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

The patient has requested authorization and coverage for eight weeks of continued physical therapy. The records provided for review document that this patient has undergone extensive physical therapy consisting of 24 visits for her feet and ankles. The notes from her foot and ankle physical therapy suggest that the repeated objective examination findings of flexibility, joint integrity, muscle testing, palpation of soft tissues and pain levels do not reveal significant improvement from the start of physical therapy. The patient has not completed physical therapy for her low back pain. There is documentation of a lumbar x-ray revealing facet disease. However, there is no objective magnetic resonance imaging (MRI) or electrodiagnostic study to rule out a possible radicular etiology causing the patients back and ankle symptoms. The records indicate that the patient has received instruction on a home exercise program for her foot and ankle pain. The documentation reviewed does not demonstrate that the patient requires the unique skills of a therapist for continued rehabilitation or that the patient has made objective gains to support an indication for additional physical therapy. The requested services are not part of a maintenance program and the specialized skill, knowledge and judgment of a qualified therapist are not required to establish, design or deliver a program to maintain the patients current condition or to prevent or slow further deterioration. All told, the requested eight weeks of continued physical therapy 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 physical medicine and rehabilitation with subspecialty 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: Upheld

A 58-year-old male enrollee requested authorization and coverage of out-of-plan intra-arterial chemotherapy for the treatment of osteosarcoma.  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 upheld the health plans denial on the basis that the requested services are not medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary:  An enrollee has requested authorization and coverage for acupuncture visits twice a week.Vickers and colleagues state, Acupuncture is effective for the treatment of chronic musculoskeletal, headache, and osteoarthritis pain. Treatment effects of acupuncture persist over time and cannot be explained solely in terms of placebo effects. Further, Yin and colleagues state, Acupuncture is effective and safe for treating several chronic pain conditions when performed by well-trained healthcare professionals. However, the use of acupuncture for maintenance, prophylactic or custodial care is not supported by the peer-reviewed literature. In this case, although the patient reported a temporary reduction of symptoms from prior acupuncture care, no pre-acupuncture, and post-acupuncture functional improvement baselines were documented for comparison purposes. After prior acupuncture sessions were completed, the total number of sessions completed, and any measurable, progressive, significant, objective functional improvement (quantifiable response to treatment) obtained with previous acupuncture to support the necessity of the additional acupuncture requested were not documented. Per the records, the patient is not presenting a flare-up of the condition or a re-injury. Additionally, there is no clear documentation indicating whether the patient is currently undergoing an independent exercise program. Therefore, based on the lack of documentation demonstrating quantifiable medication intake reduction, measurable activities of daily living improvement directly attributable to prior acupuncture, or any extraordinary circumstances, additional acupuncture sessions are not recommended. Thus, the requested acupuncture visits twice a week are not medically necessary for the treatment of the patients medical condition.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 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

Nature of Statutory Criteria/Case Summary: An enrollees parent has requested authorization and coverage for double mastectomy with nipple reconstruction.The World Professional Association for Transgender Health (WPATH), a worldwide authority on transgender health issues, has stated that chest surgery in transgender male patients is often of greater practical significance in the patient's daily life than reconstruction of the genitals (WPATH 2016). The WPATH Standard of Care, version 7, clearly mentions that chest surgery in Female to Male (FTM) patients could be carried out earlier than the age of majority. Mastectomy with male chest reconstruction in transgender male youth is now commonly done in minors, and has been demonstrated to be a safe and effective treatment for gender dysphoria in this population. In this case, the patient has a long history of gender dysphoria, and he has been living as male, on testosterone. The patient has substantial documentation from the medical team at his gender clinic program as well as from psychologists of gender dysphoria regarding his chest, and documentation of clinically significant symptoms supporting the medical necessity of bilateral mastectomy with male chest reconstruction. Under these circumstances, the requested double mastectomy with nipple reconstruction is medically necessary to treat the patients medical condition.Final Result: The reviewer determined that the requested services are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.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 63-year-old female enrollee has requested authorization and coverage for a left lower extremity WalkAide.  Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested device in this patients case.  In general, post-stroke foot drop is managed with either a plastic molded ankle foot orthosis or a double-metal upright ankle foot orthosis depending on various clinical factors.  However, some post-stroke patients may have significantly improved gait mechanics with the use of a functional electrical stimulation unit, such as the WalkAide.  This can only be determined through a detailed assessment of a patients gait mechanics with the use of an appropriately prescribed ankle foot orthosis versus a functional electrical stimulation unit.  This evaluation is typically done by a licensed physical therapist.  In this case, such a comparison analysis does not appear to have been done.  The records do not include a detailed assessment of the patients gait with the use of an appropriately prescribed ankle foot orthosis, nor do they include documentation of significantly improved gait mechanics with use of the WalkAide when compared with a standard ankle foot orthosis.  All told, the requested left lower extremity WalkAide is not medically indicated in this patients case.
Appeal type: Experimental/Investigational
Decision: Upheld

