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

A 56-year-old female enrollee has requested minimally invasive lumbar decompression (MILD) for treatment of her low back pain. Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested services.  The current medical evidence has not established the long-term safety and efficacy of the requested services.  Chopko and Caraway reported on 78 patients who had undergone the MILD procedure.  Six-week follow-up was obtained on 75 patients. Although outcomes were generally favorable, this follow-up period is too short to draw conclusions from this study.  Lingreen and Grider reported on 42 patients who experienced some relief of symptoms immediately after the procedure, but the period of follow-up was limited to the perioperative period.  Mekhail and colleagues reported on 58 patients who underwent the MILD procedure.  One-year data showed significant reduction of pain as measured by the visual analog scale.  However, this was not a controlled or randomized trial comparing MILD to other procedures, such as standard laminectomy.  Also, the one-year follow-up period is not long enough to determine the efficacy of this procedure.  All told, the requested MILD procedure is not medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Overturned

 An enrollee has requested authorization and coverage for Magnetic Resonance Imaging (MRI) of the pelvis.Endometriosis is an inflammatory disease in which endometrial-like tissue forms lesions outside the uterus. Its primary manifestations include dyspareunia, dysmenorrhea, chronic pelvic pain, and infertility. In general, hormonal therapies do not eliminate endometriosis. The diagnosis is made clinically in most patients. Often, pelvic examination findings correlate with laparoscopic diagnosis, however many patients diagnosed with endometriosis have normal pelvic exam findings. Ultrasonography is indicated in all patients, but MRI is said to be indicated for those patients in whom ectopic endometrial tissue was not clearly detected (Collinet, P., et al). Mendez Fernandez and colleague have stated that MRI, with careful examination technique and interpretation, enables more accurate and complete diagnosis and staging than ultrasonography, especially in cases of deep pelvic endometriosis. Moore and colleagues have noted that chronic pelvic pain is a multispecialty complaint that is difficult to treat. The physician reviewer found that  conducted a retrospective study of pelvic MRI and concluded with a recommendation of pelvic MRI in the evaluation of patients with refractory pelvic pain.In this case, the patient has chronic pelvic pain that persists following two surgical procedures and a recent celiac plexus block. The patient has had multiple negative imaging studies that include ultrasound and CT imaging. Under these circumstances, MRI of the pelvis is a reasonable next step that is supported by medical literature. Therefore, MRI of the pelvis is medically necessary to treat 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
Appeal type: Experimental/Investigational
Decision: Overturned

A 47-year-old female enrollee has requested cryoablation of the left breast for treatment of her fibroadenoma. Findings:  Two physician reviewers found that cryoablation of fibroadenomas is a widely-accepted treatment modality with good to excellent results in treating benign lesions. The procedure is appropriate for treatment of a specific lesion and is not used for the purpose of reducing an individuals lifetime risk of breast cancer. This patient has persistent pain at the biopsy site and wishes to undergo cryoablation for removal of a lesion that has already been determined to be benign. Given the patients elevated risk for breast cancer, this lesion may interfere with future surveillance efforts if left untreated. In light of this, as well as the fact that the patient has a history of two prior surgical biopsies, cryoablation is a medically appropriate and reasonable option for this patient. The requested cryoablation procedure is likely to be more beneficial for treatment of the patients fibroadenoma than any available standard therapy.
Appeal type: Medical Necessity
Decision: Upheld

The parents of a three-year-old enrollee have requested for partial hospitalization program services for treatment of the enrollees autism, attention deficit/hyperactivity disorder, obsessive compulsive disorder and anxiety. Findings:  Three physician reviewers found that there was no attempt at local alternative facilities, in-home Applied Behavior Analysis, child psychiatrists, or other in-home programs. There is no physician referral recorded recommending the ECPHP program.
Appeal type: Urgent Care
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for medical services. The Health Plan has denied this request indicating the enrollee did not receive emergency medical services. Findings:  The physician reviewer found that the medical services provided were not necessary for treatment of an emergency medical condition. In this case, there was no emergent medical condition noted in the records submitted for review. The patient presented with a history of breast augmentation. The patient states that she had extreme pain from her breast implants and thus needed to have them removed. However, the provider notes that the primary diagnosis is that the patient is dissatisfied with her implants and that the patient feels the implants are making her sick. The operative note does not support that there were significantly abnormal conditions. There was no evidence of capsular contracture or gross evidence of infection. The provider does not document that this procedure was performed emergently or that there was an indication for emergency surgery. In addition, there was no medical documentation to support significant pain or any attempted treatment of significant pain. Therefore, the services provided were not considered emergency medical services. Thus, the patient did not receive emergency medical services on the date of service at issue. Final Result: The reviewer determined that the patient did not receive emergency medical services on the date of service at issue. Therefore, the Health Plans denial should be upheld. 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: Upheld

