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

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for manual lymphatic drainage massage therapy and hydrotherapy. This patients records support diagnoses of obesity, chronic pain, and hypermobile Ehlers-Danlos syndrome. A diagnosis of lipedema is supported with findings such as a disproportional but symmetric distribution of fatty tissue in the buttocks, thighs and legs, while sparing the abdomen, feet, and hands (Aksoy, et al.). This patients records do not adequately support a diagnosis of lipedema. The records note the presence of pain and easy bruising. Lipedema is often unmasked only after successful weight loss surgery, which selectively reduces non-lipedema adipose tissue while sparing the lipedema (Kruppa, et al.; Sanchez-De la Torre, et al.). Halk and Damstra noted that manual lymphatic drainage has not been demonstrated to be effective on adipose tissue. This patients records do not adequately support lymphedema based on the documented physical examination findings, negative lymphoscintigraphy, and generally unremarkable response of the patients symptomatology to manual lymphatic drainage. Moreover, this patient has already undergone treatment with manual lymphatic drainage without significant benefit in her symptoms. The patient may continue to apply this intervention independently. Thus, the requested manual lymphatic drainage massage therapy is not medically necessary for this patient. Furthermore, there is a lack of indication for hydrotherapy for treatment of this patients medical condition. There is a paucity of high-grade evidence demonstrating the benefit of hydrotherapy for hypermobility syndromes. Exercise in an aquatic setting is one of several modalities that can provide symptom relief for various pain conditions (Baena-Beato, et al.). However, this patients records do not report that the patient requires therapy in a partially weight unloaded environment with the formal guidance, instruction, and supervision of a skilled provider. The records suggest that this patient is able to perform the applicable exercises safely and effectively without provider assistance. Therefore, the requested hydrotherapy is not medically necessary for this patient. Given these findings, the requested manual lymphatic drainage massage therapy and hydrotherapy 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 physical medicine and rehabilitation 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

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for mandibular maxillary advancement performed and the related dental x-ray performed.  Findings:  The physician reviewer found that maxillomandibular advancement is an effective surgical option for obstructive sleep apnea that achieves enlargement of the upper airway by physically expanding the facial skeletal framework. Patients with high residual AHI and respiratory disturbance index (RDI) after failure of other surgical procedures for obstructive sleep apnea are likely to benefit from mandibular maxillary advancement. In this case, the patient has had chronic sleep deprivation and sleep disturbance. She has failed treatment with CPAP as well as sleep surgery. She has suffered serious sequelae from obstructive sleep apnea. As such, the pre-operative dental x-ray performed , and mandibular maxillary advancement performed were medically necessary for treatment of the patients obstructive sleep apnea, retro- and micro-gnathia and mandibular hypoplasia.  Final Result: The reviewers 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: Physician reviewer is board certified in otolaryngology and plastic surgery and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the injection of 100 Units of Botox (CPT J0585). Findings:  The physician reviewer found that Luvisetto and colleagues performed a review of available evidence in favor or against the use of botulinum neurotoxin A (BoNT/A) for the treatment of headaches. They concluded that there is much basic science evidence for an analgesic effect of BoNT/A, and clinical trials confirmed the efficacy, safety and tolerability of the toxin in the prophylactic treatment of certain headaches in adults, such as chronic migraine and trigeminal neuralgia. Botox has received FDA approval for the treatment of migraine headaches in patients who have more than 14 headache days per month. Kutuk and colleagues conducted a randomized controlled trial to compare the efficacies of botulinum toxin-A injection and dry needling methods in the treatment of patients with myofascial pain syndrome (MPS) in the temporomandibular joint (TMJ). They concluded that abobotulinum toxin-A injection and dry needling yield satisfactory therapeutic outcomes regarding pain relief and restoration of function in patients with MPS involving TMJ. In this case, the patient has been diagnosed with migraines and MPS. Records demonstrate that the patient suffers from chronic headaches. The patient is noted to have received Botox for the treatment of pain in the past, and the patient reported that Botox injections have been the only treatment to help relieve her pain and jaw locking. Under these circumstances, the 100 units of Botox (CPT J0585) injected on the date of service were medically necessary for the patients medical condition.Final Result: The reviewer determined that the services at issue were medically necessary for the patient's medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in 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: Medical Necessity
Decision: Upheld

