Persius/imr-appeals huggingface dataset:
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/ Case Summary:  The enrollee requested reimbursement for proton beam radiation therapy. The enrollee has a history of recurrent sarcoma of the thigh. The enrollees radiation oncologist reports the enrollee has experienced multiple, recurrent, high-grade, undifferentiated spindle cell sarcomas of his left thigh. He had a surgical resection, followed by conventional photon radiation therapy. Four years later, he required a re-excision for local recurrence. He recently developed a biopsy-proven recurrence in his left thigh within the area of the previous radiation portal. He was initially treated with chemotherapy. His disease continued to progress. His provider believes the use of proton beam therapy in these circumstances is needed because it is the most advanced form of proton therapy. It allows physicians to precisely paint the tumor with radiation, minimizing radiation exposure to healthy tissue and reducing the risk of side effects. Literature describes protons as particularly useful in bone tumors, pediatric sarcomas, and spinal lesions, due to the ability to restrict the dose to critical anatomical structures or vulnerable developing tissues. Studies show the use of high-dose photon/proton radiotherapy resulted in local control rates in the management of non-spine (long bone) sarcomas of 81 percent at five years and 74 percent at eight years. This enrollee cannot be effectively treated with photons alone in this clinical situation. Professional society guidelines do allow the use of proton therapy for this extensive recurrent sarcoma.Final Result: Three of the three reviewers determined that the requested services were likely to have been more beneficial than any available standard therapy for treatment of the enrollees medical condition. Credentials/Qualifications: Three reviewers are board certified in radiation oncology 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

The patient has requested authorization and coverage for power wheelchair with tilt recline, elevated leg rest, and power seat elevation. This patient has a history of limb girdle muscular dystrophy, which causes muscle fiber loss, primarily affecting skeletal muscles. She has functionally deteriorated from independent with a walker for short distance ambulation with occasional falls, to a functional non-ambulatory status. The records provided for review do not document that this patient requires the assistance of a power wheelchair with power seat elevation in order to be independent with slide board transfers. The patient has greater than antigravity strength at her shoulders. However, additional specifics on the patients upper limb strength and function are limited. There is no documentation of persistent leg swelling in the injured leg and a long-term need for an elevated leg rest. There is no documentation on physical and functional evaluation confirming the need for tilt recline. The records do not suggest that the patient cannot perform effective pressure relief using her own body power, including body lifts, side shifts, or forward leaning. Overall, the records do not establish that the patients current power wheelchair is inadequate or that the requested components are medically necessary. All told, a power wheelchair with tilt, elevated leg rest, and power seat elevation is not medically necessary for treatment of this patient. Final Result: The reviewer determined that the requested equipment 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 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 collagen gel injections to be administered to both knees for treatment of his bilateral knee osteoarthritis.   The physician reviewer found that the submitted documentation fails to establish the medical necessity of the requested services. There is a lack of medical literature supported by double blinded studies with comparison to placebo demonstrating the efficacy of collagen gel injections. In the article by Burrage and colleagues, there is a description of the destructive effect on proteoglycans and type 2 collagen by inflammatory cytokines, interleukin 1 and tumor necrosis factor alpha stimulating the production matrix metalloproteinases (MMPs) enzymes that can degrade proteoglycans and extracellular matrix. Collagenases such as MMP1 and MMP13 limit the rate of collagen degradation. While this basic science has been established, the authors state as yet there have been no effective clinical inhibitors identified. The authors provide the opinion that further study and knowledge of molecular mechanisms may provide new therapeutics. Based on the medical literature and clinical documentation provided, the request for collagen gel injections to be administered to both knees is not medically necessary for treatment of the patients medical condition.  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 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 46-year-old male enrollee has requested physical therapy (three times per week)for treatment of his adhesive capsulitis.  Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested therapy.  As of the date in question, the patient had already received extensive formal physical therapy for adhesive capsulitis, for the right side in the past, and an additional six weeks for the left side recently.  Although there are still ongoing symptoms and range of motion loss, no marginally significant improvement in the patients clinical course or outcomes would be anticipated with additional manual therapy and supervised exercise in the formal therapy setting over an independent exercise program and self-applied modalities.  The records do not document the need or provision of any specific exercises that the patient needs to perform that cannot be performed independently or substituted with independent exercise.  There is no proven benefit of passive modality therapy, including manual therapy, in the setting of adhesive capsulitis over a committed self-directed strengthening and range of motion exercise program, combined with independently-applied palliative modalities.  All told, physical therapy (three times per week) is not medically indicated for the treatment of this patient.
Appeal type: Experimental/Investigational
Decision: Upheld