The patient is a 34-year-old multiparous patient with pain and bleeding who wishes to undergo a hysterectomy. A pelvic ultrasound revealed a 2.6cm fundal fibroid with a normal endometrial complex and a 1.5cm complex cyst of the right ovary consistent with a hemorrhagic cyst. In the submitted records there is no documentation of the duration or the extent of the bleeding, intensity or quality of the pain or the duration of oral contraceptive treatment.The submitted documentation does not demonstrate the extent and quality of the patients pain and bleeding or indicate how long she has been on oral contraceptives. In general, abnormal uterine bleeding in premenopausal patients should be treated with a trial of oral contraceptives for three to six months, assuming that there are no medical contraindications to oral contraceptives. It should be noted that in this patients case, it is unlikely the fibroid described on ultrasound is responsible for her abnormal bleeding because it does not appear to impinge on the endometrium.Regarding the patients pain, again it is unlikely that the fibroid is a contributing factor given its size and location. Before hysterectomy is considered, a trial of oral contraceptives and/or NSAIDs should be given. The small cyst noted on the right ovary, if in fact it is a hemorrhagic cyst, may be responsible for some pain, but again, should respond to cycling on oral contraceptives.After a therapeutic trial of three to six months the patient should be re-evaluated. If at that time it is documented she has received insufficient relief from her pain and/or bleeding, a hysterectomy would be a medically reasonable option. Therefore, I have determined that the requested procedure is not medically necessary for treatment of the patients medical condition at this time. The Health Plans denial should be upheld at this time.
Appeal type: Urgent Care
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested reimbursement for services. The records indicate that the patient had a long history of mental illness that included a history of autism spectrum disorder. The progress notes indicate that the patients sedation was well-documented by his psychiatrist. He presented to a second psychiatrist to reevaluate his medications due to sedation. The second psychiatrist made other medication changes. There is no indication in the records that there was any emergency condition discovered. The patient was on two medications that are well-known for causing sedation. The records do not demonstrate an emergent need for evaluation. Rather, the patients symptoms appear to be standard side effects that would occur with these particular medications at the doses that were listed in the chart. Psychosis, self-harm and suicidal or homicidal ideation are typically considered emergencies in psychiatric care. There was no indication of dangerous symptoms which required inpatient psychiatric acute-care. The services at issue were not necessary for treatment of a psychiatric emergency medical condition. Thus, the patient did not receive psychiatric emergency medical services on the dates of service at issue. Therefore, the services at issue were not psychiatric emergency medical services.Final Result: The reviewer determined that the patient did not receive psychiatric emergency medical services on the dates of service at issue. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is board certified in psychiatry with sub-specialty certification in child and adolescent 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 has requested reimbursement and prospective authorization and coverage for dual-diagnosis residential treatment center (RTC) level of care services. Per the American Society of Addiction Medicine (ASAM) criteria, this patient meets Level 3.5 criteria for Clinically Managed High-Intensity Residential Services. ASAM criteria focuses on six dimensions to determine the appropriate level of care including: (1) intoxication and withdrawal potential; (2) biomedical conditions; (3) emotional, behavioral and cognitive conditions; (4) readiness to change; (5) relapse, continued use, or continued problem potential; and (6) recovery environment. This patients records document that he presents as fidgety and restless with COWS scoring in mild to moderate range. He does not have any documented biomedical conditions that interfere with his progress. The patient does have comorbid ADHD and depressive symptoms. He has not demonstrated readiness to change, given his continued use while in RTC, which indicates even less chance of success at a lower level of care. The patients history is positive for relapse despite incarceration. In addition, he states that he is now scared to leave treatment at this stage. The patients recovery environment includes living with his girlfriend who has also been unable to maintain sobriety. The patient requires safe and stable living environments in order to develop his recovery skills. These findings qualify the patient for ASAM Level III treatment, which is at least what patient has been receiving at the current facility. Given the severity of the patients illness, dual-diagnosis RTC level of care was and is medically necessary for treatment of this patient. Final Result: The reviewer determined that the services at issue were and 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 with expertise in addiction medicine and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for digital breast tomosynthesis for evaluation of the enrollee, who was asymptomatic. Findings:  Three physician reviewers found that she has a history of having had a prior benign stereotactic core biopsy of her right breast.  She underwent a routine screening mammogram and breast tomosynthesis examination.   The current images were compared to prior mammograms, and no interval changes were noted.  There were no masses, areas of suspicious calcifications, or areas of architectural distortion.  Her breast tissue was described as dense.  The Health Plan has denied reimbursement for digital breast tomosynthesis.  Per the Health Plan, the service at issue was investigational for the evaluation of this patient.  Breast tomosynthesis is a technique that was developed several years ago as a problem solving adjunct to routine mammography.  Applying the same basic concept as computed tomography (CT) scanning, the logic is that by separating the various layers of breast tissue, one can better detect abnormalities.  This has been shown to be most useful in the evaluation of dense breasts.  In this patients case, the records noted dense breast tissue.  It is specifically those patients who have dense breasts that can benefit most from tomosynthesis.   The ability to separate out the overlapping structures enables the possibility of demonstrating an otherwise occult tumor.  Thus, digital breast tomosynthesis performed was likely to have been superior over other available modalities for evaluating this patient. Final Result: The reviewers determined that the service at issue was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: All three 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

