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

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for lumbar/sacral facet joint injections. Findings:  The physician reviewer found that This patient presents with chronic low back pain from multiple etiologies including spinal stenosis and facet hypertrophy noted at L4-5 and L5-S1 on MRI. The provider reported increased pain with facet loading on physical examination. Facet arthropathy is likely a contributing etiology to the patients chronic pain. While other etiologies are likely causing his radicular symptoms, the patients facet hypertrophy is contributing to his axial back pain. In this clinical setting, the medical literature supports use of diagnostic medial branch blocks to assess facet hypertrophy as a contributing etiology for the patients chronic pain. Therefore, the requested lumbar/sacral facet joint injections are medically necessary for this patient. Final Result: The reviewer determined that the requested services are medically necessary for evaluation of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in anesthesiology with subspecialty certification in pain management 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 female enrollee requested Percocet and embolization of pelvic varices for medical treatment of her abdominal pain.  The physician reviewer found that according to the documentation submitted for review, the patients abdominal symptoms may be related to chronic opioid use which was initiated for the treatment of knee pain.  The clinical picture of her severe abdominal pain began after a period of chronic and escalating opiate use status post knee surgery, and the opioids given for pain treatment may be a contributor to her pain. All told, the request for the embolization of pelvic varices and Percocet is not supported as medically necessary.
Appeal type: Experimental/Investigational
Decision: Upheld

A 46-year-old female enrollee has requested spinal nerve treatment (radiofrequency neurolysis) for treatment of her pain. Findings:  Three physician reviewers found that in this patients case, the services at issue were not likely to have been superior over other available treatment options.  There is a lack of support for the services at issue in this clinical setting.  Niemisto and colleagues conducted a review assessing the efficacy of radiofrequency denervation for the treatment of musculoskeletal pain disorders.  The authors noted that there was limited evidence indicating that radiofrequency denervation offers short-term relief for chronic cervicobrachial pain and chronic neck pain of zygapophyseal joint origin.  The reviewers concluded that there was a need for further high-quality randomized controlled trials with larger patient samples.  Thus, there is a need for additional well-designed randomized controlled trials demonstrating the efficacy of the services at issue.  All told, spinal nerve treatment (radiofrequency neurolysis) was not likely to have been of greater benefit than other treatment modalities.
Appeal type: Medical Necessity
Decision: Upheld