A 37-year-old female enrollee has requested electrothermal shrinkage and the water circulating cold pad with pump for treatment of the enrollees fibrocartilage complex tear, dorsal compartment tenosynovitis, and carpometacarpal boss.  Findings:  Three physician reviewers found that an electrothermal shrinkage procedure to treat an elongated saggy scapholunate ligament was not likely to have been more beneficial for treatment of this patients medical condition than any available standard therapy. In this study, a case series of 16 patients were presented. Diagnostic arthroscopy had demonstrated a partial scapholunate tear and redundancy of the ligament in two of the patients evaluated. In a follow-up of a mean 19 months, there was improvement in radial sided wrist pain in most of the patients. However, there is a paucity of well designed clinical trials demonstrating similar reproducible results. Martimbianco and colleagues provided support for reduction in pain levels at 48 hours but does not provide sufficient evidence for efficacy of cryotherapy for other outcomes such as analgesic medication use, range of motion, blood loss, hospital stay or quality of life. The authors concluded that there is a need for additional studies with randomized trials to demonstrate the efficacy of cryotherapy. Overall, there is a lack of properly randomized controlled trials showing improved health outcomes with the use of electrothermal shrinkage or a water circulating cold pad with pump.
Appeal type: Medical Necessity
Decision: Overturned

The parent of an eight-year-old female enrollee has requested speech therapy services for the treatment of the enrollees dysarthria and dyspraxia secondary to Down syndrome. Findings:  The physician reviewer found that the crux of this case rests upon the utility of speech and language interventions in Down syndrome patients in general and for this particular patient specifically. Kumin highlights the goals and methods for helping these patients at different stages in their lives and indicates that a comprehensive approach to the Down syndrome school aged child requires communication skills that often need to be addressed through speech and language therapy. The author states that, There is growing recognition that formal testing does not always provide an accurate picture of a childs actual daily communication skills. In a testing situation, children with Down syndrome may respond inconsistently, shift their attention rapidly, or be difficult to motivate. This could account for discrepancies in test results in the case of this patient. Consistent with the medical literature for Down syndrome patients, speech therapy services were, and continue to be, medically necessary for this patient. Formal baselines were not obtained due to the patients lack of cooperation at that time. However, steady progress can be measured through behavioral and contextual ways. According to her therapist, the patient continues to make excellent progress, and that is verifiable through parental and school reports in addition to the evidence set forth by the therapist. Down syndrome, as a genetic condition, along with the patients dysarthria and dyspraxia constitute medical necessity for speech therapy. Per the records provided for review, this patient is functioning at a much higher level than would be expected if no therapy was initiated. She has made remarkable progress to the point where she has been mainstreamed to a much higher level in school. While her condition is not curable, marked improvement can continue with additional intensive speech therapy services.
Appeal type: Experimental/Investigational
Decision: Overturned

A 46-year-old male enrollee has requested implantation of neuroelectrodes (spinal cord stimulator) for treatment of his failed back surgery syndrome and neuropathic back pain and lower extremity pain. Findings:  Two physician reviewers found that in the peer-reviewed medical literature, North and Wetzel conducted a literature review on the indications and efficacy of spinal cord stimulation, particularly in reference to chronic pain of spinal origin. The authors determined that on the basis of current evidence, spinal cord stimulation is a valuable treatment option for patients with chronic spinal pain. Kumar and colleagues conducted a 22-year study to present an in depth analysis of clinical predictors of outcome following spinal cord stimulation in the treatment of chronic benign pain. Following analysis, the authors determined that spinal cord stimulation provides significant long-term pain relief with improved quality of life and employment, if the time interval between pain onset and implantation was short. Consistent with this scientific support, the requested neuroelectrode placement (spinal cord stimulator) is likely to provide this patient with an improved health outcome when compared to standard therapies.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for lumbar/sacral transforaminal epidural injections. Lumbar epidural steroid injections under fluoroscopic guidance can be advantageous in diagnosing a patients pain source as well as for treatment of low back and lower extremity radicular pain. These procedures have been shown to be effective for pain relief in the short-term with few adverse events. In this case, the patient presents with a history of low back and left lower extremity pain associated with positive straight leg raise on the left. In determining the source of her pain, there are two factors to consider: the sacral insufficiency fracture resulting from radiation therapy; and the spinal pathology with L4-5 spondylolisthesis associated with lateral stenosis and L5 radiculopathy. The provider has recommended transforaminal epidural steroid injections for determination of the pain source to be followed by a limited laminotomy, if needed. Based upon the review of the literature, this is a reasonable indication for transforaminal epidural steroid injections and will help direct this patients care. As such, the requested transforaminal lumbar/sacral epidural steroid injections are supported as medically necessary for evaluation and treatment of this 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 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: Overturned

A 43-year-old female enrollee requested authorization and coverage of bilateral breast reduction surgery. The Health Plan denied the request indicating that the procedure is not medically necessary for treatment of the enrollees excess breast tissue.One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer overturned the Health Plans denial on the basis that the requested procedure is medically necessary.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested digital breast tomosynthesis for evaluation of the enrollees medical condition.  Findings: Two physician reviewers found that tomosynthesis is a technique that was developed as a problem solving adjunct to routine mammography. However, in this case there were no problems to be resolved. The patient did not have dense breasts, she did not have a mass, there were no palpable lumps, and she did not have suspicious calcifications. A routine mammogram would have been sufficient in this clinical setting. Tomosynthesis has not been shown to provide significant increased value in patients who do not have dense tissue that could obscure an abnormality, especially when there has been no change when compared to prior mammograms. Therefore, the breast tomosynthesis was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Final Result: Two reviewers determined that the services at issue were not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: All three physician reviewers are board certified in diagnostic radiology 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: Experimental/Investigational
Decision: Upheld

