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

An 18-year-old female enrollee has requested an upper gastrointestinal (GI) endoscopy, or esophagogastroduodenoscopy (EGD) for evaluation of her epigastric abdominal pain.  Findings:  The physician reviewer found that this patients records suggest that there is a low to moderate suspicion for celiac disease. In general, the first step in management includes assessing for celiac antibodies such as IgA tissue transglutamase antibodies. To that end, an EGD would not be indicated as a first diagnostic step. However, in this patient with upper GI tract symptoms and occult blood in the stool, performing an EGD is clinically indicated and supported in the medical literature. Rockey and colleagues concluded that, In a group of patients with positive fecal occult-blood tests who were referred for further evaluation, from which those with iron-deficiency anemia and active bleeding had been excluded, upper gastrointestinal lesions were identified more frequently than colonic lesions. As this patient has been ruled out for anemia and had a positive fecal occult blood test, the requested EGD diagnostic procedure should be approved as medically necessary for further evaluation of this patients condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for an Orthovisc injection series (weekly for a total of 4 injections) in the left knee.Findings: Current medical literature pertaining to viscosupplementation reveals mixed results. Evidence from eight systematic reviews and six randomized controlled trials indicates that although viscosupplementation may relieve knee pain in some individuals with osteoarthritis, it is not known which individuals will benefit. Different studies have tried mixing hyaluronic acid with corticosteroids, platelet rich plasma, and other agents to make it more effective. The current evidence is limited, and guidelines from organizations such as the American Academy of Orthopedic Surgeons indicate that the evidence is not conclusive. As such, the academy does not currently support viscosupplementation as standard treatment for osteoarthritis of the knees. In light of the foregoing, viscosupplementation can only be recommended in individuals with a history of lasting benefit from prior injections and in carefully selected cases where everything else has been tried and the options are limited. In this case, there is a history of benefit from viscosupplementation of the left knee for several years and other modalities have not provided significant improvement. Under these circumstances, the requested Orthovisc injection series (weekly for a total of 4 injections) in the left knee is medically necessary for the patients medical condition.Final Result: The reviewer determined that the requested services are medically necessary for 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: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested brachytherapy with catheter placement for treatment of her ductal carcinoma in situ. Findings:  Two physician reviewers found that brachytherapy is a form of radiation therapy that involves the implantation of radioactive seeds or sources in or near an existing tumor to maximize delivery of radiation to cancerous cells while minimizing exposure and potential damage to adjacent normal structures.  High dose rate brachytherapy consists of the placement of thin catheters into the tumor.  There has been recent interest regarding the use of brachytherapy for the treatment of breast cancer.  There are a few published trials in the medical literature suggesting safety and efficacy of brachytherapy.  However, there is a lack of randomized or long-term cohort trials for long-term clinical outcome compared to external beam radiation therapy.  Additionally, National Comprehensive Cancer Network guidelines do not recommend this treatment for patients younger than 60 years of age.  Thus, the current medical evidence has not established the superior efficacy of the requested brachytherapy with catheter placement in this patients case.  Final Result: Two reviewers determined that the requested services are 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: All 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: Experimental/Investigational
Decision: Upheld

A female enrollee requested bilateral sacroiliac joint fusion surgery for medical treatment of her medical condition.  Findings:  Three physician reviewers found that while it is noted that the patient has failed multiple conservative treatment options, there is a lack of imaging provided for review to validate that there is a dysfunction within the patients sacroiliac joint that would support the requested services.  Without clear evidence that the patient has objective findings per an imaging study of a deficit within the bilateral sacroiliac joints, the requested procedure would not be supported.  All told, the requested bilateral sacroiliac joint fusion surgery is not likely to be of greater benefit than other treatment options in this patients case.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for bilateral facet joint injection at three (3) levels (CPT 64493, 64494, 64495, HCPCS J1100). Authors studied the effectiveness of different lumbar facet blocks, concluding, This study establishes that facet blocks are not therapeutic. The higher responder rates in the treatment groups suggest a hypothesis that facet blocks might provide prognostic value before radiofrequency ablation. Researchers supported the use of lumbar facet joint nerve blocks as a diagnostic tool, while evidence for therapeutic facet joint interventions was limited for intraarticular injections. In this case, the patient had low back pain without radiation into the lower extremities. Her physical examination findings were notable for lumbar paraspinal tenderness and a limited range of motion with lumbar extension. There was no documentation that the recommended bilateral lumbar medial branch blocks of L3-4 to L5-S1 were for diagnostic purposes to evaluate for a future radiofrequency ablation procedure at these levels. Rather, the provider notes suggest that these injections are intended for therapeutic purposes only. Based on the current medical literature and this patients medical records, the requested services are not medically indicated. Therefore, bilateral facet joint injection at three (3) levels (CPT 64493, 64494, 64495, HCPCS J1100) are not medically necessary for the 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 anesthesiology with sub-specialty certification in pain 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: Urgent Care
Decision: Overturned

