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

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for magnetic resonance imaging (MRI) of the brain sinuses without contrast. Chua and colleagues note that MRI is more specific than computed tomography (CT) in characterizing unilateral maxillary sinus opacification, with greater diagnostic certainty and reproducibility. The authors further note that the additive diagnostic value of MRI complements CT, potentially reducing diagnostic delays in some cases and the need for diagnostic endoscopic sinus surgery in others. Alves and colleagues note that CT and MRI are commonly used in evaluation of paranasal sinuses and that description of such findings by a radiologist can lead to a change in treatment strategy. In this case, the patient had a history of severe facial pain, perhaps due to a dental abscess, and underwent an MRI for evaluation. In this clinical setting, given the patients symptoms were of unknown etiology, the service at issue was medically indicated to aid in diagnosis and treatment strategy. Therefore, MRI of the brain sinuses without contrast was medically necessary for the evaluation of this patient.Final Result: The reviewer determined that the services at issue was medically necessary for evaluation of the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in otolaryngology 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 authorization and coverage for a portable oxygen concentrator that weighs less than three pounds. The Health Plan has approved a request for a portable oxygen concentrator from a company that can offer equipment weighing approximately 5 to 6 pounds; and has denied this request for a specific portable concentrator weighing less than three pounds, indicating that the requested equipment weighing less than three pounds is not medically necessary for treatment of the enrollees hypoxemia.The submitted documentation does not support the medical necessity of the requested smaller portable concentrator. The Health Plan has provided the patient with a larger home concentrator and a portable oxygen concentrator for travel and for her outdoor activities. The patient states it is too heavy for her to lift. The difference in the weight of her current concentrator and the one she is requesting is only 2-3 pounds.A study indicates that Every attempt should be made to provide portable or wearable oxygen systems in support of patients striving for an active lifestyle. The patient doesnt have a known cause at this time for her hypoxia and there is no documentation of a specific lung disease that would be causing hypoxia. Moreover there is not any documentation that the patient is capable of lifting 3 pounds but not capable of lifting 5-6 pounds. The patient has what she needs to treat her unknown cause of hypoxia at this time. Therefore, the requested equipment is not medically necessary for treatment of this beneficiary.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 internal medicine with sub-specialty certification in pulmonary 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: An enrollee has requested authorization and coverage for viscosupplementation therapy, hyaluronan or derivative, Hyalgan, Supartz or Visco-3, for intra-articular injection (CPT J7321), one unit weekly for three doses.Current medical literature pertaining to viscosupplementation reveals mixed results. Evidence from eight systematic reviews and six randomized controlled trials indicates that although viscosupplementation may relieve knee pain in some individuals with osteoarthritis, it is not known which individuals will benefit. Different studies have tried mixing hyaluronic acid with corticosteroids, platelet rich plasma, and other agents to make it more effective. The current evidence is limited and guidelines from organizations such as the American Academy of Orthopedic Surgeons indicate that the evidence is not conclusive. As such, the Academy does not currently support viscosupplementation as standard treatment for osteoarthritis of the knees. In light of the foregoing, viscosupplementation can only be recommended in individuals with a history of lasting benefit from prior injections and in carefully selected cases where everything else has been tried and the options are limited. In this case, the patient has tried and failed other conservative treatments including frequent intra-articular injections of corticosteroids, which only provided short term relief. The patients alternative is total knee arthroplasty at a relatively young age. Under these circumstances, the requested viscosupplementation therapy, hyaluronan or derivative, Hyalgan, Supartz or Visco-3, for intra-articular injection (CPT J7321), one unit weekly for three doses, is medically necessary to treat the patients medical condition.Final Result: The reviewer determined that the requested services are medically necessary for the treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in orthopedic surgery and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for teriparatide (Forteo) for treatment of the enrollees osteoporosis.Findings:  The physician reviewer found that osteoporosis is an increasingly widespread condition, affecting 55% of Americans aged 50 and older. Of those affected, approximately 80% are women. Fractures are the most dangerous aspect of osteoporosis, which can lead to acute and chronic pain as well as increased mortality. Until recently, pharmacological options for the treatment of osteoporosis have been limited to antiresorptive agents, including oral bisphosphonates.  Newer treatment agents have become available over the past few years, including Forteo, which is a recombinant form of the biologically active component of parathyroid hormone which has been shown to increase bone mass and prevent fractures in osteoporotic bone. Forteo is indicated for the treatment of postmenopausal women with osteoporosis at high risk for fracture or patients who have failed or are intolerant to other available osteoporosis therapy. This patient has severe osteoporosis and is at high risk for a fracture. As this patients provider noted, treatment with Forteo may promote an increase in her bone mineral density, whereas prior treatment with a bisphosphonate may actually diminish or delay the efficacy of Forteo. 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 endocrinology, diabetes and metabolism 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 46-year-old male enrollee requested authorization and coverage of aortoiliac thromboendarterectomy surgery for infrarenal aortic occlusion with bilateral iliac artery occlusions. The health plan denied the enrollees request indicating that the requested surgery 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 surgery is not medically necessary.
Appeal type: Experimental/Investigational
Decision: Upheld

