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

A 47-year-old female enrollee has requested electronic controlled thermal therapy post-operative cooling device for the treatment of her left knee status post arthroscopy and reconstruction. Findings:  The physician reviewer found that the use of cold therapy in the post-operative period has been practiced for nearly as long as knee surgery has been performed. The specific device in question uses ice placed in a bucket as the source of the lower temperature and needs to be filled less frequently than an ice pack. This convenience, however, has not been shown to add any additional benefit over treatment with simple ice packs. The maximum cooling that can be obtained through the post-operative dressing is the same and the two methods have similar outcomes. Therefore, given the absence of a proven medical benefit with the use of an electronic controlled thermal therapy device over a simple ice pack, the device cannot be determined to have been clinically necessary.
Appeal type: Medical Necessity
Decision: Upheld

An enrollee has requested reimbursement for ambulatory event monitor (loop recorder). Findings:  The physician reviewer found that in this patients case, there was no documentation that the patient would not be able to manage these devices or that these external devices have been tried and failed.  Guidelines endorsed by national organizations also consider these external monitoring devices appropriate for the initial evaluation of recurrent dysrhythmias.  Although implantable loop recorder monitoring may be a more sensitive method of detecting recurrent dysrhythmias compared to wearable devices it is not clear that the incremental identification of a low burden of atrial dysrhythmias would change treatment in this patient, who is already anticoagulated and on appropriate medical therapy.  Therefore, the ambulatory event monitor (loop recorder), either patient activated or auto-activated was not medically necessary for evaluation of this patient. Final Result: The reviewer determined that  the services at issue were 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 internal medicine with sub-specialty certification in cardiovascular disease 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 patient has requested reimbursement for magnetic resonance imaging (MRI) of the left arm. Cho and colleagues explain that neurogenic thoracic outlet syndrome is produced by compression of neurovascular structures exiting the thoracic outlet. The thoracic outlet is an anatomical area in the lower neck defined as a group of three spaces between the clavicle and the first rib through which several important neurovascular structures pass. Jones and colleagues report that MRI can evaluate the anatomy of the thoracic outlet, the soft tissue structures causing compression, and allow direct visualization of brachial plexus compression. Given that anatomical abnormalities or defects, such as prominent cervical ribs, fracture calluses, or compressive tumors are commonly demonstrated on imaging and may support a history and physical examination consistent with thoracic outlet syndrome, the service at issue was medically indicated. Therefore, MRI of the left arm was medically necessary for the evaluation of this patient.Final Result: The reviewer determined that the service at issue 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 neurology with sub-specialty certification in vascular neurology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