A 38-year-old female enrollee has requested emergency services for the treatment of her postoperative complications (shoulder). Findings:  The physician reviewer found that the patient had arthroscopic surgery two days prior. She was concerned about bleeding and complained of pain that was moderate in nature.The patients symptoms met prudent layperson criteria for emergency care. A prudent layperson with an average knowledge of medicine and pain and bleeding after attempting to remove a catheter placed during shoulder surgery two days earlier would reasonably expect the absence of emergency care to jeopardize their health.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for transcranial magnetic stimulation (TMS). Current medical literature supports the use of TMS for the treatment of refractory and chronic depression. McClintock and colleagues note that there is an abundance of data pertaining to the safety and efficacy of TMS for individuals with major depressive disorder. The American Psychiatric Association (APA) guideline for the treatment of major depressive disorder recognizes the safety and efficacy of TMS in the treatment of patients with a prolonged course of depression. Kisely and colleagues report that deep brain stimulation shows promise for treatment-resistant depression. In this case, the patient has a long history of refractory depression, with continued significant neurovegetative symptoms. The records document numerous medication trials and difficulty tolerating most medications due to adverse effects and limited efficacy. The patient has been in evidence-based therapy with limited improvement. In this clinical setting, the requested service is medically indicated. In this patients case, TMS is in accordance with the generally accepted standards of mental health and substance use disorder care. Additionally, the requested service is clinically appropriate in terms of type, frequency, extent, site, and duration. The requested service is not primarily for the economic benefit of the health care service plan and subscribers or for the convenience of the patient, treating physician, or other health care provider. Therefore, TMS is medically necessary for the treatment of this patient.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: Upheld

The parent of a 16-year-old male has requested coverage for Provigil or Nuvigil for treatment of his narcolepsy.  Findings:  The physician reviewer found that the submitted documentation fails to establish the medical necessity of the requested medications in this clinical situation.  The documentation noted that Adderall has been discontinued.  However, details regarding possible side effects with this treatment were not provided. Additionally, there is no evidence that therapeutic alternatives, such as Ritalin or Dexedrine, were considered.  Furthermore, the medical records do not demonstrate that this patient has been evaluated by a pediatric sleep specialist.  The medical records do not show that this patient has been treated with alternatives to Adderall which are approved for children under the age of 17.  The current medical evidence does not support the requested medications in this patients case.
Appeal type: Medical Necessity
Decision: Overturned

The parent of an enrollee requested residential treatment for medical treatment of the enrollees depression and anxiety. Findings:  The physician reviewer found that the weekly notes prior to discharge and the last master treatment plan indicate that the patient continued to have difficulty engaging in treatment and communicating with his treatment team and family. He was at less than 50% in his achievement of his treatment goals. Given the level of the patients involvement and progress, continuation of residential treatment services was medically necessary to prevent relapse and ensure a smooth transition to a lower level of care.
Appeal type: Medical Necessity
Decision: Overturned

The enrollee is a 40-year-old female who has requested a duodenal switch procedure for treatment of her morbid obesity.  Findings:  The physician reviewer found that this patient is morbidly obese, has failed supervised weight loss and has completed a thorough multidisciplinary evaluation that did not reveal any obvious barriers to surgery. The patient is requesting the duodenal switch, a standard procedure for treatment of morbid obesity that is approved by the American Society of Metabolic and Bariatric Surgery, the American Medical Association and the Centers for Medicare and Medicaid Services. There are no contraindications to the duodenal switch procedure based on the information provided. Therefore, the duodenal switch procedure is a medically appropriate and reasonable option for treatment of this patients morbid obesity.
Appeal type: Medical Necessity
Decision: Overturned

A 51-year-old female enrollee requested authorization and coverage of a referral to an opthomologist for the treatment of poor vision.  The Health Plan denied the enrollees request indicating that the requested treatment is not medically necessary.One physician reviewer performed a medical necessity Independent Medical Review.  The physician reviewer overturned the health plans denial on the basis that the requested services are  medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned

