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

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for the residential treatment center (RTC) services provided, partial hospitalization program (PHP) level of care provided, and intensive outpatient program (IOP). Findings:  The physician reviewer found that according to the American Psychiatric Association (APA) guidelines, the records provided for review do not support the medical necessity of the residential treatment center (RTC), partial hospitalization program (PHP) and intensive outpatient program (IOP) levels of care services provided to this patient during the period under review. The patient had reported symptoms of nausea, vomiting, headaches, and a sensation of cloudiness. However, there was no evidence of suicidality or homicidality, he did not appear to be manic, psychotic, or delusional, and he was medically and psychiatrically stable. Based on the blood pressure readings provided, his hypertension did not require RTC or PHP level of care for management. The records do not specify whether the patient was engaged in the processes related to his substance abuse, or if he made progress in the 12 step programs. These brief notes documented his levels of anxiety and depression, which were highly correlated to interactions he had with his parents and girlfriend. Throughout all levels of care, the patient slept at least five to six hours a night and ate two to three meals per day. He had episodic nightmares and drug dreams, and endorsed cravings. Overall, it is unclear what progress he had made on a relapse prevention plan, developing coping mechanisms, or learning to identify triggers. The patient did not require the structure and supervision provided in the restrictive RTC setting. The patient could have safely and effectively been treated in a less restrictive treatment setting. All told, the RTC services, PHP level of care, and IOP services were not medically necessary for treatment of this patients behavioral health issues.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 psychiatry with sub-specialty certification in addiction 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: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for Polar Cube fluid circulating cold pad with pump (HCPCS code E0218) for the right shoulder. In this case, the provider recommended postoperative use of a cold unit to decrease pain, increase healing, and reduce narcotic usage following shoulder surgery. A review of the literature reveals that active cold therapy units, such as the Polar Cube fluid circulating cold pad with pump, have not been demonstrated to provide clinically significant benefits over passive cold compression therapy. Moreover, there is a paucity of high quality trials on the use of active cold therapy units for the treatment of postoperative shoulder pain. One study by Researchers noted that there is a lack of data demonstrating significant benefits with use of compressive cryotherapy over standard ice wraps in patients undergoing shoulder arthroscopy. The submitted documentation does not add extenuating factors that necessitate this device over a standard ice pack after this patients arthroscopic shoulder surgery. Therefore, the Polar Cube fluid circulating cold pad with pump (HCPCS code E0218) for the right shoulder was not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Findings:  Three of the three physician reviewers found the Polar Cube fluid circulating cold pad with pump (HCPCS code E0218) for the right shoulder was not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the device at issue was 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: Physician reviewers 1, 2, and 3 are board certified in orthopedic surgery 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 reimbursement for the digital breast tomosynthesis for evaluation of the enrollees risk for breast cancer. Findings:  Two physician reviewers found that 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, by separating the various layers of breast tissue, one can better detect abnormalities. However, in this particular patient, there were no problems to be resolved. That is, the patient did not have dense breasts, she did not have a mass, there were no palpable lumps, and she did not have suspicious calcifications. While in this patient the extra radiation dose is not a factor, as the 2D images were reconstructed from the primary tomosynthesis acquisition, a routine mammogram would have been sufficient. Tomosynthesis has not been shown to provide significant increased value in patients who do not have dense tissue that could obscure an abnormality, especially when there has been no change when compared to multiple prior mammograms over 11 years. Final Result: Two reviewers determined that the diagnostic procedure 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: 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: Overturned

A 50-year-old female enrollee has requested surgical correction of diastasis recti for treatment of her medical condition.  Findings:  The physician reviewer found that the patients records describe the patient to have abdominal pain, which may constitute an abnormal state from some structure or disease process that has not yet been fully diagnosed. Umbilical hernias can cause abdominal pain as suggested by the patients primary care physician but a thorough abdominal examination has not been well documented. The patients weight and height could be considered an overweight condition. Thus, there could be an abdominal pannus contributing to the patients pain and referral to a plastic surgeon may help diagnose this patients condition. As discussed by Toranto in the medical literature, there is some evidence low back pain may be treated with plication of the anterior abdominal wall, which is the primary treatment of diastasis recti. As this patients general surgeon noted the presence of painful diastasis recti, and a plastic surgeon may perform the procedure, an evaluation by a plastic surgeon is indicated (Oneal, et al). However, diastasis recti are not typically associated with pain, which further suggests that this patients condition needs to be further investigated. In summary, a thorough evaluation by a plastic surgeon should be performed to evaluate the patients abdominal pain, which is the functional issue in this case. However, there is a lack of evidence in the records presented for review to establish the requested surgical intervention as medically necessary or reconstructive in nature at this time.
Appeal type: Experimental/Investigational
Decision: Upheld

