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

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for digital breast tomosynthesis for the evaluation of the enrollees breast cancer screening. Findings:  The 3 physician reviewers found that the patient is a female who presented for a bilateral screening mammogram with digital breast tomosynthesis. There was no mammographic evidence of malignancy. The patient reported a history of breast cancer in her mother. The current study noted her breast tissue was dense. The impression was benign. The Health Plan denied the request for reimbursement for the digital breast tomosynthesis performed. Per the Health Plan, the service at issue was investigational for the evaluation of this patient. The medical studies support the service at issue. According to colleagues, the use of mammography plus tomosynthesis in a screening environment resulted in a significantly higher cancer detection rate and enabled the detection of more invasive cancers. Colleagues noted that integrated two dimensional and three dimensional mammography improves breast cancer detection and has the potential to reduce false positive recalls. The literature supports the use of breast tomosynthesis over conventional mammogram due to improved cancer detection rate.  As such, digital breast tomosynthesis performed was likely to have been more effective than other methods of evaluating this patient. Final Result: The 3 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: Physician reviewer number one is board certified in diagnostic radiology 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.Physician reviewer number two is board certified in diagnostic radiology 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.Physician reviewer number three is board certified in diagnostic radiology 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:  The enrollees parent is requesting authorization and coverage for occupational therapy services. The enrollee received occupational therapy on for sensory processing difficulty, motor delay, lack of coordination, difficulty with activities of daily living, and feeding difficulties. Records show the enrollee demonstrated decreased strength, decreased endurance, decreased self-care skills, and decreased safety. Records show he was struggling with a variety of food textures, clothing textures, fine motor skills, writing, and pedaling a tricycle. Literature shows atypical behavior can negatively influence a child's enjoyment and participation in everyday activities. Poor participation in everyday activities negatively affects developmental skills. Allen and colleagues indicate occupational therapy is the standard of care for children with developmental delays and/or a sensory processing disorder.Final Result: The reviewer determined that the requested services are medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The physician 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 similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

A 42-year-old female enrollee has requested Neulasta injections for the treatment of her medical condition. Findings:  The physician reviewer found that the use of pegfilgrastim (Neulasta) to prevent febrile neutropenia following TAC chemotherapy is justified under both the National Comprehensive Cancer Network (NCCN) guidelines and the American Society of Clinical Oncology (ASCO) guidelines. The FDA approval label for the drug states that it is approved for the prevention of febrile neutropenia in patients treated with cytotoxic chemotherapy from which a high incidence of febrile neutropenia is expected.
Appeal type: Medical Necessity
Decision: Overturned

A 49-year-old female enrollee has requested for a total hysterectomy and bilateral salpingo-oophorectomy utilizing the da Vinci Surgical System for treatment of her stage IV endometriosis. Findings:  The physician reviewer found that the surgical treatment of stage IV endometriosis is one of the most difficult procedures facing the non-oncologic gynecologic surgeon.  The da Vinci Surgical System is an appropriate alternative to both the traditional open approach as well as conventional laparoscopy. The robotic platform allows the most complex procedures to be performed with incredible precision. For a patient with stage IV endometriosis who requires a hysterectomy or ureterolysis or enterolysis, it would most likely allow significantly less postoperative pain, less blood loss and quicker recovery.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The Enrollee has requested authorization and coverage for residential detoxification and chemical dependency treatment program. The enrollee has been non-adherent with past treatment recommendations. The enrollee has not engaged in a recent evaluation of medical, psychiatric and substance use symptoms. The treatment team has recommended against residential treatment on several occasions due to the patients lack of treatment adherence. A study found, the requested services are not medically necessary. For dimension 1) acute intoxication and/or withdrawal potential, the progress notes indicate that the patient has no reported recent significant withdrawal symptoms. The clinical information provided does not support acute intoxication and withdrawal. For dimension 2) biomedical condition and complications, the patient does not have any reported comorbid conditions or complications. The clinical information provided does not support significant biomedical conditions and complications. According to the criteria, the patient must meet all six dimensions for placement in at the residential level of care. This enrollee does not meet the first two dimensions, and thus does not meet the criteria for residential treatment. Therefore, the requested residential detoxification and chemical dependency treatment program is 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 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: Upheld

A 66-year-old male has requested a specific surgical procedure as recommended in a consultation report for treatment of his left lower back pain radiating to the left leg and foot.  Findings:  The physician reviewer found that the submitted documentation fails to establish the medical necessity of the requested procedure in this patients case.  In this case, CT myelogram showed medial placement of the L3 and L4 pedicle screws.  The immediate postoperative onset of this patients symptoms was consistent with nerve impingement from these screws.  Nerve impingement is a known complication of medial screw placement.  Lonstein and colleagues performed a retrospective review on pedicle screw procedures.  The authors reported 4790 screw placements during 915 operative procedures on 875 patients.  Nerve impingement occurred in 1% of these procedures.  Three patients had residual neurological weakness despite removal of the screws.  Thus, the utility of removing the screws was not demonstrated.  The current medical evidence does not support the requested procedure in this patients case.
Appeal type: Medical Necessity
Decision: Upheld