A 64-year-old male enrollee has requested reimbursement for computed tomography (CT) scan of the heart.  Findings:  Two physician reviewers found that the patient is a 64-year-old male with a history of hyperlipidemia.  He presented with exertional dyspnea without chest pain.  Per the submitted documentation, prior examination was significant for an irregular heartbeat.  The cardiac physical examination was otherwise normal. Approximately two weeks later, an electrocardiogram revealed premature ventricular contractions. Computed tomography (CT) scan of the heart was performed that same day.  The Health Plan has denied reimbursement for the CT scan of the heart and reported that the diagnostic procedure at issue was investigational for the evaluation of this patient.  The patient is appealing this denial.  The submitted documentation noted exertional dyspnea symptoms thought possibly due to an ischemic equivalent, premature ventricular contractions, mitral regurgitation and no objective evidence of ischemia on electrocardiography or echocardiography.  Coronary CT angiography only provides an assessment of coronary anatomy and does not assess the functional significance of any potential stenosis identified.   Therefore, coronary CT angiography would not directly assess the cause of the patients symptoms.  Additionally, coronary CT angiography does not assess for ischemia from causes other than fixed obstructive coronary disease and does not assess for other potential causes of exertional dyspnea, such as exercise-induced dysrhythmias, diastolic dysfunction or exercise-induced worsening valvular regurgitation.  If an assessment of coronary anatomy is considered medically necessary, then invasive coronary angiography is generally preferred given improved accuracy relative to CT angiography and the ability to intervene with revascularization during the same procedure, if clinically indicated.  All told, CT scan of the heart provided on the date in question was not likely to have been more effective than other available tools for evaluating this patient.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested re-exploration and repair of the failed subarachnoid shunts by placing a pleural shunt at each cyst location anterolateral at T5-6 and posterior lateral at T7-8 for treatment of the enrollees medical condition.  Findings: The physician reviewer found that there is sufficient medical evidence to support the requested procedure in this clinical setting. The standard procedure is cysto-subarachnoid shunts but they have a greater tendency to fail since they are a passive conduit for fluid, such as in this patients case. Instead, the recommended pleural shunt utilizes the negative pressure of the pleural cavity to draw fluid from the cyst which provides better long term results for patients. Thus, the recommended pleural shunt is clinically appropriate and effective to relieve spinal pressure and stop the progression of this patients symptoms. All told, the requested re-exploration and repair of the failed subarachnoid shunts by placing a pleural shunt at each cyst location anterolateral at T5-6 and posterior lateral at T7-8 is medically necessary for treatment of this patient.Final Result: The reviewer determined that the requested procedure is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.  Credentials/Qualifications: The physician reviewer is board certified in neurological 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 65-year-old male has requested coverage for a referral to a radiation oncologist for treatment of prostate cancer. Findings:  The physician reviewer found that the submitted documentation demonstrates the medical necessity of the requested service in this patients case.  It is medically necessary for this patient to be followed by a radiation oncologist.  While urologists treat prostate cancer, they do not do so with external beam radiation.  Radiation oncologists follow patients for toxicity after radiation, including rectal bleeding, urinary symptoms, and sexual function.  It is medically appropriate for this patient to be followed by a physician who is accustomed to managing radiation-related outcomes and toxicities.  The current medical evidence supports the requested service in this clinical setting.  All told, the requested referral to a radiation oncologist is medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for aquatic therapy; OxyContin 30mg 90 pills for 30 days; Valium 10mg 120 pills for 30 days; Soma 350mg 90 pills for 30 days; a consultation with an orthopedic specialist; a consultation with a neurologist; and magnetic resonance imaging of the head. The Health Plan has denied these requests indicating that the requested services are not medically necessary for treatment of the enrollees chronic left sided low back pain with left sided sciatica; chronic pain; chronic left knee pain; chronic neck pain; mandibular pain; left retinal disease; concussion without loss of consciousness; and anxiety.At issue in this case is whether the requested aquatic therapy; OxyContin 30mg 90 pills for 30 days; Valium 10mg 120 pills for 30 days; Soma 350mg 90 pills for 30 days; a consultation with an orthopedic specialist; a consultation with a neurologist; and magnetic resonance imaging of the head are medically necessary for treatment of the enrollees medical condition.The submitted documentation fails to demonstrate the medical necessity of the requested services. The patient has no new findings to warrant the above treatments. He is non-compliant. There are issues of diversion. The medical evidence does not support the requested services in this clinical setting. Therefore, the requested services are not medically necessary.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 internal 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.