A 57-year-old female enrollee has requested for CEA CA15-3 testing for evaluation of her breast cancer. Findings:  Three physician reviewers found that the most recent ASCO Technological Assessment from 2007 does not recommend that tumor markers CEA or CA15-3 be used in routine surveillance of breast cancer patients following adjuvant treatment. This has been the ASCO position since 2000. The NCCN Guidelines for breast cancer (v.2.2008) affirm this opinion, noting no evidence to support the use of CEA and CA15-3 in the follow-up of breast cancer patients. Despite this consensus opinion, these tests are indeed widely used in the follow-up of breast cancer. Regardless of this practice pattern, there is no evidence to support the monitoring of CEA or CA15-3 over standard history and physical examination.
Appeal type: Medical Necessity
Decision: Upheld

A 36-year-old female enrollee has requested  an abdominoplasty for treatment of her ventral and umbilical hernias.  Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested services in this patients case.  Abdominoplasty involves the removal of skin and fat from the pubis to the umbilicus or above.  Unlike a hernia, diastasis is a benign condition with no long-term sequelae because the intestines and omentum cannot escape from the intra-abdominal space via the diastasis.  Additionally, it is not necessary to perform abdominoplasty at the same time as hernia surgery.  There is no decreased scarring in performing all of the procedures at one time versus in separate times.  In this patients case, the excess abdominal skin does not constitute an abnormal structure of the body, and the requested abdominoplasty would not be performed to improve function.  All told, the requested abdominoplasty is not reconstructive in nature and is not medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Overturned

A 29-year-old male has requested past and future coverage for 50 additional physical therapy (PT) sessions for the dates under review for treatment of his C7 spinal cord lesion.  Findings:  The physician reviewer found that based on review of the available records, this patient has a neuroenteric cyst at the C7 level which is causing his neck and bilateral shoulder and upper extremity pain. The patients right shoulder pain and weakness can be partially attributed to his shoulder pathology. His history is consistent with chronic pain syndrome, given the fact that his pain issues have persisted for more than three months. He is being treated by a psychiatrist for anxiety and depression, both of which are components of chronic pain syndrome. His providers documented that the patient is not a good surgical candidate at this time. One provider described the patients symptoms as difficult to interpret in the context of the lesion. Although PT can help improve pain and function for patients with chronic neck pain, it is unclear how many sessions are adequate and optimal to help control symptoms and improve function. In the medical literature Chiu and colleagues evaluated the efficacy of a neck exercise program for patients with chronic neck pain and found that, At week 6, patients with chronic neck pain can benefit from the neck exercise program with significant improvement in disability, pain, and isometric neck muscle strength in different directions. Despite these findings however, the authors concluded that the effect of exercise was less favorable at 6 months. In one case study, Pastor reported that, Rehabilitation following spinal cord compression injuries often focuses on increasing muscle strength and improving functional gait, but unfortunately, there is no literature to support either of these conventional interventions. Based on these findings, the clinically indicated PT sessions that should be provided include 30 additionally sessions, in lieu of the requested 50 additional PT sessions, per year. Thus, 30 additional PT sessions for the dates under review are medically necessary for management of this patients medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: A female enrollee has requested reimbursement for the transcranial magnetic stimulation (TMS) treatments. Depression is considered treatment resistant when multiple antidepressants and augmentation strategies have not successfully brought on remission. The guidelines for treatment of depression endorsed the value of TMS in the acute phase of treatment for patients with depression. Moreover, in the peer-reviewed medical literature, studies show that a moderate improvement in symptoms in patients with treatment resistant depression. Studies demonstrated that TMS was significantly more likely than sham treatment to produce remission in patients with treatment resistant depression. Furthermore, studies provided evidence that TMS is a safe and effective treatment option for patients with major depressive disorder. This patients records document failure to significantly improve with medications and augmentation strategies. Given these findings, the TMS treatments provided were likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. One reviewer found that the TMS treatments provided were not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: Two of the three reviewers determined that the services at issue were 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:  One reviewer is board certified in psychiatry and is actively practicing. One Reviewer is board certified in psychiatry and is actively practicing.  One Reviewer is board certified in psychiatry 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: Experimental/Investigational
Decision: Overturned

