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

A 58-year-old male enrollee has requested monitored anesthesia services provided during a colonoscopy performed for treatment of his medical condition.  Findings:  The physician reviewer found that the submitted clinical documentation demonstrates no indication for the use of MAC services during this patients colonoscopy. According to the American Society of Anesthesiologists (ASA) physical status classification system which assesses the fitness of patients before surgery, this patient was an ASA 1-2 risk (a normal healthy patient or a patient with mild systemic disease). This indicates he was not at increased risk for complications due to severe comorbidity. Further, he had no history of substance abuse or prescription narcotic/benzodiazepine use. All told, the patient was a healthy male who would not be predicted to have risks for sedation. As such, standard conscious sedation administered by a gastroenterologist was within the standard of care in this setting and would have been medically reasonable and appropriate for this patient.
Appeal type: Medical Necessity
Decision: Upheld

A 60-year-old male enrollee has requested ultrasound bone density measurement and interpretation for evaluation of his medical condition. Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the services at issue.  The first choice for screening for osteoporosis is a DEXA scan.  This patient previously had a low Vitamin D level.  However, repeat testing  showed a normal Vitamin D level.  He did not have a fracture indicating high risk for osteoporosis.  Per the current medical evidence, although ultrasound has some utility for fracture prediction, DEXA is recommended for screening purposes.  All told, ultrasound bone density measurement and interpretation were not medically indicated for the evaluation of this patient.
Appeal type: Medical Necessity
Decision: Overturned

The patient is a 27-year-old man with a history of open bite dental malocclusion with posterior cross bite. The patient has a history of pain in teeth and jaws with chewing, headaches, and pain in the muscles of mastication. The patients discomfort and inability to chew a wide variety of foods has increased over the last 18 months. His pain is temporarily relieved with altered (soft) diet, NSAIDS and a dental orthotic splint.The submitted medical and dental records confirm a dental malocclusion compound class III jaw relation, posterior cross bite, and anterior open bite in excess of 3mm. Periodontal records show anterior maxillary gingival recession, which is abnormal for this age group. A request has been made for orthognathic surgery. The Health Plan indicates that surgical intervention is not medically indicated.The patient exhibits chronic pain and headaches with compromised ability to masticate. The patients provider has confirmed a dysfunctional class III open bite malocclusion with an anterior open bite in excess of 3mm. The patients condition cannot be resolved with orthodontic treatment alone. Furthermore, the fact that the patients symptoms are temporarily relieved with a splint indicates an excellent prognosis for success in resolving the problem with orthognathic surgery. All of the above-mentioned factors are indications for surgical intervention. Therefore, I have determined that the requested procedure is medically necessary for treatment of the patients medical condition. The Health Plans denial should be overturned.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested immunotherapy for treatment of her medical condition.   Findings:  Two physician reviewers found that the patient has had recurrence after treatment for her cervical cancer.  The standard of care would be chemotherapy using conventional platinum/taxane combined with bevacizumab targeted therapy.  There is a lack of medical literature demonstrating the superior efficacy of immunotherapy in this clinical setting.  Therefore, the superior benefits of the requested immunotherapy have not been established.  Final Result: Two 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 reviewers are board certified in obstetrics and gynecology with sub-specialty certification in gynecologic oncology 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

The patient is a 46-year-old male who has had a painful fungus infection of his toenails for many years. He received many forms of treatment, including Sporanox from July 2004 to September 2004, without improvement. The Health Plan has denied coverage for Lamisil on the basis that it is not medically necessary. The Health Plan indicates Sporanox stays in the nail plate for nine months.The question is whether Sporanox treatment, which demonstrated no improvement in the patients condition during a six-month period, can result in cure or significant improvement in nine months. If there has not been improvement within six months, it is medically reasonable and appropriate to conclude that the Sporanox treatment was ineffective. Lamisil treatment is medically indicated for treatment of the patients painful fungus toenail infection. Therefore, I have determined that the requested medication is medically necessary for treatment of the patients medical condition. The Health Plans denial should be overturned.
Appeal type: Experimental/Investigational
Decision: Upheld