The patient is a 17-year-old female whose parent has requested authorization for augmentation mammaplasty. The patient was seen and evaluated by a plastic surgeon. The submitted notes indicate the patient has a lack of fullness of the left breast with approximately an 80cc difference between the left breast and right breast. The Health Plan has denied authorization for the requested procedure on the basis that it is not medically necessary.Review of the submitted records and photographic evidence of the patient demonstrates no medical necessity for augmentation mammaplasty. The patient has been examined by a plastic surgeon without findings of medical necessity for augmentation mammaplasty. There is no indication that the requested procedure is medically warranted in order to treat clinical symptoms or functional complaints. Therefore, I have determined that the requested procedure is not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for computed tomography (CT) coronary angiogram. This patient presented with increased coronary risk and a screening stress test that reported no chest pain and mild non-diagnostic electrocardiographic changes. In this circumstance, if further evaluation for coronary ischemia were thought to be medically necessary, some form of imaging stress test would be most appropriate. Coronary CT angiography defines anatomy only and does not assess the functional significance of any potential stenosis that may be identified, and thus cannot assess for coronary ischemia.  Moreover, current guidelines on the evaluation and management of dyslipidemia do not recommend routine performance of coronary CT angiography to help guide lipid therapy since treatment change based on CT results has not been shown to incrementally improve outcome compared to treatment based on clinical risk and standard lipid analysis alone.  All told, the requested coronary CT angiogram is not medically necessary for the evaluation of this patient.Final Result: The reviewer determined that the requested services are not medically necessary for evaluation 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: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Xyrem 500 mg/mL for treatment of the enrollees narcolepsy. Findings:  The physician reviewer found that review of the submitted documentation and relevant literature fails to demonstrate the medical necessity of the requested medication. The records provided for review do not support a diagnosis of type 1 or type 2 narcolepsy. The records indicate that the patient has a diagnosis of obstructive sleep apnea for which the patient has been prescribed and initiated on CPAP. The medical records do not contain the results of a multiple sleep latency test (MSLT) conducted in accordance with current practice guidelines that is required to establish a diagnosis of narcolepsy. The records provided for review do not include reports of any hallmark symptoms of narcolepsy besides the mention of excessive daytime sleepiness. As such a diagnosis of narcolepsy is unable to be established based on the documentation provided for review. Xyrem is U.S. Food and Drug Administration (FDA) approved for the treatment of narcolepsy, and it is not supported for patients with excessive daytime sleepiness. Given that the records provided for review do not establish a diagnosis of narcolepsy based on current diagnostic criteria the use of Xyrem cannot be determined to be clinically appropriate for this patient. Therefore, the request for Xyrem 500 mg/mL has not been established as medically necessary for treatment of the patients medical condition. .Final Result: The reviewer determined that the requested medication is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in neurology with sub-specialty certification in sleep medicine and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary:  An enrollee has requested Praluent injections every two weeks for treatment of her medical condition.  Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested medication.  This patient has hyperlipidemia, although the documentation does not support known coronary disease or familial heterozygous or homozygous hyperlipidemia.  Familial hypercholesterolemia usually manifests by a combination of physical exam findings low-density lipoprotein (LDL) cholesterol levels that are at minimum above 180 mg/dl.  This is not documented in the medical records provided.  Praluent is a PCSK9 inhibitor studied in and approved for patients with heterozygous familial hypercholesterolemia or for patients with documented atherosclerotic heart disease who require additional lowering of LDL cholesterol.  The medical records do not support the patient meets any of those criteria.  PCSK9 inhibitors have not been studied in other patient populations such as this patient.  Current guidelines which are endorsed by several national organizations do not recommend the use of PCSK9 inhibitors in this primary prevention setting.  Finally, there are other statin medications which have lower side effect profiles and have not been documented to be tried or not tolerated in this patient.  All told, the requested Praluent injections every two weeks is not medically indicated 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: Medical Necessity
Decision: Overturned

The parent of a 13-year-old male enrollee has requested continued growth hormone (GH) therapy for the treatment of the enrollees pituitary dwarfism. Findings:  The physician reviewer found that the patient has a clear medical need for GH therapy together with replacement of other pituitary hormone deficiencies. His excellent response to GH therapy is not an appropriate basis for discontinuing the treatment. The patients prospects for reaching his mid-parental height of 65.5 are good with continued GH supplementation. GH therapy should continue until the patient has had epiphyseal closure and growth arrest.
Appeal type: Medical Necessity
Decision: Upheld

A 21-year-old female enrollee has requested for continued Skilled Nursing Facility (SNF) stay for treatment of her femoral fracture status post spiral osteotomy of the femur and intramedullary fusion.   Findings:  The physician reviewer found that that there is insufficient evidence to support on-going therapy. She made no meaningful clinical progress. The physical therapy notes assert that the patient is making progress and needs more intensive therapy. However, this assertion is not supported with comparable findings.
Appeal type: Medical Necessity
Decision: Overturned

The parent of an 11-year-old male has requested coverage for speech therapy services for treatment of the enrollees Down syndrome and oral phase dysphagia.  Findings: The physician reviewer found that speech and language therapy is noted as one of the most important parts of intervention services for children with Down syndrome (Buckley, et al.) The goals of speech therapy in this patient population include improving the quality and quantity of everyday communication and the need to work on specifically targeted activities for speech and language skills. Expressive (verbal) language in children with Down syndrome tends to be more delayed than cognitive and receptive language skills (Cohen). Appropriate communication techniques are recommended as part of a total communication approach to overcome problems with verbal expression and improve communication in general. A paper by Baum notes that ongoing speech therapy is advised as part of accepted health supervision guidelines for children and adolescents with Down syndrome. Some children continue to require weekly individual sessions with a therapist who has knowledge and skills to address the childs profile of difficulty for speech. In the case of this patient, therapy notes demonstrate that he has made some progress with speech therapy in the past. As such, additional speech therapy services are medically appropriate and necessary for treatment of the patients continued speech and language deficits.
Appeal type: Urgent Care
Decision: Upheld

