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

The patient has requested reimbursement for mobile cardiac telemetry monitoring. Current expert consensus guidelines endorsed by several national organizations consider patient activated event recorders and other offline monitoring devices appropriate initial tests for evaluation of supraventricular dysrhythmias. Immediate recognition and reporting of dysrhythmias through a call center provided by real-time mobile telemetry services has not been shown to improve health outcomes compared to standard monitoring techniques. In this patients clinical circumstance, cardiac monitoring during recurrent symptoms with non-real-time monitoring devices, such as 48-hour Holter monitoring or event monitoring, would have been sufficient for identification of both symptomatic and asymptomatic dysrhythmias. Similarly, self-activated non-continuous monitoring devices that are not real-time are effective at recording symptomatic dysrhythmias during less frequent symptoms. In cases of infrequent asymptomatic dysrhythmias that require identification, monitoring devices with auto-triggering capability without real-time monitoring are appropriate. In this case, the patients diagnoses include essential thrombocythemia as well as intermittent chest discomfort, and presyncope. There is no documentation to indicate that the patient was unable to manage standard monitoring devices or that these options were attempted to evaluate the patients condition. For these reasons, the mobile cardiac telemetry monitoring was not medically necessary for 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 subspecialty 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: Upheld

A 50-year-old female enrollee requested authorization and coverage of back surgery. The Health Plan denied the request indicating that the requested surgery is not medically necessary for treatment of the enrollees back pain.One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer upheld the Health Plans denial on the basis that the requested procedure is not medically necessary.
Appeal type: Experimental/Investigational
Decision: Overturned

A 51-year-old female enrollee has requested low or high field magnetic resonance imaging (MRI) scan of one or both upper extremities (hands) for evaluation of her hand pain.  Findings:  Three physician reviewers found that there is clinical concern that the patient has seronegative rheumatoid arthritis.  The outcome of the MRI study would have a direct impact on the treatment plan for this patient.  The peer-reviewed literature supports the use of MRI in the evaluation of early signs of rheumatoid arthritis and other inflammatory arthritis.  Narvaez and colleagues noted that MRI is increasingly being used in the assessment of rheumatoid arthritis due to its capacity to help identify the key pathologic features of this disease entity at presentation.   In this case, low or high field MRI of one or both upper extremities (hands) is likely to be more effective than other available tools for the evaluation of this patient.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for left knee magnetic resonance imaging (MRI) for evaluation of the enrollees left knee pain. Findings:  The physician reviewer found that this patient has had no x-rays of his symptomatic knee and has not undergone an adequate trial of physical therapy. While his legs have documented atrophy there are no physical signs documented to provide medical necessity for MRI prior to repeat x-rays and a trial of physical therapy. In this patient with severe atrophy, physical therapy is likely to be of little or no benefit as he is apparently wheelchair bound. Repeat x-rays may be of benefit for orthopedic evaluation as well as for analysis of patellofemoral changes. The examination was only two views by report which means a sunrise view of the patellofemoral joint was not included and according to the patients appeal letter he has severe patellofemoral crepitus. Thus, while the patient does not meet the medical necessity criteria for MRI which includes recent x-rays and physical therapy, repeat x-rays may provide enough information to support an indication for MRI even absent a trial of physical therapy. However, based on the current available documentation, the requested MRI of the left knee is not supported as medically necessary for evaluation of this patients knee pain. Final Result: The reviewer determined that the requested diagnostic procedure is 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 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: Experimental/Investigational
Decision: Upheld

A 55-year-old male enrollee has requested for spinal surgery and use of the X-Stop interspinous implant for treatment of his lower back pain. Findings:  Three physician reviewers found that the use of the X-Stop interspinous process decompression system has had some success in reports of short-term use, as noted by Christie and colleagues. Later reports have been less favorable, and further studies have been recommended to evaluate the procedure and to determine optimal design and clinical indications, as noted by Nockels. The anatomic characteristics of the patient are of importance and have been implicated as a cause of complications and need investigation, as noted by Barbagallo and colleagues. Studies of long-term outcomes are in progress, but the results are not yet available. At this time, the superior efficacy of the requested procedure has not yet been proven.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The parent of the patient has requested authorization and coverage for direct 1:1 applied behavior analysis (ABA) and ABA supervision by a BCBA. This patients treatment plan covers 21 active treatment goals, four problem behavior areas, and two parent-training goals. These goals are being addressed in the school and clinic settings. With the requested treatment plan, this allows each goal to be addressed for approximately 90 minutes per week, or less when the patient displays problem behaviors. Combined, the patient's problem behaviors occur dozens of times per day. The problem behaviors pose potential harm to the patient and others. Thus, the requested level of support does meet the comprehensive level of treatment. The BACB outlines the provision of comprehensive treatment as subsequently increased or decreased based on the clients response to treatment and current needs. Hours may be increased to more efficiently reach treatment goals. Decreases in hours of therapy per week typically occur when a client has met a majority of the treatment goals and is moving toward discharge. While this patient has made some progress, his problem behaviors have almost tripled since baseline.  While the patients scores have improved in socialization and motor skills, the remainder of the scores are unchanged or worse. Specifically, all scores are between one and three standard deviations below the mean, and the age equivalents are approximately three years, or more, from the patients age.  Based on the presenting information, the patient is not maintaining at the current level and an increase in ABA treatment intensity is warranted. Research supports higher treatment intensity for better outcomes for children on the autism spectrum.  iven these findings, direct 1:1 applied behavior analysis (ABA) and ABA supervision by a BCBA are medically necessary for 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 a licensed B.C.B.A, board certified in psychology, 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

