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

A 42-year-old female has requested an MRI for evaluation of her knee pain.  Findings:  The physician reviewer found that the peer-reviewed medical literature does not support MRI of the knee for this patient who presents with non-traumatic knee pain.  The American College of Radiology does not recommend MRI of the knee as an initial imaging study.  As noted by Miller, if imaging is required, an initial radiographic (x-ray) examination should be ordered.  Miller noted that MRI of the knee is only indicated for pain without mechanical symptoms if unexplained pain persists for three to six weeks. This patient presented with non-traumatic knee pain, and she has not had a trial of conservative care, such as NSAIDs, a home exercise program, or physical therapy.  Additionally, the medical records do not demonstrate that radiographs of the knee were performed.  The submitted documentation fails to establish the medical necessity of the requested diagnostic procedure.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patients parent has requested authorization and coverage for speech therapy services for one hour per week. Findings:  The physician reviewer found that the records provided for review document a diagnosis of autism. Given this diagnosis, the patient is at risk of impairment in social interaction with his peers. The treating speech therapist reported that the patient continues to make progress towards goals, and he should continue speech therapy sessions once a week. The provider charted that the patient has difficulty expressive language, as well as use of appropriate sequencing during play, familiar activities and narratives. The patients goals include generation of appropriate questions with moderate verbal and/or visual cues in order to maintain the conversation, when engaged in conversation with an adult on an unfamiliar topic, in three of five opportunities. In a meta-analysis of pragmatic language interventions for children with autism spectrum disorder, Parsons and colleagues reported that deficits in pragmatic language affect patients with autism throughout childhood necessitate effective, evidence-based interventions that can minimize the isolating, and long-term impacts of pragmatic language difficulties. All told, the requested speech therapy services for one hour per week are medically necessary for 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 neurology with special qualification in child 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: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the radiofrequency ablation (RFA) of the sacroiliac (SI) joint. In the documentation available for review, the provider states the patient had two days of pain relief after doing an injection with steroids. However, the literature indicates that RFA may be effective if performed after a diagnostic block with local anesthetic alone and a pain diary with notations of medication usage. This patients records do not include documentation that this protocol was followed. In addition, the most recent physical examination is not specific to SI joint dysfunction. Finally, there is no documentation of a home exercise program, physical therapy, or other conservative, non-invasive and non-pharmacological, treatment options in the records provided for review. Therefore, the RFA of the SI joint performed was not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Findings:  Three physician reviewers found the RFA of the SI joint performed was not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the RFA of the SI joint performed was not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Credentials/Qualifications: Physician reviewers 1, 2 and 3 are board certified in anesthesiology with sub-specialty certification in pain medicine and are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

The patient is an 11-year-old male who has a diagnosis of idiopathic short stature. He had a growth hormone stimulation test in November 2004, which had a normal response. A radiologic report found the patient had a bone age reading of 8 years at the chronologic age of 10 years 8 months. The consulting pediatric endocrinologist indicated the patient had a bone age of 9 years and 6 months at the chronologic age of 10 years 1 month. By calculating the patients predicted adult height based on each x-ray reading using Greulich & Pyles Radiographic Atlas of Skeletal Development of the Hand and Wrist, the respective final height predictions differ by less than 2 inches, (65 inches using a bone age of 9 years 6 months and 66 inches using a bone age of 8 years 10 months). The patient began receiving growth hormone therapy in February 2005. His parents are requesting coverage for continued growth hormone therapy. The Health Plan has denied this request on the basis that the requested therapy is not medically necessary for treatment of the patients condition.The patients clinical history and laboratory findings are not consistent with the accepted diagnosis of idiopathic, isolated growth hormone deficiency. However, the patients stature is below the 5th percentile and less than -2 standard deviations below the mean for his age, as well as less than 2 standard deviations below his expected mean parental height. Additionally, his growth velocity was 3.6 cm per year prior to starting therapy at around the 3rd percentile for his age. Furthermore, there is an absence of a specific conservative process. These findings suggest a diagnosis of idiopathic short stature as the most likely etiology for the patients small size, slow growth and low growth hormone dependent proteins. The Food and Drug Administration has recently approved growth hormone for the treatment of idiopathic short stature as a medically indicated therapeutic intervention to promote growth velocity and final adult height. Thus, given the available evidence-based data, it is medically reasonable and appropriate for the patient to continue to receive growth hormone therapy until he has completed a 12-month trial of therapy with close monitoring of his height response. It is essential, however, that the patients pubertal development be periodically evaluated because of his age and the potential for the onset of puberty to confound his growth velocity response to growth hormone. 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: Experimental/Investigational
Decision: Upheld