A then 36-year-old female enrollee has requested reimbursement for services provided in Hong Kong. The Health Plan has denied this request indicating the services at issue were not required on an urgent basis for treatment of the enrollees uterine fibroids.  Findings:  The physician reviewer found that the patient was traveling out of the country in Hong Kong. The patient reports that she developed abdominal pain, difficulty with urination and excess bleeding. According to the provider in Hong Kong, the patient presented with uterine fibroid with difficulty in urination and abdominal pain and her symptoms could not be relieved by conservative means. The patient was admitted to the hospital and underwent a laparoscopic myomectomy. At issue in this case is whether a prudent layperson in the patients circumstances would have sought urgent services.There are many treatment modalities available for abnormal uterine bleeding related to leiomyomas. In this case, the patient consulted a provider in Hong Kong for her symptoms and decided to undergo surgical intervention. There is no indication in the records provided that the patients symptoms were of such severity to cause a prudent layperson to seek surgical intervention on an urgent basis. No details regarding conservative treatment methods have been provided. There is no evidence that treatment of the patients uterine fibroid could not have been delayed until she returned home. There is a lack of objective clinical documentation in the records provided to demonstrate that the patients symptoms were sufficiently severe to cause her to seek surgical intervention on an urgent basis.
Appeal type: Medical Necessity
Decision: Upheld

The patient is a 54-year-old male who has celiac sprue, diarrhea, and anemia. He is OB negative. A small bowel series was negative. A colonoscopy suggested the possibility of inflammatory bowel disease. The patients mild anemia is believed to have been caused by early myelodysplastic syndrome. An IBD Prometheus test was positive for Crohns disease. The patient wishes to undergo a wireless capsule endoscopy for further evaluation of his symptomatology. The Health Plan indicates the requested procedure is not medically necessary.Review of the submitted medical records reveals no medical indication for a wireless capsule endoscopy. Based upon the information provided, it appears the patients anemia is due to myelodysplastic syndrome. The patient is OB negative. Furthermore, though the patient had a positive IBD Prometheus test, this test is not 100% sensitive. If there is a high suspicion for Crohns disease based on the colonoscopy, then a trial of empiric therapy is medically reasonable and appropriate. If the patient fails to respond to a trial of empiric therapy or if his condition worsens, further testing may then be necessary. At this time, a wireless capsule endoscopy is not medically warranted. Based upon the information set forth above, I have determined that the requested procedure is not medically necessary for evaluation of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned

A 43-year-old female enrollee has requested for the prescription drug Differin 1% cream for treatment of her rosacea.  Findings:  The physician reviewer found that every standard textbook of dermatology recognizes topical retinoids as accepted treatment for acne rosacea. It is part of the standard of practice, according to the American Academy of Dermatology.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary:   An enrollee has requested genetic testing for evaluation of her thyroid nodule. Three physician reviewers found that the Afirma fine needle aspiration analysis was likely to be more effective for this patient than other available treatment options. The medical literature supports the services at issue in this clinical setting. Approximately 15 to 30% of thyroid nodules evaluated by means of fine-needle aspiration are not clearly benign or malignant. Patients with cytologically indeterminate nodules are often referred for diagnostic surgery, though most of these nodules prove to be benign.   According to McIver and colleagues The Afirma GEC demonstrates a lower than expected rate of benign reports in follicular or Hurthle cell neoplasm and a lower than anticipated malignancy rate within GEC-suspicious nodules. Therefore, the genetic testing was clinically indicated and likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Final Result: Three reviewers determined that the testing at issue was likely to be more beneficial for evaluation and treatment 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 medical oncology and is actively practicing.  Two reviewers are board certified 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: Overturned