A 37-year-old female enrollee requested authorization and coverage for continued Botox injections for the treatment of migraines.  The health plan has denied this request indicating that the requested therapy is considered experimental for treatment of the enrollees medical condition.Three physician reviewers performed an experimental/investigational Independent Medical Review. All three-physician reviewers concluded that the requested therapy is not likely to be more beneficial for treatment of your medical condition than any available standard therapy.  Because all three-physician reviewers concluded that the requested therapy is not likely to be more beneficial for treatment of your medical condition than any available standard therapy, the health plans denial has been upheld.
Appeal type: Medical Necessity
Decision: Upheld

A 42-year-old male enrollee has requested a continuous passive motion (CPM) machine and cold polar therapy for the treatment of his knee condition. Findings:  The physician reviewer found that there is not sufficient literature to support the use of cold polar therapy. Cold polar therapy remains experimental at this time as more outcomes data that is peer-reviewed and demonstrates efficacy over standard heat or ice pack treatment is needed. Conflicting studies with relatively short-term follow-up exist in the literature. Based on the available literature, cold polar therapy and CPM are not medically necessary for this patient who had routine knee arthroscopy and anterior cruciate ligament reconstruction. Specifically, there is no class 1 data to demonstrate that cold therapy and CPM are better than intermittent ice pack use or even nothing at all with respect to improving mid-term and long-term functional outcomes. Furthermore, no class 1 study exists to demonstrate improved functional outcomes to justify cold therapy and CPM use after anterior cruciate ligament surgery.
Appeal type: Medical Necessity
Decision: Overturned

A 61-year-old female enrollee has requested Forteo for treatment of the enrollees osteoporosis.  Findings:  The physician reviewer found that according to the NOF, Forteo is indicated for the treatment of glucocorticoid induced osteoporosis. In addition, Forteo is FDA approved for the treatment of osteoporosis in post-menopausal women at high risk for fracture. Saag and colleagues stated that, On the basis of the known pathophysiology of glucocorticoid-induced osteoporosis, teriparatide might be considered as a therapeutic strategy for patients at high risk for fracture. The authors reported significant increases in bone mineral density in patients treated with Forteo when compared to alendronate. Therapy with Forteo is generally limited to two years and antiresorptive therapy is recommended following the course with Forteo. The NOF notes that if treatment is stopped, bone loss can be rapid and alternative agents should be considered. Specifically, the NOF recommends sequential treatment with anabolic therapy followed by an antiresorptive agent. Prolia is approved for treatment of osteoporosis, but is not approved for the prevention or treatment of glucocorticoid induced osteoporosis. Accordingly, Forteo is medically justified in this patient provided that she does not have other secondary and treatable causes of bone loss and osteoporosis, and that her calcium and vitamin D are properly replaced. Prolia can be considered after therapy with Forteo to maintain the bone density. All told, the requested medication is medically necessary for treatment of this patients osteopenia.
Appeal type: Medical Necessity
Decision: Upheld

A 60-year-old male enrollee has requested 10% Tincture of Opium (948ml size) for treatment of his Crohns disease and diarrhea.   Findings:  The physician reviewer found that the submitted documentation and relevant literature fails to demonstrate the medical necessity of the requested medication. The patient has Crohns disease with active inflammation. The standard of care in this setting is to control active disease with immune modulators or biologic therapy. Such therapies tend to reduce symptoms. In addition, the use of high dose narcotics should be discouraged in inflammatory bowel disease. This can mask more serious complications and lead to narcotic bowel syndrome. For the reasons set forth above, the requested 10% Tincture of Opium is 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 monitored anesthesia care (MAC) services during a colonoscopy for evaluation of his recurrent diverticulitis and colon polyp. Findings:  The physician reviewer found that the medical literature reports that conscious sedation is safe and effective for patients who need minor surgery or a procedure to diagnose a condition. Conscious sedation is often utilized for colonoscopies. According to the medical literature, indications for MAC services include the nature of the procedure, the patients clinical condition and/or the potential need to convert to a general or regional anesthetic. In this patients case, there is a lack of clinical documentation supporting an indication for MAC services instead of general anesthetics or conscious sedation. Moreover, there is no evidence that the patient has required MAC previously during prior colonoscopies or surgical procedures to warrant continued use of MAC services. All told, MAC services during a colonoscopy were not medically necessary for evaluation of this patients medical condition. 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 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: Experimental/Investigational
Decision: Overturned