The mother of a six-year-old male enrollee requested authorization and coverage of applied behavioral analysis therapy for treatment of the enrollees medical condition. The Health Plan denied the request indicating that the requested therapy is considered experimental for the treatment of the enrollees autism. Three physician reviewers performed an experimental/investigational Independent Medical Review. Two of the three physician reviewers concluded that the requested therapy is likely to be more beneficial for treatment of the enrollees medical condition than any available standard therapy. One physician reviewer concluded that the requested therapy is not likely to be more beneficial for treatment of the enrollees medical condition than any available standard therapy. Because two of the three  physician reviewers concluded that the requested therapy is likely to be more beneficial for treatment of the enrollees medical condition than any available standard therapy, the Health Plans denial has been overturned.
Appeal type: Medical Necessity
Decision: Overturned

A 37-year-old male enrollee requested inpatient psychiatric hospital services for medical treatment of his psychosis, not otherwise specified (NOS).   Findings:  The physician reviewer found thatthe records indicate this patient was plagued with a serious psychotic episode and co-occurring addictive illness, and his condition was determined to be gravely disabled. Thus, a conservative hospital stay was appropriate.  The services were for active treatment and delivered in accordance with a treatment plan. Additionally, the services were reasonably expected to improve the patients condition and prevent a more serious episode of illness. In the absence of inpatient services, this patient would have more than likely experienced unnecessary psychiatric morbidity, which in turn could have jeopardized the successful transition to a less restrictive treatment setting and resulted in prompt re-admission to the inpatient level of care. Thus, the services were medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: an enrollee has requested authorization and coverage for magnetic resonance imaging (MRI) of the lumbar spine. Findings: The physician reviewer found that evidence based medical guidelines support the use of early MRI when signs or symptoms suggest a serious or specific underlying condition is present. The guidelines support imaging following motor vehicle accident when radicular findings are present. This patient was involved in a rear-ended motor vehicle accident with acute onset of lower back pain radiating into the left lower extremity with numbness in the toes. Clinical examination findings documented spinous process tenderness with no focal neurologic deficit. Given the history of trauma and radicular complaints, proceeding with a lumbar spine MRI is medically reasonable and necessary at this time. Final Result: The reviewer determined that the requested procedure is medically necessary for evaluation of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in orthopedic surgery and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested Nucynta for treatment of her medical condition. Findings:  The physician reviewer found that the submitted documentation supports the medical necessity of the requested medication.  The patient has undergone multiple injections and spinal surgeries. In a letter, the provider reported that the patient has tried and failed multiple opioid and non-opioid analgesics and multimodal regimen including physical therapy, psychotherapy and interventional procedures.  She would not be taking multiple long-acting opioids together, but would be utilizing Nucynta in place of methadone secondary to intolerable side effects.  A trial of Nucynta is reasonable based on the documentation submitted for review.  All told, Nucynta is medically indicated for the treatment of this patient.  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 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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Xenical 120 mg for treatment of obesity and chronic back pain. Findings:  The physician reviewer found that current medical literature supports the requested medication in this clinical setting and supports an exception to the formulary alternatives. This patient has been diagnosed with class II obesity and has not sustained durable success with diet, exercise or with weight loss medications phentermine or topiramate. The patient also has comorbidities such as obstructive sleep apnea and low back pain. Guidelines for pharmacological management of obesity released in 2015 by the Endocrine Society state that patients who have a history of being unable to successfully lose and maintain weight loss are candidates for weight loss medications. Specifically, pharmacotherapy is recommended in patients with BMI higher than 30 kg/m2 or 27 kg/m2 if comorbidities are present. Xenical is U.S. Food and Drug Administration approved at the dose of 120 mg, three times daily for chronic weight management in patients with BMI over 30 kg/m2, or 27 kg/m2 with comorbidities (Package insert). This patient has a BMI of 37 kg/m2. 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 expertise in weight management 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 58-year-old male enrollee has requested  for right shoulder surgery with GraftJacket with repair of subscapularis and rotator cuff for treatment of his sprain/strained rotator cuff.  Findings:  Two physician reviewers found that this patient appears to have full-thickness disruption of the rotator cuff with retraction indicative of chronicity for which surgery has been recommended. The recommended GraftJacket is not supported in the various evidence-based guidelines. The Official Disability Guidelines (ODG) suggest that these grafts are under study. Further, the American College of Environmental and Occupational Medicine (ACEOM) do not address use of the GraftJacket. As such, these evidence-based guidelines would suggest that the use of the GraftJacket is not likely to be more beneficial than other standard treatments for this patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned

A 50-year-old female enrollee has requested Dexilant/Kapidex for treatment of her gastroesophageal reflux disease.  Findings:  The physician reviewer found that given that this patient has failed treatment with several medications and at varied dosages, Dexilant/Kapidex is an appropriate next step for treatment of her reflux. In this patients case, Dexilant/Kapidex is medically indicated.