld

A 58-year-old female enrollee has requested endoscopic injection implant for treatment of her urinary incontinence.  Findings:  Three physician reviewers found that there is limited evidence in the published peer-reviewed medical literature that supports the use of transvaginal radiofrequency bladder neck suspension as a treatment for female stress urinary incontinence. In addition, there are little data demonstrating the efficacy of its use after sling failure. The safety and long-term efficacy of transvaginal radiofrequency bladder neck suspension on health outcomes is limited and randomized controlled studies with longer follow-up are needed. All told, the requested endoscopic injection implant  is not likely to provide this patient with greater benefit than standard alternatives.
Appeal type: Medical Necessity
Decision: Upheld

A 55-year-old female enrollee has requested for surgical resection of lung nodules through a clamshell incision or stage thoracotomies for treatment of her adenocystic carcinoma.  Findings:  The physician reviewer found that the decision to approach by a single operative approach (clam-shell) or separate bilateral thoracotomies is not relatively significant, since they would be considered to be essentially equivalent. Although a biopsy has been recommended, the radiologic appearance is very consistent with metastatic disease, and this seems most likely. The question is whether to proceed immediately to surgery to provide a survival benefit (especially as the patient is currently asymptomatic).
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for left cervical transforaminal epidural steroid injections at C5-6 and C6-7. Multiple prospective randomized studies have demonstrated the benefit of transforaminal epidural steroid injections to improve pain and disability in patients with cervical foraminal stenosis. The records document that this patient has cervical foraminal stenosis at C5-6 and C6-7 on the left. Based on the records, there is evidence that the patients medical condition is generated by the foraminal stenosis at C5-6 and C6-7. However, the confidence in this assessment is confounded by the patients history of thoracic outlet syndrome, which could produce similar symptoms. There are therapeutic benefits to treatment with cervical transforaminal epidural steroid injections in the treatment of radicular symptoms. In addition, cervical epidural steroid injections can help determine whether a patients pain is significantly reduced when performed at a specific level. This has implications for future treatment including possible surgical interventions. Given this support, the left cervical transforaminal epidural steroid injections at C5-6 and C6-7 were medically necessary for treatment of this patient. Final Result: The reviewer determined that the services at issue were 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 physical medicine and rehabilitation 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: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for facial feminization services. Facial feminization surgery is medically necessary for many transgender women to help alleviate the psychological distress they experience related to gender dysphoria. The World Professional Association for Transgender Health (WPATH) supports facial feminization surgery to help remedy an incongruent physical appearance and gender identity. In addition, WPATH noted that non-genital surgical procedures, especially facial feminization procedures, are of greater practical significance in a patients daily life than reconstruction of the genitals. The guidelines further report that these reconstructive procedures are not optional in any meaningful sense, but are understood to be medically necessary for the treatment of the diagnosed condition. Studies demonstrated that facial feminization surgery, like genital surgery, improved patients mental health-related quality of life. The records provided for review include documentation from several providers who support the patients facial feminization surgeries as medically necessary to help alleviate her significant discomfort due to the masculine features of her face. Given these findings, the facial feminization services  were medically necessary for treatment of this patient. Final Result: The reviewer determined that the services at issue were 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 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: Overturned

A 60-year-old male requested authorization and coverage for a liver transplant evaluation.  The health plan has denied this request indicating that the requested evaluation is not medically necessary for treatment of the enrollees liver cancer.One physician reviewer performed a medical necessity Independent Medical Review.  The physician reviewer overturned the health plans denial on the basis that the requested evaluation is medically necessary.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested sestamibi parathyroid scan for evaluation of her medical condition.  Findings: Three physician reviewers found that the sestamibi parathyroid scan was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The sestamibi parathyroid scan is the standard of care in this clinical setting. In this case, the localization study confirmed the location of the adenoma and hence made the surgery technically easier and less invasive. The scan allows the treating provider to confirm the location of the adenoma. In sum, the study is a standard procedure for localization and confirmation of diagnosis. All told, the services at issue were likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Final Result: Three 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: All three physician reviewers are board certified in internal medicine with sub-specialty certification in endocrinology and metabolism 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: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for bilateral knee replacement surgeries. Researchers concluded that the risk-to-benefit for total knee arthroplasty favors patients who have intense or severe symptoms of knee osteoarthritis, are at least 55-years-old, have limited mobility, and have a body mass index (BMI) less than 40 kg/m2. The authors concluded that outcomes are substantially less favorable for patients who have slight or moderate symptoms and functional loss. This patient is being treated for bilateral knee osteoarthritis. The patient reports persistent knee pain. X-rays demonstrated osteoarthrosis especially at the medial compartment, mild to moderate, left more than right, with joint space narrowing. However, detailed documentation is not evident regarding updated physical examination findings for the left and right knees. There is a lack of data regarding trial and failure of recent, reasonable and comprehensive less invasive conservative care measures. Furthermore, the patient is noted to be obese with a BMI over 45 kg/m2, without evidence of a comprehensive trial and failure of BMI management. Therefore, the requested bilateral knee replacement surgeries are not medically necessary for 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 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

A 53-year-old female enrollee has requested coverage for skilled nursing facility services from a specific date and forward for treatment of her medical condition status post knee replacement surgery. Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the services at issue in this patients case.  Per Medicare guidelines, discharge is appropriate when treatment can be provided at a lower level of care.  This patient has been documented as modified independent in transfers, bed mobility, and ambulation, with a similar level of function in activities of daily living.  In this patients case, she received care in a skilled nursing facility, with good outcomes.  In this clinical setting, the time for recovery for discharge averages between six and ten days.  This patient does not require daily skilled therapy to restore or maintain function.  Continued improvement in function can be achieved with continued exercise without daily supervision from a skilled therapist.  Per the medical records, there are no daily skilled nursing needs.  All told, continued skilled nursing facility services from the date in question and forward were not and are not medically indicated.