A 60-year-old male enrollee has requested chiropractic care (including intersegmental traction, massage, joint manipulation, or spinal manipulation) for treatment of his muscle rigidity secondary to Parkinsons disease.  Findings:  Three physician reviewers found that after careful review of all submitted documentation, there is insufficient clinical documentation that supports the clinical indication for the requested chiropractic services. The submitted notes from the provider are vague and lack all clinical/record keeping requirements for chiropractic care. The provider fails to establish that the patients treatment plan is beneficial for his diagnosis or that the services are more beneficial than standard alternatives. Specifically, the submitted documentation of the physical examination and subsequent visits lacks documentation of any evaluation of the patients musculoskeletal/nervous system, documentation of duration and frequency of visit, indication of treatment goals and objective measures evaluating the patients response. Moreover, there is no evidence of incremental improvement from visit to visit in terms of activities of daily living or functionality. According to the Council on Chiropractic Practices and the Centers for Medicare and Medicaid Services (CMS), the treating provider is expected to keep and maintain adequate case records showing progression of care, diagnosis, clinical impressions, assessment of the patients condition, and treatment effectiveness. However in this case, the provider has not shown that the treatments provided this patient with muscle rigidity caused by Parkinsons disease have been or are more likely to be more beneficial than standard therapies.
Appeal type: Urgent Care
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for emergency medical services.Findings:  The physician reviewer found that the services at issue were necessary for treatment of an emergency medical condition. In this case, the patient presented with a gradual decompensation of his PANDAS condition, demonstrating a decrease in cognitive function and school performance, with an inability to focus, worsening fatigue, increase in tics, and increase in obsessive compulsive tendencies. The standard of care for managing PANDAS exacerbation, includes obtaining the Cunningham Panel for diagnostic purposes and administration of IVIG. The Cunningham Panel provided, met the criteria for emergency medical services. The Cunningham Panel showed abnormal findings for anti-D1 receptor, which is twice the level of normal and abnormal level of calmodulin kinase II, which is 155% of normal. The laboratory abnormalities were evidence of disruption of the blood-brain barrier and were indicative of substantial elevation of inflammation in the basal ganglia, therefore representative of an exacerbation in PANDAS condition and neuroinflammation. Moreover, the return of specialty labs and review of those findings and discussion about the next level of care can take a period of time.  It is typically usual to have a minor delay in time for this review and discussion between provider and patient to occur.  As such, the IVIG services provided were emergent. For the reasons provided, emergency medical services provided were necessary for an emergent medical condition.Final Result: The reviewer determined that the patient received emergency medical services on the date of service at issue. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in allergy and immunology 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 enrollee requested coverage for the medication hydroquinone. The enrollee has been diagnosed with hyperpigmentation of the skin on her face due to acne. She has a history of treatment for acne. She reported she has used Hydroquinone in the past with good results. On examination, the physician reported pustular acne on the face with some scarring and hyperpigmented patches on her chin, cheeks, and neck. The enrollee reports that she has heavy acne with dark spots and the only medications that help treat her acne are hydroquinone and tazoratene and without these two creams her acne will never heal. According to the American Academy of Dermatology Acne Guidelines and dermatology literature, hydroquinone is not medically necessary for the treatment of the enrollee's post-inflammatory hyperpigmentation. The evidence-based literature is consistent. After review of the medical record provided, there is no documentation that would justify the enrollee requiring treatment with hydroquinone.Final Result: The reviewer determined that the requested service is not medically necessary for the treatment of the enrollees medical condition.Credentials/Qualifications: The physician 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 similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for transoral incisionless fundoplication procedure using EsophyX device for treatment of the enrollees long segment Barretts esophagus. Findings:  The physician reviewer found that the efficacy of transoral incisionless fundoplication has been studied in randomized controlled trials. However, there is paucity of medical literature demonstrating improved health outcomes in this clinical setting. One large randomized trial including 60 patients found no improvement in esophageal acid exposure compared with baseline at 12 months. The American College of Gastroenterology (ACG) guidelines for treatment of GERD reported that the usage of current endoscopic therapy or transoral incisionless fundoplication cannot be recommended as an alternative to medical or traditional surgical therapy. In addition, the Society of American Gastrointestinal and Endoscopic Surgeons reported that numerous published series have reported significant adverse events and that there is a lack of sham-controlled trials comparing transoral incisionless fundoplication with anti-reflux surgery. Moreover, the guidelines from the American Society for Gastrointestinal Endoscopy (ASGE) do not recommend endoscopic procedures for GERD in patients with complicated GERD, which the guideline defines as dysphagia or Barretts esophagus. These conclusions are bolstered by recent reports of severe adverse events during the procedure and the need for surgery to revise ineffective transoral incisionless fundoplication. Final Result: The reviewer determined that the requested procedure 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 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: Upheld