A 59-year-old male enrollee has requested cervical disc replacement for the treatment of his neck pain. Findings:  Three physician reviewers found that cervical disc arthroplasty is indicated for patients with cervical radiculopathy or myelopathy, neither of which is present in this patient (Acosta, et al. and Brown, et al.). In addition, cervical disc replacement is only indicated for a one-level procedure, and in this case a two-level procedure is being proposed. There are ongoing studies to determine the long-term safety and efficacy of cervical disc replacement. The longest study completed to date involved only two years of follow-up and included a small number of patients. Until longer-term studies have been completed showing safety and efficacy, cervical disc replacement remains of unproven efficacy.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for radiofrequency volumetric tissue reduction (tongue surgery) for treatment of the enrollees obstructive sleep apnea. Findings:  The physician reviewers found that long-term studies are lacking which demonstrate the superior efficacy of the requested services in this clinical setting. This patient has been documented to have mild sleep apnea based on the results of the prior polysomnogram. The patient had been on CPAP therapy with a relatively low pressure of 7 cm of water with some improvement and elimination of obstructive events during sleep. The multiple prior surgical procedures included nasal reconstructive septoplasty and maxilla mandibular advancement therapy. The patient has undergone drug induced sleep endoscopy and the interpretation of the results by the clinical surgeon did suggest narrow anteroposterior hypopharyngeal airway with a suggestion that radiofrequency tongue base reduction on sequential visits should improve symptoms.  Patients treated with greater frequency tongue base reduction had only a mild reduction of apnea hypopnea index.  Most of those patients were massively overweight.  Reductions in the respiratory disturbance index and Epworth sleepiness scale but that the degree of heterogeneity of the medical studies was difficult, as the patient evaluations did not show strong similarity and so, conclusions were difficult to obtain. Based on the above medically peer reviewed evidence, current treatment and use of tongue base reduction surgery is still undergoing further evaluation. Active references that demonstrate the efficacy of the use of this procedure are lacking. Consequently, radiofrequency volumetric tissue reduction (tongue surgery) is not likely to be superior to other methods of treating this patients medical condition. Final Result: Two of three 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: Physician reviewers number one, two, and three are board certified in otolaryngology and actively practicing. The reviewers are expertsin 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 an eight-year-old male enrollee requested applied behavior analysis (ABA) services (35 hours per week of direct care and 16 hours per month of supervision) for medical treatment of the enrollees autism spectrum disorder.  Findings:  Three physician reviewers found that the submitted documentation supports the medical necessity of the requested services.  The submitted documentation indicates that the patient has had an exceptionably favorable response to ABA therapy.  Plasticity in the developing brain exists, and can be utilized to improve overall neurologic health.  ABA therapy 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 the developmental delays and social disconnection associated with autism spectrum disorder.  All told, the requested ABA services (35 hours per week of direct care and 16 hours per month of supervision) are medically indicated for the treatment of this patient.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary:   An enrollee has requested positional magnetic resonance imaging (MRI) for evaluation of her medical condition. Findings:  Three physician reviewers found that the submitted documentation fails to demonstrate the superior efficacy of the requested services.  The peer-reviewed, evidence-based, medical literature does not support the use of positional (sitting) MRI for evaluation of coccydynia or coccyx fracture. This patient presents with chronic lower back pain in the coccyx area, with excruciating pain while sitting and significant functional limitation in sitting tolerance.  A sacral computed tomography (CT) scan was reportedly negative for fracture or dislocation. There is also documentation of a lumbar MRI with no discussion of sacral findings. There is no evidence that dynamic radiography has been performed. There is no orthopedic report of clinical findings relative to the coccyx. There is no compelling rationale presented to support the need for positional MRI in the absence of evidence based support and lacking clear and thorough documentation of previous imaging and radiographic tests and findings. Therefore, the requested positional MRI is not likely to be of greater benefit than other modalities for evaluating this patient.  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:   All three reviewers are board certified in orthopedic surgery 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: Medical Necessity
Decision: Overturned