A 52-year-old female enrollee has requested intensity modulated radiation therapy (IMRT) for treatment of her recurrent breast cancer in the left axilla.  Findings:  The physician reviewer found that intensity modulated radiation therapy (IMRT) is a technique used to improve the dose conformality. The use of IMRT for the treatment of breast cancer is becoming a standard approach. In general, IMRT is a radiation planning and delivery tool available to the radiation oncologist to better shape the radiation dose distribution, and therefore minimize the dose to normal structures. IMRT is a tool that clinicians can use when there is concern about sparing normal tissues from high dose exposure. IMRT generally implies inverse planning algorithms, i.e., the physician determines radiation treatment parameters to maximize dose to the target and minimize dose to normal tissues, and the planning algorithm maximizes the adherence to these parameters by modifying the beam spatially and/or temporally. This patients situation is unique in that traditional radiation fields are not being used because the chest wall is not being treated, and in fact, effort is being made to avoid the chest wall. The use of IMRT in the treatment of breast cancer has been well studied in the scientific literature. Advantages of IMRT are to reduce the dose to the heart (which is relevant to this patient with a left sided tumor), lungs, skin and contralateral breast/chest.  IMRT can also improve the dose homogeneity of the treatment volume, and therefore reduce the hot spots that are often seen in the lateral chest wall. In general, with complex radiation targets, IMRT is useful in maximizing target coverage and minimizing normal tissue coverage. IMRT can be considered medically necessary to reduce the dose delivery to the lung and heart, and in this case, the chest wall. Given the specifics of this case, IMRT is superior to a 3D conformal plan as typical breast cancer radiation treatment fields are not being used, but rather a complex treatment of axillary and supraclavicular nodal irradiation is planned, with explicit planned avoidance of the implant. As such, the medical necessity of IMRT in this particular setting has been established.
Appeal type: Medical Necessity
Decision: Overturned

A 25-year-old female enrollee requested authorization and coverage of the medication Yasmin for the treatment of polycystic ovarian syndrome and hirsutism.  The health plan denied the enrollees request indicating that the requested treatment is not medically necessary.One physician reviewer performed a medical necessity Independent Medical Review.  The physician reviewer overturned the health plans denial on the basis that the requested medication is medically necessary.
Appeal type: Medical Necessity
Decision: Upheld

A 47-year-old male enrollee has requested BioMat 7000MX infrared heating pad system for treatment of his multiple myeloma. Findings:  The physician reviewer found the Centers for Medicare and Medicaid Services (CMS) indicate that the BioMat and similar devices are not considered medically necessary due to lack of evidence of therapeutic value. The guidelines state that, there are no indications for which these devices have been demonstrated to have any therapeutic effect. The device and any related accessories will be denied as not medically reasonable and necessary. In addition, the National Comprehensive Cancer Network (NCCN) guidelines do not support the utility of infrared heating pads in treating patients with multiple myeloma. All told, there is a lack of evidence that the requested device is medically necessary for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Genotropin MiniQuick 1.2 mg SQ injection daily. The Health Plan has denied this request indicating that the requested medication is not medically necessary for treatment of the enrollees idiopathic short stature.Findings: The medical necessity for growth hormone therapy is not supported by the submitted records. Based on the documentation provided, the patient may have a component of short stature, on the basis of mild constitutional delay. The patients adult predicted height is at the lower limit of normal for the presumed genetic target. As such, the data provided does not indicate that the patient meets criteria for supplemental growth hormone therapy. The ongoing height velocity appears to be consistent with what is commonly observed in children with short stature on the basis of constitutional delay. The available laboratory data does not support a diagnosis of growth hormone deficiency. Accordingly, growth hormone therapy would not be recommended based on this patients current growth pattern. Therefore, Genotropin MiniQuick 1.2 mg SQ injection daily has not been established as medically necessary for the treatment of this patients medical condition.Final Result: The reviewer determined that the requested medication is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is board certified in pediatrics with sub-specialty certification in pediatric endocrinology 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

An enrollee has requested authorization and coverage for OxyContin 10 mg, twice daily. Findings:  The physician reviewer found that this patient had pain which was not adequately controlled with doses of immediate release oxycodone and non-steroidal analgesics such as ibuprofen. He required increased analgesic doses and sustained release and breakthrough short acting opioid analgesic.  It is understandable that the provider would choose OxyContin since the patient was already on short acting oxycodone. However, there is no reason to expect sustained release morphine, at equianalgesic dose, would not be as effective. Therefore, in this patients case, the requested OxyContin 10 mg, twice daily is not medically indicated for treatment of this patient. Final Result: The reviewer determined that the requested medication is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in internal medicine with sub-specialty certification in medical oncology 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 a hospital stay for treatment of her medical condition. Findings:  The physician reviewer found that the services at issue have not been established as medically necessary in this clinical setting. The patients altered mental status (AMS) had resolved.  The patient was tolerating an oral diet and medications, she was voiding without problems and was ambulating independently. The laboratory studies were unremarkable. The physical exam was normal. According to Uptodate.com, confusional states can take days to weeks to manage.  Because delirium may require weeks or months to fully resolve, management often extends into subacute settings. In this case the patients AMS had resolved. Thus, the patient was stable with improved symptoms and lab studies, she could have safely been discharged for further outpatient care.  Given the above, the services at issue were not clinically indicated for the treatment of the patients medical condition. Final Result: The reviewer determined that the services at issue were 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.