The parent of a female enrollee requested Botox injections (Xeomin) for medical treatment of the enrollees post-concussion migraines.  Findings:  Two physician reviewers found that Botox has been well studied in treatment of chronic migraine and there is evidence that Botox injections can be of benefit in treatment of chronic migraine consequent to TBI. However, Xeomin is a different product, with no indication for chronic migraine. According to Xeomins prescribing information insert The potency units of Xeomin are not interchangeable with other preparations of botulinum toxin products. There is a lack of data in the peer-reviewed literature supporting Xeomin for chronic migraine. Based on the peer-reviewed literature and clinical documentation provided, the requested Botox injections (Xeomin) are not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Vascepa (icosapent ethyl) 1 gm oral capsules. In this primary prevention setting, studies suggest there is a benefit to lowering triglycerides in patients with established coronary artery disease. In this patients case, the records document a pretreatment triglyceride level of 708 mg/dL in August 2018 but do not substantiate pre-existing coronary artery disease. On this date, hemoglobin A1c level was 9.5%, indicating poor diabetic control as the likely cause of hypertriglyceridemia. She had a mildly elevated low-density lipoprotein (LDL) level of 107 in May 2020, which suggested that medication to further lower LDL levels may be more important for the treatment of this patient than medications to lower triglyceride levels. In this clinical setting, the requested medication is not medically indicated. Therefore, Vascepa (icosapent ethyl) 1 gm oral capsules are 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 internal medicine with sub-specialty certification in cardiovascular disease and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for a magnetic resonance neurography (MRI pelvis, 72197, MRI spinal 72158). One newer magnetic resonance imaging (MRI) sequence, magnetic resonance neurography, has emerged extending the range of conventional MRI techniques. The advanced sequences are able to provide detailed information, including the course and function of individual neural fascicles. These data are utilized to tailor a suitable surgical procedure, reducing the risks of postoperative neurological deficit. This patient presented with a left sciatic nerve sheath tumor. The provider recommended evaluation with magnetic resonance neurography to locate the fibers of the sciatic nerve in preparation for surgery. Given the value of this technique, the magnetic resonance neurography (MRI pelvis, 72197, MRI spinal 72158) was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Findings:  Two of the three physician reviewers found the magnetic resonance neurography (MRI pelvis, 72197, MRI spinal 72158) was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Final Result: The reviewers determined that the services at issue were likely to be more beneficial for 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 neurological surgery and are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

The patient is a 41-year-old female who weighs 373 pounds and is 55 tall with a BMI of 62.1. In addition, she has comorbid conditions of sleep apnea and arthritis. She has undergone a psychological evaluation and is considered an appropriate candidate for bariatric surgery. She has requested authorization and coverage for gastric bypass surgery. The Health Plan has denied this request indicating the patient has not undergone a six-month supervised weight loss program and therefore, does not meet plan criteria for the requested procedure.With a BMI of over 60 the patient meets nationally accepted criteria for consideration of weight loss surgery. In addition, it is unlikely that the patient will be able to lose weight and maintain the weight loss through non-surgical means. There is no scientific evidence demonstrating that structured diet or exercise plans have been successful in the treatment of the obese. In fact, the Swedish obesity study identifies that even though there may be reduction or resolution of some symptoms with diet and exercise, surgery has the longest and best long-term outcome for the obese. Furthermore, the patient has undergone an appropriate psychological evaluation and is considered an appropriate candidate for weight loss surgery.Based upon the information set forth above, I have determined that the requested procedure is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Opsumit for treatment of the enrollees pulmonary arterial hypertension.  Findings:  The physician reviewer found that Current guidelines and studies have demonstrated improved health outcomes in pulmonary arterial hypertension patients who are initiated on double therapy. In addition, the U.S. Food and Drug Administration (FDA) approved a new endothelin receptor antagonist Opsumit after the SERAPHIN trial which demonstrated reduction in pulmonary arterial hypertension worsening (Pulido, et al). The majority of patients were taking a PDE inhibitor and prostanoid and remained on triple therapy throughout the study. Triple therapy has become the mainstay of therapy for pulmonary arterial hypertension patients with Class III to IV symptoms in order to address to all three pathways of disease. This patient was already treated with triple therapy and switching to a newer endothelin receptor antagonist (ERA), Opsumit from Tracleer, may benefit this patient. Thus, the requested treatment with Opsumit is supported as medically necessary for treatment of this patients medical condition. 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 sub-specialty certifications in pulmonary disease and critical care 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.