The patient is a 58-year-old male with a smoking history of approximately 60 pack/year. He has had episodes of acute bronchitis that were treated with antibiotics. He complains of cough, fatigue, chest tightness, and shortness of breath. A chest x-ray performed in December 2003 was normal. The patient is requesting a low-dose helical screening CT scan of the chest. The Health Plan has denied the request on the basis that the requested CT scan is not medically necessary for evaluation of the patients medical condition. The Health Plan recommends further evaluation by a pulmonologist.  Currently, there are several on-going clinical trials evaluating the efficacy of screening CT scans of the chest for lung cancer. This patient may qualify for one of these studies. However, earlier detection of lung cancer by screening CT scans of the chest (low-dose or otherwise) has not yet shown to decrease mortality from lung cancer and is currently not the standard of practice. The Health Plans recommendation that the patient be evaluated by a pulmonologist is medically reasonable and appropriate. Low-dose helical screening CT scans of the chest are of unknown efficacy at this time and therefore, not medically necessary. Based upon the information set forth above, I have determined that the requested CT scan is not medically necessary for evaluation of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Experimental/Investigational
Decision: Overturned

A 58-year-old male enrollee has requested a trial of spinal cord stimulator for treatment of his low back pain.   Findings:  Two physician reviewers found that the patient has refractory pain that is unlikely to benefit from a very large and risky surgical procedure.  The surgical notes detail a history of tried and failed interventional and medical therapy.   The patients providers agree he is a reasonable candidate for trial stimulation.  The trial of spinal cord stimulator will allow for extended assessment with minimal risk.  The use of spinal cord stimulation in this patient has the potential to restore function, decrease medication use, and avoid a large surgical procedure with uncertain outcome.  In this patients case, there is sufficient evidence supporting the requested trial of spinal cord stimulator.  Therefore, the requested services are likely to be of greater benefit than other treatment options in this clinical situation.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for occipital nerve block treatment (CPT code 64405). Findings:  The physician reviewer found that there is sufficient support in the medical literature for the efficacy of the services at issue in this clinical setting. The records indicate that this patient has chronic migraine, despite a variety of preventives. The patient continues to be treated with rescue therapeutics including opiates, butalbital, and Decadron. Moreover, the diagnoses and examinations are consistent with occipital neuralgia as well as chronic migraine. There is evidence for the treatment of migraine and occipital neuralgia with occipital nerve block. Occipital nerve block is a standard of care for patients with chronic migraine, episodic migraine for rescue, as well as occipital neuralgia. All told, the occipital nerve block treatment (CPT code 64405) was likely to have been more efficacious than the standard options for the treatment this patients medical condition.Final Result: Two of the three reviewers determined that the services 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: Physician reviewers 1,2 & 3 are board certified in neurology and are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient was diagnosed with right shoulder osteoarthritis, right shoulder impingement syndrome, right shoulder pain, and right shoulder incomplete rotator cuff tear or rupture. The records noted that the patient received a right shoulder subacromial injection, which did not provide significant pain relief. Her prior treatment included physical therapy and medications, including meloxicam and cyclobenzaprine. The patients provider noted a magnetic resonance arthrogram of the right shoulder showed moderate acromioclavicular arthrosis, rotator cuff tendinosis, and a high grade partial tear of the supraspinatus. The patient has requested reimbursement for right shoulder arthroscopy with rotator cuff repair, subacromial decompression, and distal clavicle excision that was performed. The Health Plan denied the request and reported the services at issue were not medically necessary for the treatment of this patient. At issue in this case is whether right shoulder arthroscopy with rotator cuff repair, subacromial decompression, and distal clavicle excision that was performed were medically necessary for the treatment of the patients medical condition. Studies reported that if conservative management fails, surgical procedures are suggested, including arthroscopic debridement of the tear, debridement with acromioplasty, rotator cuff repair with or without acromioplasty, tear completion and repair, and transtendon procedure. The medical evidence supports the services at issue in this clinical setting. In this patients case, the records noted that the patient had adequate conservative measures for shoulder pain. The clinical notes documented that her prior treatment included physical therapy and injection therapy. The criteria for surgery was met, and the services at issue were medically indicated. Therefore, right shoulder arthroscopy with rotator cuff repair, subacromial decompression, and distal clavicle excision that was performed was medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested service was 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 47-year-old female enrollee has requested for continued skilled nursing for treatment of her back pain. Findings:  The physician reviewer found that review of the submitted clinical evidence demonstrates that although the patient was unable to complete a course of rehabilitation, she has been making some progress. While the patient is not likely to experience a dramatic recovery, additional skilled care services are appropriate to continue the gains she has already made.
Appeal type: Medical Necessity
Decision: Overturned

The representative of a 20-year-old female enrollee requested authorization and coverage of extensive inpatient residential care treatment.  The Health Plan denied the request indicating that inpatient care is not medically necessary at this time.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 is medically necessary.
Appeal type: Urgent Care
Decision: Overturned