A 19-year-old male enrollee requested reimbursement of a knee brace. The Health Plan denied the request indicating that the equipment at issue is not medically necessary for the enrollees right knee rehabilitation.One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer overturned the Health Plans denial on the basis that the equipment at issue is medically necessary.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for bilateral sacroiliac (SI) joint injections for treatment of the enrollees SI joint dysfunction.  Findings:  The physician reviewer found that The request for bilateral SI joint injections are medically necessary for treatment of the patients medical condition. SI joint injections are an appropriate, evidence-based treatment option for low back pain of sacroiliac origin and are standard of care for the treatment of this condition. The physical examination supports the diagnosis of SI joint dysfunction. In addition, the patient has not responded to conservative care. The presence of neural compression does not indicate that the patient lacks SI joint pathology. The patient has both lumbar radicular pain secondary to neural compression and lumbar axial pain secondary to sacroiliac joint pathology. Therefore, the requested services have been established as medically necessary for the treatment of 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 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: Medical Necessity
Decision: Overturned

A 56-year-old female has requested past and future coverage for home health services for treatment of her Parkinsons disease.  Findings:  The physician reviewer found that treatment for Parkinsons disease includes medical therapy, surgical measures, and brain stimulation.  This patient has advanced idiopathic Parkinsons disease.  She has undergone multiple neurology evaluations and has been tried on multiple medications.  Per the submitted documentation, there is increased dystonia with increased on-off phenomena, making any ambulation difficult.  In addition, she has bladder involvement, requiring regular self-catheterization, and mild constipation.  The documentation from her treating providers indicates that she requires regular daily assistance with activities of daily living, including bathing, dressing, and toileting.  The submitted documentation demonstrates the medical necessity of the services at issue in this patients case.
Appeal type: Medical Necessity
Decision: Upheld

A 16-year-old male enrollee has requested for Humatrope (growth hormone therapy) for treatment of the enrollees short stature. Findings:  The physician reviewer found that ge has had normal GH responses to stimuli, two normal IGF-1 levels with respect to his stage of sexual development and a normal brain MRI (albeit chronic sinusitis was reported). His FSH and LH levels were prepubertal. His adult height predictions made by the endocrinologist were normal at 59.5 - 510. There was no workup to suggest that Kallmans syndrome or treatment with an aromatase inhibitor had been considered.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for a back brace. Findings:  The physician reviewer found that Back braces have not been found to prevent lower back pain. The North American Spine Society stated that there was insufficient evidence to recommend the use of bracing in patients with low back pain. Steffens and colleagues investigated the effectiveness of interventions for the prevention of low back pain. The authors noted that current evidence suggests that back belts do not prevent low back pain. In this case, the use of a back brace is being requested to treat mid back and low back pain. There is no radiographic evidence of spondylolisthesis, instability or fracture. There is a lack of support for the requested equipment in this clinical setting. Therefore, the requested back brace is not medically necessary for the treatment of the patients medical condition.Final Result: The reviewer determined that the requested equipment 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 orthopedic surgery and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

A 65-year-old female enrollee has requested mental health outpatient therapy for treatment of her behavioral health issues.  Findings:  The physician reviewer found that the psychiatric evaluation is incomplete and the patients diagnosis is mild depression. There is no history of inpatient treatment and no indication that the patient could not be managed safely and effectively with therapy once weekly. The American Psychiatric Association (APA) practice guidelines for treating patients with suicidal behavior recommend treatment in the least intensive setting that is likely to be safe and effective. Furthermore, the APA practice guidelines for treating patients with major depressive disorders indicate that patients should be treated in the most appropriate setting given their symptoms. For these reasons, therapy three times per week is not the most appropriate intensity of treatment for this patient given the data submitted for review.
Appeal type: Medical Necessity
Decision: Upheld

A 63-year-old male enrollee has requested Lyrica for treatment of his eye pain.Findings:  The physician reviewer found that there are other medications including antidepressants, topical anesthetics and anticonvulsants within the same class of Lyrica that are covered by the patients Health Plan. There are no reports that the patient has used these medications for treatment of his eye pain.  Gabapentin is an anticonvulsant sharing the same class of medication as Lyrica and is covered by the Health Plan. Gabapentin may be as equally effective as Lyrica in the treatment of neuropathic pain. Numerous clinical studies show that first-line therapy should include antidepressants, anticonvulsants and/or topical anesthetics. Collins and colleagues performed a review to determine the relative efficacy and adverse effects of antidepressants and anticonvulsants in the treatment of neuropathic pain. Overall, the review reported that antidepressants and anticonvulsants had the same efficacy and incidence of minor adverse effects in neuropathic pain conditions.  Thus, Lyrica is not medically indicated for this patient