A 59-year-old female enrollee has requested Rituxan, 1000 mg for treatment of her relapsing remitting multiple sclerosis. Findings:  Two physician reviewers found that the medical literature reveals that MS is frequently treated with immune suppression when progressing despite immune modulation treatment. Rituxan has been subject to small studies for treatment of MS and it has been beneficial. This patient has a reported diagnosis of MS, however prior treatment trials and responses are not noted. Without data showing that the patient has tried and failed standard medications, Rituxan cannot be shown to be more effective than standard treatments and is investigational in this clinical setting.
Appeal type: Experimental/Investigational
Decision: Upheld

A 33-year-old female enrollee has requested LAPEX laparoscopic excision for treatment of her pelvic pain and endometriosis. Findings:  Three physician reviewers found that this patients provider has recommended LAPEX surgery for treatment of endometriosis. It appears the term is being used to describe laparoscopic excision of endometriosis. To date there are no peer-reviewed publications in the medical literature specifically evaluating surgical techniques termed LAPEX. There are claims within the record that the surgeon has a specific and different surgical technique for the treatment of endometriosis, with significantly reduced recurrence rates compared to those published in the peer reviewed literature. Despite these contentions, there is no conclusive evidence in the clinical trials or well designed cohort studies that this specific technique is more effective in comparison to standard techniques. Based on the available data, the requested surgery is within the expertise and skill of a board-certified, competent gynecologic surgeon. Therefore, the patients request for LAPEX to be provided by an out-of-network provider is not likely to be more beneficial than treatment within the Health Plans network.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the DecisionDx melanoma assay gene testing for evaluation of the enrollees cutaneous melanoma. Findings:  Two of the three physician reviewers found that this patient presented with a melanoma with a Breslow depth of 2.3 mm. This places him into at least stage 2 disease. In stage 2 disease, the American Joint Committee on Cancer (AJCC) and National Cancer Guidelines dictate certain protocols for further diagnosis, staging and prognosis as well as treatment paradigms. The DecisionDx melanoma assay results would not change the staging, guidelines or care of this patient based on these guidelines. The DecisionDx testing has shown some accuracy in predicting which stage 1 patients might be at risk for metastasis but at this time what to do with the information has not been scientifically elucidated. This patients care would not change based on the testing results. Final Result: The reviewers determined that the testing at issue was 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: Reviewers 1, 2, and 3 are board certified in dermatology 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 reimbursement for SpaceOAR hydrogel insertion (CPT code 55874). Hydrogel spacer can be utilized during external beam radiation treatment of the prostate to increase the space between the rectum and prostate and decrease the amount of radiation that is delivered to the rectum. In a randomized phase III study of patients undergoing external beam radiation for prostate cancer, Hamstra and colleagues found that the risk of late adverse events declined from 5.7% to 0% in the control versus hydrogel space group, and that the spacer group also had a significant reduction in bowel quality of life decline. In this case, however, notes dated 8/10/21 reported that the patient elected to undergo prostate brachytherapy, the placement of radioactive seeds into the prostate, which is already associated with a very low risk of rectal toxicity. There is a lack of data in current medical literature supporting the use of hydro-gel spacer in patients who undergo brachytherapy. The National Comprehensive Cancer Network (NCCN) guidelines for the management of prostate cancer do not endorse the use of hydrogel spacer in patients undergoing brachytherapy. Therefore, SpaceOAR hydrogel insertion (CPT code 55874) was not likely to have been more beneficial for treatment of the patient's condition than any available standard therapy.Findings:  Two of the three physician reviewers found the SpaceOAR hydrogel insertion (CPT code 55874) at issue was not likely to have been more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the service at issue was not likely to have been more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: Physician reviewers 1, 2, and 3 are board certified in radiation oncology 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 13-year-old female enrollee has requested growth hormone therapy for the treatment of the enrollees short stature. Findings:  The physician reviewer found that the Food and Drug Administration (FDA) has approved growth hormone therapy for the treatment of idiopathic short stature. From the standpoint of the FDA, GH is indicated for girls whose predicted adult height is less than 411. Review of the submitted clinical evidence demonstrates that this patient has had significant growth failure for over the past year. On the basis of the information provided, it appears unlikely that she will attain a normal adult height over the FDA cut-off of 411 for GH therapy. Thus, the patient is an appropriate candidate for GH therapy under the FDA guidelines and is likely to benefit from the therapy given her initial response.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for wearable cardioverter defibrillator for treatment of the enrollees dilated cardiomyopathy. Findings:  The 3 physician reviewers found that the physician reviewers found the documented high risk of sudden cardiac death in patients with severe left ventricular dysfunction has led to the recommendation of implantable cardioverter defibrillators in this group of patients. Current data from multiple trials and registries have advocated the use of a wearable cardioverter defibrillator after an initial diagnosis of severe left ventricular dysfunction. In this patients case, the records documented an ejection fraction of 35 to 40%. Given the absence of significant coronary artery obstructive disease, this was considered a non-ischemic cardiomyopathy. The patient was also noted to have a significant amount of ventricular ectopic activity on telemetry monitoring. Current guidelines recommend against placement of implantable cardioverter defibrillators within 40 days of an acute myocardial infarction, or within 90 days of an initial diagnosis of congestive heart failure with a low ejection fraction, as in this case. Therefore, the placement of the was appropriate given the patients diagnosis of severe left ventricular dysfunction with its associated high risk for sudden cardiac death. Thus, the wearable cardioverter defibrillator was likely to have been more effective than other available treatment modalities. Final Result: The 3 reviewers determined that the device at issue was 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 reviewer number one 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.Physician reviewer number two 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.Physician reviewer number three 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: Upheld