A 49-year-old male enrollee has requested for Alfa 2b injections for treatment of his Peyronies disease.  Findings:  The physician reviewer found that Peyronies plaques are a scarring of the penile shaft which causes curvature of the erect penis and some loss of erection. The etiology is not known, therefore treatment options remain limited. Multiple oral preparations have been tried including Potaba and Vitamin E, in addition to injections with Verapamil, collagenase, steroids and now interferon. An overall review of the medical literature supports the benefits of interferon Alfa 2b as an alternative to surgery, which most patients are reluctant to undergo given the degree of invasiveness of the procedure.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested digital breast tomosynthesis for breast cancer screening of the enrollee, who was asymptomatic.  Findings: Three physician reviewers found that 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, her breast tissue was described as heterogeneously dense.  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 was likely to have been more effective than other modalities for evaluating this patient.Final Result: Three reviewers determined that the service at issue is 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 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: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement and prospective authorization and coverage for skilled nursing facility (SNF) services. Findings:  The physician reviewer found that the patent has chronic medical conditions, but no new, significant medical issues. As of late November 2020, he was largely independent to supervision level for basic self-care and household level mobility, as well as with small sets of stairs. He was familiarized with the hip precautions but still required some verbal cues. The patients rehabilitation continued with additional progress and his family was trained. By the first date of the Health Plans denial, the patient could have reintegrated to the community with occasional custodial level assistance, community-based therapy, and nursing services. There are no documented therapy, nursing or medical issues that would have required ongoing SNF level care services by the date of . Further rehabilitation to potentially help the patient improve to ambulating without an assistive device could have been pursued in the community setting. For patients undergoing major lower limb joint arthroplasty, the standard of care includes aggressive pain management and early mobilization and rehabilitation (Masaracchio, et al.). Many patients can be discharged home safely following short-term rehabilitation on the acute post-surgical ward followed by outpatient care following total joint arthroplasty (Basques, et al.; Fleischman, et al.). The data do not generally support the benefit of long-term inpatient rehabilitation programs in the setting of total joint arthroplasty (Mak, et al.; Hutchinson, et al.; Naylor, et al.). Given these findings, the SNF services were not and are not medically necessary for treatment of this patient.Final Result: The reviewer determined that the services at issue at issue were not and are not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in physical medicine and rehabilitation and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested Harvoni for treatment of his hepatitis C virus.   Findings:  The physician reviewer found that according to the most recent joint guidelines issued by the American Association for the Study of Liver Diseases (AASLD) and the Infectious Diseases Society of America (IDSA), all patients with chronic hepatitis C should be treated except those with limited life expectancy due to nonliver-related conditions. This applies regardless of fibrosis stage or viral load. The guidelines recommend that treatment-naive genotype 1a patients should be treated with Harvoni for 12 weeks. These guideline recommendations are based on multiple randomized clinical trials, and the medication is U.S. Food and Drug Administration (FDA) approved for all patients with chronic hepatitis C genotype 1 regardless of fibrosis stage (Kowdley, et al; Afdhal, et al). Non-cirrhotic patients who have failed the PEG-interferon/ribavirin with or without a protease inhibitor are recommended to have the same treatment (Lawitz, et al).  AASLD/IDSA guidelines cite data showing reduced survival with delayed treatment (Jezequel, et al). No alternative therapies have been approved. For these reasons, the requested treatment with Harvoni is supported as medically necessary for the treatment of this patients hepatitis C infection. Final Result: The reviewer determined that the requested medication 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 gastroenterology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary:   An enrollee has requested vestibular autorotation testing (VAT) for evaluation of his medical condition. Findings:  Three physician reviewers found that vestibular rotation testing is a high frequency, active head rotation test used to subjectively evaluate the vestibular-ocular reflex and its function. Patients wear a lightweight head-strap with a velocity sensor on the back. The patients follow instructions to shake their head, first side-to-side, and then up-and-down. Conventional electro-olfactogram electrodes placed around the eyes measure eye movements. Although some published studies have suggested that the VAT may be useful in evaluating patients with vestibular disorders/diseases, there are few studies that examined the sensitivity and specificity of the VAT in evaluating patients with suspected vestibular abnormalities. Furthermore, there is a lack of data supporting the value of the VAT in the management of patients with vestibular disorders/diseases. There are other accepted tests of the vestibular system that are available. For the reasons provided, the requested services are not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.  Final Result: Three reviewers determined that the requested services are 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: One reviewer is board certified in physical medicine and rehabilitation with a sub-specialty certification in pain management and is actively practicing. One reviewer is board certified in physical medicine and rehabilitation with sub-specialty certification in neuromuscular medicine and is actively practicing.  One reviewer is board certified in physical medicine and rehabilitation and is 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: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Admission to a skilled nursing facility (SNF) until the patient is mobile and able to care for herself. Based on  the available information, the SNF-level services provided from 10/11/21 forward are medically necessary for the management of this patients post-COVID-19 syndrome. The patient remains acutely deconditioned after a prolonged hospitalization for COVID-19 pneumonia and acute hypoxemic respiratory failure requiring mechanical ventilation with tracheostomy and PEG placement. The patients current condition remains an acute deterioration of her former baseline level of functioning. The admission to a SNF has not provided an adequate amount of time to allow for the patient to improve with physical therapy and occupational therapy. As noted in the medical literature, patients often requirement multiple months to fully recover after severe illness from COVID-19 (Bowles, et al.; Chopra, et al.). These findings support that continuation of SNF services with a focus on aggressive physical therapy and occupational therapy with the goal to regain mobility and independence in ADLs is appropriate for this patient. Therefore, the admission to a SNF until the patient is mobile and able to care for herself 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 internal medicine with subspecialty certifications in pulmonary diseases and critical care 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: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested Viagra 50 mg for treatment of the enrollees erectile dysfunction. Findings: The physician reviewer found that this patient had very limited evaluation of his erectile dysfunction. There should be detailed sexual history obtained. There should also be detailed genitourinary examination performed on this patient. Blood work including serum testosterone should also be assessed. In the absence of this documentation, the requested Viagra 50 mg is not supported as medically necessary for 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 urology 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 58-year-old woman who is requesting reimbursement for a series of Hyalgan injections given for clinically significant osteoarthritis of the left knee.  She had her first series of Hyalgan injections several years ago as well as two arthroscopic surgeries.  The patient had a recurrence of her left knee pain in August 2004 and completed a second series of five Hyalgan injections on the recommendation of her provider.  The Health Plan has denied the patients request for reimbursement for the Hyalgan injections as they have determined that a repeat series of injections was not medically necessary.After one series of Hyalgan injections has been given for an arthritic knee, the standard treatment alternatives include NSAIDs, cortisone injections, physical therapy, etc.  There is insufficient evidence in the current literature to support the theory that a repeated series of Hyalgan injections will improve outcomes for arthritic knees over those achieved with standard treatment alternatives. Therefore, I have determined the therapy at issue was not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld

The patient is a 54-year-old female who has a history of facial cellulitis. This is due to a long healing process. She has a noted deformity on the left side of her nose measuring 1cm at its widest point. Her plastic surgeon has recommended she under go an excision and reconstruction with bilobed flap. The Health Plan has denied this request indicating the requested procedure is cosmetic in nature and not medically necessary.The patient is requesting scar revision of the left side of the nose. The photograph demonstrates a 1cm depressed scar. This does not interfere with nasal function. This acquired deformity is cosmetic in nature. In addition, scar revision entails the creation of a new scar. A bilobed flap will cause additional scarring on the thick sebaceous skin of the nose. As such, if this were deemed a reconstructive procedure there is high probability there would only be minimal, if any, improvement in appearance. Therefore, I have determined that the requested procedure is not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for participation in the Stanford Comprehensive Interdisciplinary Pain Program (SCIPP) for treatment of the enrollees degenerative disc disease. Findings:  The physician reviewer found that the Joint Commission standards for pain management supports the efficacy of a multidisciplinary approach to pain management. The study re-enforced this approach citing the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) standards. The medical literature has shown that the multidisciplinary approach is statistically better than no treatment or single specialty treatment.  The benefits of this approach were also found to be longer lasting than either of the alternatives. In this patients case, he was identified as a viable candidate for a multidisciplinary program. As such, this patient may benefit from participating in this multidisciplinary treatment option. All told, the SCIPP program is medically indicated for the treatment of this patient. Final Result: The reviewer determined that I have 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 anesthesiology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested for acupuncture services for treatment of the enrollees back pain.  Findings: The physician reviewer found that there is support in the medical studies for the requested services in this clinical setting. The current research supports the use of acupuncture for neck pain and also for acute pain. The standard of care for acupuncture services is not limited only for the treatment of chronic pain. In this patients case, he was also diagnosed with chronic pain. The patient sought acupuncture services for acute cervical radiculopathy and reported clinical improvement from the acupuncture services. The patient made multiple trips to his primary care and neurology providers. He also has made several trips to the emergency room for treatment of his pain. The provider was not able to schedule him with pain management in a timely manner. The submitted records indicate that this patient had exhausted available resources. Therefore, acupuncture is medically necessary for the 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 oriental 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

A 36-year-old female enrollee has requested for bariatric surgery for treatment of her morbid obesity. Findings:  The physician reviewer found that there is a lack of scientific data that supports pre-operative weight loss. Additionally, there is no scientific data that shows long-term or short-term benefit for non-surgical weight loss trials. This patient should be allowed to have weight loss surgery without delay for treatment of her conditions.
Appeal type: Medical Necessity
Decision: Overturned

A 37-year-old female enrollee has requested bilateral breast reduction for the treatment of her macromastia. Findings:  The physician reviewer found that this patient has the typical symptoms of macromastia. It is certainly possible that her symptoms are due to the weight of her enormous breasts. The constant pull of heavy breasts against the upper torso is a mechanical problem and conservative treatments have been shown to be ineffective for symptomatic macromastia. Non-operative treatments are unlikely to improve her pain, and it is likely in this case that surgery will provide the only real chance for symptomatic relief. However, the submitted clinical records do not include the results of a plastic surgery consultation. Given the patients symptoms and the massive size of her breasts, consultation with a plastic surgeon to determine if a breast reduction may alleviate her musculoskeletal symptoms is warranted.