A 60-year-old male enrollee has requested coverage for intensity modulated radiation therapy (IMRT) for treatment of her esophageal cancer. Findings:  Three physician reviewers found that IMRT is a tool that clinicians can use when there is concern about sparing normal tissues from high dose exposure. There is a growing body of literature on the use of IMRT for esophageal cancer, with most studies suggesting a dosimetric advantage of IMRT versus conventional 3D radiation, however, there is currently a paucity of clinical outcome data available. IMRT is a tool that enables the reduction of dose to surrounding organs.  There is no literature that explicitly shows that IMRT for esophageal cancer results in superior outcomes versus conventional 3-dimensional radiation techniques.
Appeal type: Medical Necessity
Decision: Upheld

A 48-year-old female enrollee has requested a CT scan of the thorax (71270), abdomen (74170) and pelvis (72194) for evaluation of her history of breast cancer.  Findings:  The physician reviewer found that guidelines for breast cancer surveillance have been well-studied and documented by the American Society for Clinical Oncology and are based on evidence-based and outcome-based data. The current medical evidence supports regular history, physical examination, and mammography as the cornerstone of appropriate breast cancer follow-up. All patients should have a careful history and physical examination performed by a physician experienced in the surveillance of cancer patients and in breast examination.   Examinations should be performed every three to six months for the first three years, every six to twelve months for years four and five, and annually thereafter. For those who have undergone breast-conserving surgery, a post-treatment mammogram should be obtained one year after the initial mammogram and at least six months after completion of radiation therapy. Thereafter, unless otherwise indicated, a yearly mammographic evaluation should be performed. Patients at high risk for familial breast cancer syndromes should be referred for genetic counseling. CT scans are not recommended for routine breast cancer follow-up in an otherwise asymptomatic patient with no specific findings on clinical examination.  There is no reason to suspect recurrence in this patients case based on the clinical history provided.  Based upon the evidence-based literature, the requested diagnostic procedures are not likely to improve outcome.  All told, the requested CT scans of the thorax (71270), abdomen (74170) and pelvis (72194) are not medically indicated for the evaluation of this patient.
Appeal type: Medical Necessity
Decision: Overturned