A 53-year-old female enrollee has requested the prescription medication Actiq for the treatment of her chronic pain. Findings:  The physician reviewer found that Actiq is FDA approved explicitly for use in cancer pain patients only.  Although there are some cases series and individual case reports in the literature, there are no randomized controlled trials of this medication in non-malignant pain patients.  Actiqs effectiveness in non-malignant pain is unproven.
Appeal type: Medical Necessity
Decision: Upheld

The patient has requested authorization and coverage for Remicade 400 mg infusions at a frequency of every five weeks. The U.S. Food and Drug Administration (FDA) has approved Remicade for the treatment of ankylosing spondylitis. However, the requested dosage of Remicade 400 mg infusions at a frequency of every five weeks exceeds the FDA recommendations. Moreover, the records provided for review do not support that this patients neck and finger pain is due to ankylosing spondylitis. Radiographs demonstrated that the patients symptoms are consistent with degenerative arthritis. There are no radiographs confirming the presence of ankyloses or inflammatory erosive changes. In addition, there is a lack of clinical history and findings consistent with ankylosing spondylitis. Objective findings include a normal ESR and C-reactive protein. The patient reports incomplete improvement two weeks after Remicade treatment and the effects wear off prior to four weeks. Therefore, Remicade every five weeks is not expected to be beneficial. All told, Remicade 400 mg infusions at a frequency of every five weeks is not medically necessary for treatment of this patient. Final Result: The reviewer determined that the requested medication dosage 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 subspecialty certification in rheumatology 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: Urgent Care
Decision: Overturned

A 61-year-old female enrollee has requested for emergency services indicating emergency care. Findings:  The physician reviewer found that complaints including cough, chills, body aches, vomiting and abdominal pain.The patient was diagnosed with an upper respiratory infection. The patients condition did not improve and she sought medical attention at a facility.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary:  An enrollee has requested weekly individual psychotherapy for treatment of her behavioral health condition.  Findings:  The physician reviewer found that effective psychotherapy is a trusted intervention in the treatment armamentarium for those afflicted with major depressive disorder, PTSD and hoarding.  Current practice in this country is focused on aggressive treatment in the acute phase of these illnesses, in which more restrictive settings such as IOP may be necessary, followed by progressively less intensive services in the maintenance phase to foster patient autonomy and recovery.  In this particular case, it does not appear that the patient has received an evidence-based exposure therapy or behavioral therapy during the episode of illness. Further, recalling that depressive disorders are often chronically recurring conditions, the patient was described as having significant affective symptoms. Although supportive group therapies are an important complementary intervention in any case, the patients current plan is both inadequate for therapeutic consolidation and inconsistent with good medical practice. In accordance with the American Psychiatric Association (APA) clinical practice guideline, a course of individual sessions should be pursued. APA guidelines further state If 4-8 weeks of treatment do not yield at least moderate improvement (20% diminution in symptoms), the clinician should thoroughly review and reappraise the treatment plan. For the reasons provided above, weekly individual psychotherapy sessions are medically necessary for treatment of the patients medical condition.  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 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