A 24-year-old male enrollee requested urgent care on an emergent or urgent basis for medical treatment of his right ankle.  Findings:  The patient presented with unexplained pain, swelling and inflammation of the right ankle which was preventing normal function and activity. In addition, his vital signs were abnormal and the possible etiologies of infection, acute inflammatory arthritis, malignancy, could have potentially led to serious dysfunction to bodily functions and serious dysfunction of any bodily organ or part.  Based on the documentation submitted for review a prudent layperson in a similar situation would have believed immediate medical attention was necessary to prevent serious deterioration of ones health. In sum, based on the patients clinical presentation he did meet prudent layperson criteria for urgently needed services.
Appeal type: Experimental/Investigational
Decision: Overturned

The enrollee requested reimbursement for the blood test to measure antibodies to vedolizumab. The enrollee has a history of Crohns disease. She was admitted as an in-enrollee for abdominal pain from Crohns disease with complications. The provider instructed the enrollee to follow-up with the Entyvio drug levels. Literature reports that in enrollees with Crohn's disease who are being treated with biologic medications, the use of therapeutic drug monitoring leads to a personalized approach to optimize treatment. Measurement of drug concentrations and anti-drug antibodies can be used to improve treatment outcomes. Therapeutic drug concentrations and absence of antibodies are associated with improved clinical and endoscopic outcomes. In clinical practice, therapeutic drug monitoring has been shown to be clinically useful in enrollees experiencing a loss of response to treatment.Final Result: The reviewers determined that the requested service was likely to have been more beneficial than any available standard therapy for treatment of the enrollees medical condition. Credentials/Qualifications: The reviewers are board certified in gastroenterology and are actively practicing.  The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a five-year-old male enrollee has requested for 30 hours per week of applied behavioral analysis (ABA) therapy for treatment of the enrollees autism. Findings:  The physician reviewer found that many studies show that ABA therapy is effective in improving sensory issues and teaching new skills. In addition, many studies demonstrate that ABA is effective in reducing problem behavior (Horner, et al.). A number of studies also indicate that, when implemented intensively (more than 20 hours per week) and beginning prior to the age of 4 years of age, ABA may produce large gains in development. This patient exhibits high sensory needs which pose a challenge to his ability to self-regulate and control his impulses. He becomes easily frustrated with his communication delays and resorts to negative behaviors of tantrums and inappropriate sensory seeking behaviors. These deficits continue to limit his participation in less restrictive environments within his school and community settings. Further, his difficulties continue to cause significant safety concerns requiring very close supervision at all times.
Appeal type: Medical Necessity
Decision: Upheld

A 62-year-old female enrollee has requested for augmented soft tissue mobilization (ASTYM) for treatment of her lower leg edema and excess scar tissue. Findings:  The physician reviewer found that proponents of ASTYM contend that the therapy stimulates regeneration and healing of soft tissues, improving tissue strength and alignment in patients with soft tissue injuries. While the therapy appears to be promising, it has not been subjected to large scale, double-blind, randomized clinical trials. In the absence of head-to-head studies comparing ASTYM to standard physical therapy, the medical necessity of ASTYM for this patient has not been established.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary:  An enrollee has requested home health aide services during the evenings and weekends for treatment of her medical condition. Findings:  The physician reviewer found that according to the documentation submitted for review, the patient presents with ALS and is in hospice. She has chosen to receive hospice care in the home setting. The medical literature notes that intensive home hospice services can be necessary to meet the goals of the patient. In the present case the patient is dependent for self-care and functional mobility which requires assistance twice daily to ensure she remains clean and comfortable. A study found that respiratory symptoms are a significant problem for ALS patients in hospice. Patient positioning is an important part of managing these symptoms and having home health aides visit twice daily will improve the patients positioning. Evidence supports that the patient will benefit from home health aide services twice daily.  In sum, home health aide services during the evenings and weekends, twice daily is medically necessary in this clinical setting.  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 physical medicine and rehabilitation with sub-specialty certification in neuromuscular 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: Overturned

The patient is a female toddler with port wine stain V2 distribution. She underwent six V-beam laser treatments with a pediatric laser expert. It has been noted that results of the treatment were partial and the response was not entirely satisfactory. The patients provider has indicated that she does not have any alternative therapy to offer the patient. The patient has been examined by another provider who has recommended C-beam pulsed dye laser therapy (PDL).An abundance of medical literature supports treating port wine stain early in life for best long-term results. In light of the fact that there are no further treatment modalities to offer this young patient, the requested therapy is medically indicated. While available data regarding C-beam PDL is limited, preliminary data suggests that C-beam PDL has the capability of providing an improvement for this patient. Given that other established alternatives have been exhausted, treatment with C-beam PDL is medically reasonable and appropriate. Based upon the information set forth above, I have determined that the requested therapy is medically necessary for treatment of the patients medical condition. The Health Plans denial should be overturned.