The patient is a 60-year-old female with a history of neck and shoulder pain, status post cervical fusion in 1995. She has been treated with multiple medical regimens such as non-steroidal anti-inflammatory drugs, cox II inhibitors, muscle relaxants, Lido-derm patches, steroid injections, physical therapy, acupuncture and chiropractic therapy without sustained pain relief. A pain management specialist evaluated the patient in March 2006 and noted neck pain radiating to bilateral upper extremities and a pain level of 5-7/10. Studies, including a CT discogram, revealed degeneration of the zygapophyseal joints at C2-3 on the right, C3-4 on the right and C4-5 on the right. The consultant concluded the enrollees neck and shoulder pain may have been related to a combination of posterior element pain above and below her fusion and neural axial pain secondary to foraminal stenosis above her fusions. The specialty provider performed transforaminal epidural blocks at C4-5 and C6-7, cervical facet blocks at C4-5 and C6-7 and a cervical epidural block from C5 to T1. By report, the patient received significant pain relief from the procedures and has submitted a request for reimbursement. The Health Plan denied the request based upon a determination that this combination of procedures was not medically necessary.The patient has severe chronic pain syndrome. She tried and failed multiple conservative and interventional treatments and continued to have significant neck and shoulder pain. A pain management specialist evaluated the patient and offered treatment which provided durable pain relief. Imaging studies and discography demonstrated cervical degenerative joint disease and facet joint pathology and the patient had clearly exhausted all conservative treatment modalities. Epidural therapy and facet joint injection therapy were appropriate treatment alternatives given the severity of the patients pain and the failure of multiple conservative interventions. Therefore, I have determined the procedures at issue were medically necessary for treatment of the patients medical condition. The Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary:  An enrollee has requested an orchiectomy for treatment of her gender dysphoria.   Findings:  The physician reviewer found that based on the medical records provided for this review, the patient has well-documented gender dysphoria. She has undergone the recommended evaluation and consideration for gender transition.  Her transition is supported by multiple therapists and physicians.  She has been living socially as a female and has undergone hormonal therapy for an extensive period of time. According to the publication by Schechter, Prior to performing gender reassignment surgery, the surgeon must be satisfied that the diagnosis of gender dysphoria has been established. This patient meets this criterion. Further, Schechter indicates After the diagnosis of gender identity disorder is made, the therapeutic approach commonly includes three phases (triadic therapy): a real-life experience in the desired role, hormones of the desired gender, and surgery to change the genitalia and other sex characteristics. As noted above, the patient has been living as a female and has also received hormone therapy. Thus, the next appropriate step is bilateral orchiectomy as part of the surgical transition process. All told, the submitted documentation demonstrates the patient has been living socially as a female, has been undergoing hormonal therapy for the recommended amount of time and her decision and condition is supported by her therapists and physicians.  Therefore, the requested orchiectomy is medically necessary for treatment of the patients medical condition. With regard to whether the proposed procedure meets reconstructive surgery criteria, the presence of bilateral testicles would be considered abnormal for a female. Further, the patient is well-documented to have gender dysphoria which can be considered a congenital or developmental abnormality. The requested orchiectomy is part of the surgical male to female transition and thus would improve function as it would contribute to a lower testosterone level and would also create a more normal female appearance. The proposed procedure is likely to provide more than a minimal improvement in the appearance of the patient. As such, the requested orchiectomy is considered reconstructive in nature. Final Result: The reviewer determined that the requested service is medically necessary for treatment of the patients medical condition and reconstructive in nature. Therefore, the Health Plans denial should be overturned.  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: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Botox injections. Researchers noted that in cases of atypical facial pain that have failed medication management, Botox may be used successfully to treat atypical facial pain. Medical literature noted that atypical facial pain can be resistant to treatment with medications and that when medical therapy has been tried and failed, Botox treatment of the masseter and pterygoid muscles may be beneficial for long-term relief of such pain. The medical records indicate ongoing chronic facial pain that has failed conservative treatment with medications. Accordingly, the requested Botox injections are likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Findings:  Three physician reviewers found the requested Botox injections are likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the requested Botox injections are likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Credentials/Qualifications: Physician reviewers 1, 2 and 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: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary:  An enrollee has requested functional electrical stimulation (FES) for treatment his medical condition.   Findings:  Two physician reviewers found that there is a lack of proven significant health or functional benefit of exogenous neurostimulation therapy of paralyzed muscles using FES cycle ergometry. There have been a number of small papers (case reports and series) published over the years providing some preliminary data suggesting possible benefits, but larger studies designed to evaluate the actual clinical efficacy of passive exercise such as FES cycle ergometry in the setting of spinal cord injury are lacking. Purported benefits of passive cycling, such as improving cardiovascular function, and bone density have not been sufficiently investigated to allow conclusions related to clinically-relevant outcomes. To date, the limited data that are available provide mixed results regarding health measures. In, sum there are insufficient data regarding clinically-relevant outcomes related to the use of this device on bone health after spinal cord injury. All told, the services at issue have not been established as likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.   Final Result: Two reviewers determined that the services at issue were not and 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 physical medicine and rehabilitation 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 53-year-old female enrollee has requested acupuncture for treatment of her myofascial pain syndrome, lumbosacral pain (with associated myofascial neuropathic pain) and chronic multifocal arthralgias.  Findings:  Two physician reviewers found that the medical literature does not establish that acupuncture is an effective intervention in the setting of chronic pain, including multifocal arthralgias and myofascial pain. There is insufficient medical literature demonstrating that acupuncture improves health and/or pain compared to conventional care consisting of exercise, rest, palliative modalities and pharmacotherapy as needed.
Appeal type: Medical Necessity
Decision: Overturned

A 44-year-old female enrollee has requested weekly outpatient therapy visits for treatment of her major depressive disorder.  Findings:  The physician reviewer found that The American Psychiatric Association (APA) treatment guidelines for depression state that, use of a depression-focused psychotherapy alone is recommended as an initial treatment choice for patients with mild to moderate major depressive disorder. In addition, the APA reports that the clinical evidence also supports the use of cognitive behavioral therapy (CBT), interpersonal psychotherapy, psychodynamic therapy and problem-solving therapy. This patients records indicate that in addition to participating in outpatient therapy, she was also being treated with a mood stabilizer. The providers notes indicate that as the patients condition appeared more severe, medical therapy was added to the treatment regimen. As such, this provider has complied with the APA practice parameters, in that she started the patient with psychotherapy alone, but sought help with the addition of medication to the regimen when the patients condition appeared more severe.Moreover, the patients provider recorded progress in the records provided for review. Specifically, the treatment notes initially document a woman who was quite distraught and needed frequent support. However, as treatment progressed and medication was added, the patient slowly showed improvement, as anticipated with an appropriate treatment regimen. In this case, the successful outcome proves that outpatient therapy provided from the said date was and is medically necessary for management of this patients condition.