An enrollee has requested authorization and coverage for Xyrem oral solution. In this case, the provider stated that the patient has a diagnosis of type 1 narcolepsy, an indication for which Xyrem is U.S. Food and Drug Administration (FDA) approved. However, the records provided for review do not support the diagnosis of narcolepsy. The diagnostic standards for narcolepsy require performance of a thorough multiple sleep latency test (MSLT). The polysomnogram/MSLT was not conducted in accordance with standard protocols. Notably, the patient did not sleep for the minimum 360 minutes required for performance of the MSLT. Rather, the patient only slept for a few hours on the night before the sleep test. Insufficient sleep on the preceding polysomnogram can cause false positives on the MSLT. Sleep onset rapid eye movement (REM) periods are not in and of themselves readily unique/exclusive to narcolepsy, but can be seen in insufficient sleep. Further, there was an adjustment made to the patients continuous positive airway pressure (CPAP) device during the polysomnogram portion of the study, which may have altered the patients sleep on the night before the MSLT. Based on the medical records provided for review, the patient has a diagnosis of obstructive sleep apnea (OSA). There are currently three U.S. Food and Drug Administration (FDA) approved therapies for the management of daytime sleepiness in OSA, which have greater support in the medical literature than Xyrem for sleepiness due to OSA. Therefore, Xyrem oral solution is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.  Findings:  Two of the three physician reviewers found the requested medication is not likely to be more beneficial for treatment of the patients condition than any available standard therapy.Final Result: The reviewers determined that the requested medication is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: Physician reviewers 1 is board certified in internal medicine with sub-specialty certification in sleep medicine and is actively practicing. Physician reviewers 2 is board certified in otolaryngology with sub-specialty certification in sleep medicine and is actively practicing. Physician reviewers 3 is board certified in in neurology with sub-specialty certification in sleep medicine and is 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

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for continuous glucose monitoring system (CGMS) that can turn on and off the basal supply of insulin in response to hypoglycemia (or predicted hypoglycemia), including a transmitting device, receiver device, and continually renewing supply of sensors. CGMS devices have been approved by the U.S. Food and Drug Administration (FDA) for use in this clinical setting. Moreover, the utility of CGMS has been demonstrated in clinical trials. Overall, the peer-reviewed literature supports the long-term use of CGMS in adult patients with type 1 diabetes with hypoglycemia unawareness and episodes of hypoglycemia. Specifically, the American Diabetes Association (ADA) noted that CGMS may be a valuable supplemental tool to standard blood glucose monitoring in patients with hypoglycemia unawareness and/or frequent hypoglycemic episodes. CGMS device has multiple benefits for this patient who has type 1 diabetes, on insulin pump with frequent hypoglycemia. Based on readings from the Dexcom G6 CGMS, the Control-IQ algorithm automatically adjusts basal insulin to prevent high and low blood sugars. Given this support, the requested CGMS that can turn on and off the basal supply of insulin in response to hypoglycemia (or predicted hypoglycemia), including a transmitting device, receiver device, and continually renewing supply of sensors, are medically necessary for treatment of this patients medical condition. Final Result: The reviewer determined that the requested equipment 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 certification in endocrinology, diabetes and metabolism 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 two-year-old female enrollee has requested speech therapy services, one hour per day, two times per week for treatment of the enrollees receptive/expressive language delay.  Findings:  The physician reviewer found that in this patients case, the requested services are medically necessary.  As noted by Nelson and colleagues, speech and language development is considered by experts to be a useful indicator of a childs overall development and cognitive ability and is related to school success.  The authors reported that identification of children at risk for developmental delay or related problems may lead to intervention services and family assistance at a young age when chances for improvement are best. Per the current medical evidence, speech and language delay must be taken seriously in young children, as the long-term consequences may be substantial.  As noted by Law and colleagues, children whose difficulties persist into primary school may have long-term problems concerning literacy, socialization, behavior, and school attainment.  These reviewers concluded that there is a positive effect of speech and language therapy interventions for children with expressive phonological and expressive vocabulary difficulties. This patient demonstrates significant delays in expressive speech/language skills that negatively impact her ability to express her needs and interact with peers and adults.  According to her therapist, she has made slow but steady progress as the therapeutic relationship has grown. The literature supports therapeutic intervention for children such as this patient as long as progress can be demonstrated.  All told, the requested speech therapy services, one hour per day, two times per week, are medically indicated for the treatment of this patient.