The enrollee is requesting authorization and coverage for custom foot orthotics. The enrollee has foot pain and difficulty walking due to neuropathy, calcaneal spurs, and tendinitis.  The enrollee has bilateral retro calcaneal spurs.  She reported an infected, painful, swollen left 4th digit of two weeks duration, secondary to use of improper shoe gear at an office visit. Oral Keflex was prescribed with instructions to return, as needed.  The enrollee returned with a blister on the same digit of one-week duration.  She was advised against incision and drainage; and was told to soak, wear wider shoes and follow up with podiatry.  Three days later,  she returned with complaints of discoloration to digits two, three and four on the same foot; despite improvement of the prior blister of the 4th digit.  During this visit the enrollee was diagnosed with toe cyanosis and peripheral vascular disease.  At a podiatry visit, diagnoses included cavus foot, jamming of the first metatarsal, bilateral calcaneal spurs, neuroma and osteoarthritis.  The enrollee saw the podiatrist several times and was x-rayed, biomechanically evaluated and casted for custom orthotics described as UCBL type. Literature shows a high degree of variation among the many published studies on foot orthotics; often either inconclusive or negative in nature. The role of over-the-counter orthotics (OTC) in the relief of pain has been extensively researched. The physician reviewer found that studies determined OTC orthotics were effective in relieving patient foot pain. Therefore, it is reasonable to have a patient try OTC orthotics for diffuse pain, as in the case of this enrollee, rather than immediately prescribe custom orthotics. However, the documentation does not mention any trial of OTC orthotics prior to the prescription of the custom orthotics.
Appeal type: Medical Necessity
Decision: Upheld

A 51-year-old male is requesting for a custom ACL brace for treatment of her torn anterior cruciate ligament (ACL).  Findings:  The physician reviewer found that there is no evidence establishing this patient has instability requiring an ACL brace. Without such evidence there is no indication of medical necessity for the requested equipment.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for radiofrequency neurolysis. Findings:  The physician reviewers found that there is a lack of support for the requested services in this clinical setting.  The progress note does not provide sufficient details regarding the results from prior sacroiliac joint injections, blocks, or the duration of relief from prior radiofrequency ablation procedures. Additionally, no note for a diagnostic block is available for review.  The literature is clear that radiofrequency ablation is done after a diagnostic block with local anesthetic alone and a pain diary with notations of medication usage.  This was not provided in the documentation available for review. In addition, the physical examination done in the office was not specific to sacroiliac joint dysfunction. Moreover, it is unclear if the patient obtained significant relief from the prior radiofrequency ablation, why the treating office would change the location of the radiofrequency ablation procedure.  Thus, the requested radiofrequency neurolysis is not likely to be more effective than other treatment options. Final Result: 3 of 3 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 physician reviewers are board certified in anesthesiology with sub-specialty certification in pain medicine 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 three-year-old male has requested speech therapy for one hour per week for treatment of his autistic disorder.  Findings:  The physician reviewer found that at issue is the notion that plasticity in the developing brain, albeit a brain with underlying neurologic disease, still exists, and can be utilized to improve overall neurologic health.  Thus, specific modalities can be used to help induce brain plasticity, with the ultimate goal of retraining neural circuitry not compromised by the underlying pathogenetic processes that give rise to autistic spectrum disorders and their co-morbidities including, but not limited to repetitive or stereotypic behaviors as well as deficits in communication, play skills, and self-help skills. Speech therapy is one such modality. It is well established that language skills and non-verbal skills improve with long-term application of speech therapy during critical developmental periods in childhood. As such, speech therapy is a medically indicated and necessary intervention for this patient with communication deficits secondary to autism.