A 44-year-old female enrollee requested authorization and coverage for a trial of a C-PAP machine.  The health plan has denied this request indicating that a trial of C-PAP is not medically necessary for treatment of the enrollees Sleep apnea and fatigue. One physician reviewer performed a medical necessity Independent Medical Review.  The physician reviewer overturned the health plans denial on the basis that the requested services are medically necessary.
Appeal type: Medical Necessity
Decision: Overturned

The patient is a 49-year-old female status post knee surgery with restricted knee range of motion. The patients provider prescribed an ERMI Flexionater and a neuromuscular stimulator for home use. The patients provider indicates use of this equipment has resulted in an improvement in the patients range of motion to 130 degrees. The patient has requested reimbursement for the ERMI Flexionator and neuromuscular stimulator. The Health Plan has denied the request on the basis the equipment at issue was not medically necessary.The submitted evidence documents the patient experienced improvement in range of motion with use of the ERMI Flexionater and neuromuscular stimulator. A study by Talbot, et al. demonstrates the efficacy of neurostimulation for patients undergoing knee rehabilitation.  In the case of this patient, there is documented evidence the equipment at issue has been beneficial. It is unlikely that the patient would have experienced this degree of improvement with manipulations and injections. Therefore, I have determined the equipment at issue was medically necessary for treatment of the patients medical condition. The Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Upheld

The parent of a 13-year-old female enrollee has requested continued care from a pediatric ophthalmologist for treatment of the enrollees strabismus. Findings:  The physician reviewer found that the patient is stable and doing very well. In fact, she is being followed at recommended intervals of six months to one year, which indicates that her condition is very stable. All board certified ophthalmologists are trained in the treatment of accommodative esotropia and amblyopia. Thus, a general ophthalmologist can follow a patient with strabismus and amblyopia, particularly when the patient is stable as is the case with this patient. A general ophthalmologist has the knowledge and expertise to be able to refer the patient to a pediatric ophthalmologist if the patients condition was to show significant changes or any worsening. The treatment of strabismus and amblyopia is within the scope of practice of a general ophthalmologist.
Appeal type: Experimental/Investigational
Decision: Overturned

 Nature of Statutory Criteria/Case Summary:  An enrollee has requested tongue reduction surgery for treatment of his medical condition.   Findings:  Two physician reviewers found that obstructive sleep apnea is an increasingly prevalent clinical problem with significant effects on both personal and public health.  Continuous positive airway pressure (CPAP) therapy has demonstrated excellent efficacy and low morbidity.  There are also traditional upper airway surgical procedures which target the anatomic component of obstruction.  Per the medical evidence, adult patients with mild to severe obstructive sleep apnea can be successfully treated with submucosal radiofrequency tongue base ablation.  This patient had obstructive sleep apnea and cannot tolerate CPAP, the gold standard in the treatment of obstructive sleep apnea. He had an enlarged base of tongue.  Reduction of the base of tongue should improve his nighttime breathing and sleeping.  Therefore, tongue reduction surgery was likely to have been more effective than other treatment options.   Final Result: Two reviewers determined that the services at issue were likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned.  Credentials/Qualifications:   All three reviewers are board certified in otolaryngology 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: Experimental/Investigational
Decision: Upheld

A 55-year-old male enrollee has requested authorization for artificial disc replacement surgery for treatment of his degenerative disc disease.  Findings:  Three physician reviewers found that the ProDisc disc device has not been approved by the FDA for replacement at greater than two levels. A review of the relevant peer-reviewed literature indicates artificial disc replacement at three levels is considered to be inconsistent with the standard of care.  There are no long-term studies addressing multi-level disc replacement.
Appeal type: Medical Necessity
Decision: Overturned

A 27-year-old female enrollee requested reimbursement for inpatient services received from 10/29/02 through 11/28/02. The Health Plan denied the request indicating that the services at issue were not medically necessary for treatment of her behavioral health problems.One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer overturned the Health Plans denial on the basis that the requested treatment was medically necessary.