The patient is a 37-year-old male with a history of waking from sleep with a rapid pulse rate and difficulty breathing. He also has a history of hypersomnolence, vivid nightmares, and headaches. Chart notes also relate a history of snoring and witnessed apneas. Possible diagnoses for this patient have included asthma, gastroesophageal reflux disease (GERD), and obstructive sleep apnea (OSA). Evaluation by an otolaryngologist resulted in a diagnosis favoring GERD and the patient was started on Prevacid. A gastroenterologist evaluated the patient and did not agree with a diagnosis of GERD, but recommended an upper GI series for further evaluation. The gastroenterologist also noted the possibility of SVT associated with the patients known mitral valve prolapse. The patient had a polysomnography showing no significant evidence of sleep apnea with a RDI of 2.3 and oxygen saturation at 93%. However, the patients sleep pattern was noted to be consistent with upper airway resistance syndrome. In addition, the patients arousal index was elevated at 21.4 and his Epworth scale was 12. CPAP has been recommended for the patient. The Health Plan has denied this request. Although the patient does not meet criteria for the diagnosis of sleep apnea, he does meet criteria for the diagnosis of upper airway resistance syndrome (UARS). The Milliman Care Guidelines state that CPAP may be indicated with either home or sleep center titration for patients with an RDI greater than five or patients with UARS and unexplained EDS with typical UARS findings. This patient has UARS with an elevated arousal index and Epworth scale and as yet unexplained EDS. As such, the patient meets accepted guidelines for consideration of CPAP. Therefore, the patient should be provided a three-month trial of CPAP to determine whether it is useful in treatment of sleep disorder. If his condition does not improve after the trial, CPAP should be discontinued.Based upon the information set forth above, I have determined the requested therapy is medically necessary for treatment of the patients medical condition. The Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Overturned

An enrollee has requested reimbursement for a bilateral temporal hairline brow lift. Medical literature states that special attention must be given to brow position and that brow position plays a significant role in eyelid crowding. They indicate that providers cannot improve brow ptosis with a blepharoplasty procedure, and attempts to do so will cause complications. They advise that providers must look at the position of the lower border of the actual brow skin, and if the lower border of the brow is significantly below the superior orbital rim, this must be noted. Medical literature also states that brow ptosis is defined as brows that rest below the supraorbital ridge and can compromise vision via obstruction of the superior visual fields. In this case, the patient had clinically significant visual obstruction, confirmed by physical examination, visual field examination taped and untaped, and clinical photos. The patients upper eyelid skin was markedly redundant, and her brows were significantly below the supraorbital ridge, confirmed by physical examination and clinical photos. Under these circumstances, upper lid blepharoplasty alone would not adequately restore the patients superior visual field. Accordingly, bilateral temporal hairline brow lift was medically necessary to treat the patients medical condition.Final Result: The reviewer determined that the services at issue were medically necessary to treat the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in plastic surgery and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

A 45-year-old female enrollee requested authorization and coverage of continued speech therapy, cognitive therapy, physical therapy, and aquatic therapy. The Health Plan denied the request indicating that the requested therapies are not medically necessary for treatment of the enrollees traumatic brain injury.One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer partially overturned the Health Plans denial on the basis that the requested physical therapy is medically necessary but speech therapy, cognitive therapy, and aquatic therapy in excess of the therapy already approved by the Health Plan is not medically necessary.
Appeal type: Medical Necessity
Decision: Upheld

The patient is a 10-year-old male born prematurely at 31 weeks with resultant cerebral palsy with spastic quadriplegia. He is status post adductor tenotomies in 1999 and underwent hamstring lengthening and varus derotational osteotomies in 2005 with removal of hardware in 2006. He has received occupational and physical therapy since he was an infant.  He has been on monitor therapy for the last few years because of failure to progress with both therapies. A request has been made for authorization to attend intensive inpatient rehabilitation at the Euromed Rehabilitation Center in Poland to attempt to improve functional abilities. Specific functional goals are not outlined.  The Euromed Rehabilition Center uses intensive physical and occupational therapy in conjunction with a patented device called the Adeli Suit for neuromuscular reeducation.  At issue is whether treatment at the Euromed Rehabilitation Center is medically necessary for the patients cerebral palsy. Though there is anecdotal evidence that patients and families who attend programs such as the one offered by the Euromed Rehabilitation Center feel the experience was a positive one and that the patient gained from the experience, there is no objective scientific data that such programs result in significant functional gains. There are reports of subjective improvements and improvement in motor strength and range of motion immediately and up to one month post session.  However, most of the patients show a return to baseline within one to two months post treatment with or without follow-up standard therapies.  Based on the scientific data available to date, the requested services are not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld

A 47-year-old female enrollee has requested for Dilaudid for treatment of her migraines.   Findings:  The physician reviewer found that as noted in the medical literature, daily use of narcotic medication is not indicated for daily headache care. Further, the studies suggest that patients treated with daily narcotics for chronic migraine oftentimes experience a progression in the severity of their pain with an increasing need for higher doses of medication. All told, the long-term risks of using narcotics significantly outweigh the short-term benefits of continuous opioid use. For these reasons, Dilaudid has not been demonstrated to be medically necessary for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld

A 41-year-old female enrollee has requested a lymphedema pump for treatment of her lymphedema.  Findings:  The physician reviewer found that the nature of this patients limb swelling condition is unclear. The records primarily indicate that the patient is obese and has had chronic lower leg swelling, but there are no documented characteristic skin changes or other signs of lymphedema. She has not had any documented lymphatic system pathology. It is not evident that the patients condition is not due to venous insufficiency and dependent edema. There is an extensive differential diagnosis for chronic leg edema of unclear etiology besides primary lymphedema (Ely, et al). The patient, moreover, has not been documented to have compliantly undergone an appropriate trial of conservative management that includes adequate manual decompression, compression garment wear, and use of compression wraps, elevation, exercise, and weight loss. There is no documentation of a trial of compression pump therapy in the therapy setting demonstrating effective volume reduction. All told, the requested lymphedema pump is not medically necessary for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a two-year-old male enrollee has requested for occupational therapy for treatment of the enrollees feeding difficulties. Findings:  The physician reviewer found that Eckman and colleagues noted that occupational therapy has a successful role in teaching patients to respond to therapy. Seabert and colleagues noted the usefulness of multidisciplinary clinics for infants with feeding disorders. To allow a child to avoid many foods may result in a very unbalanced and very unhealthy diet throughout his lifetime. The articles note that these programs are successful and can be curative of feeding disorders.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/ Case Summary:  The enrollee is requesting authorization and coverage for consultation with an infectious disease specialist. The latest imaging shows a suspicion of ascariasis infestation in the common bile duct (CBD). Prior to this test, a computed tomography (CT) showed a dilated CBD, with endoscopic retrograde cholangiopancreatography (ERCP) recommended if the bilirubin is elevated. A gastroenterology consultation from indicates the physician suspects the enrollee has a delusional disorder and that he does not have a true continued infection. However, the physician further noted the enrollee may benefit from seeing an infectious disease (ID) specialist to confirm he truly does not have an infection. The records indicate the enrollee was referred to gastroenterology. Scheduling this procedure has been complicated by the enrollees psychosocial issues, including his belief that he has already proven he has worms. He is requesting evaluation by an infectious disease (ID) specialist. However, the ID specialist wants the enrollee to have additional testing by gastroenterology first. An evaluation by dermatology indicates the enrollee likely has delusions of parasitoids, but admitted this suspected diagnosis was out of the scope of their practice and recommended psychiatry evaluation and referral to an ID specialist. The review of documentation supports this enrollee has psychosocial co-morbidities. This enrollee may have a persistent worm infection. The MRI has raised the possibility of ascariasis in the CBD. In spite of the psychiatric disorder, there is still a possibility the enrollee has a persistent infection that is difficult to diagnose. The gastroenterologist has advised an ID evaluation. While it is unclear whether or not this weight loss is due to the suspected worm infection or other underlying cause, the enrollee reports a concerning clinical history that further supports this enrollee will benefit from a thorough infectious disease evaluation for infectious causes for enrollees weight loss and current suspicion for biliary ascariasis.  Final Result: The reviewer determined that the requested service is medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The physician reviewer is board certified 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 similar medical condition.