An enrollee has requested reimbursement for digital breast tomosynthesis that was performed. Findings:  The physician reviewer found that the patient reported a family history of breast cancer with a paternal aunt who was diagnosed. The recent study was compared to prior studies. The patients breast tissue was described as average. There was no mammographic evidence of malignancy. The impression was benign, BI-RADS 2. The Health Plan has denied the reimbursement for the digital breast tomosynthesis performed. The Health Plan denied the service at issue as investigational for the evaluation of this patient.  Final Result: The reviewers determined that the service at issue was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: the physician reviewers are board certified in diagnostic radiology and are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

A 46-year-old male enrollee has requested the Bioness Ness L300 (functional electrical stimulation) and H200 (hand rehabilitation system) for the treatment of the enrollee, who is status post traumatic brain injury. Findings:  The physician reviewer found that there is very limited research demonstrating the efficacy of the Ness H200 for the treatment of upper extremity paresis. There are two case reports that suggest the requested equipment may improve motor function in patients nine months to seven years post-stroke with profound residual upper extremity weakness. A recent review of the literature identified two small clinical control trials (N=22 and N=19) and one single group pretest to posttest study (N=77) that demonstrated some improvement in hand function in chronic stroke patients with use of the requested equipment.  In the case under review, the records do not document a response to treatment, such as functional gains following a course of treatment with the equipment. Given the limited evidence supporting the efficacy of the Ness H200, the medical necessity of the device has not been demonstrated. Similarly, there is also limited research on the Ness L300. The device was shown to improve symmetry and speed of gait in 24 patients with chronic foot-drop. Another study performed by the same group compared the effects of an ankle foot orthosis versus a neuroprosthesis on gait mechanics in 15 patients with chronic foot drop. Investigators observed better balance control during ambulation with use of the neuroprosthesis.  In the case under review, there has been no formal assessment of the patient's gait, and the clinical need for the Ness L300 over a standard ankle foot orthosis has not been documented. While these studies suggest some benefit, there are inadequate well-randomized, controlled studies involving large numbers of patients demonstrating the use of a neuroprosthesis such as the Ness L300 results in a superior outcome compared to standard modalities, i.e. ankle foot arthosis. At this time, there is insufficient data supporting the efficacy of the Ness L300 to warrant its use in this setting.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for DecisionDx-Melanoma testing for evaluation of the enrollees melanoma. Findings:  The physician reviewer found that the prognosis of cutaneous melanoma has classically been determined by applying the staging system spelled out by Balch. Mitotic index has also been thought to add a bit to these statistics. DecisionDx-Melanoma testing is a study of 31 genes in an individuals melanoma cells. It then classifies that particular melanoma as either Class 1 or Class 2, based on the risk of metastasis. It is not clear how the ten-year Balch data relates to the five-year DecisionDx-Melanoma testing data. Additionally, it is not clear if the assay can be used to make clinical decisions. There is a lack of support for the services at issue in this clinical setting. Therefore, DecisionDx-Melanoma testing was not likely to have been more effective than other methods of evaluating this patient.Final Result: Two of three reviewers determined that the services at issue were 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: Physician reviewers 1, 2 and 3 are board certified in internal medicine with sub-specialty certification in medical 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

A 53-year-old female enrollee has requested chiropractic treatment for treatment of her hip pain. Findings:  The physician reviewer found that the chiropractic treatments provided were medically necessary for treatment of the patients diagnoses of lumbosacral segment dysfunction and hip enthesopathy. On the date indicated, the patient was sufficiently evaluated through physical examination and review of x-rays to formulate a diagnosis and treatment plan. The chiropractic treatment visits in dispute were medically necessary for treatment of the patients medical conditions. In addition, the records document that the patient showed improvement with chiropractic care. Based on clinical documentation and the above-cited chiropractic guidelines, the chiropractic treatments provided were 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 Serax 15 mg.  Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested medication.  Combining opioids, such as Demerol and Norco, with benzodiazepines, such as Serax, is not recommended. Benzodiazepines in combination with opioids are contraindicated and carry significant risk. Opioid analgesics and benzodiazepines are the prescription drugs most commonly associated with drug overdose deaths. There have been many cohort studies showing the risks of overdose deaths when combining opioids and benzodiazepines. The current medical evidence does not support the requested medication in this clinical setting. Final Result: The reviewer determined that the requested medication is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: Physician 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

The patient is a 52-year-old female who has been experiencing chest pain with activity, numbness of extremities, and shortness of breath. She was found to have minimally suppressed TSH but normal FT4. These tests results were confirmed. The results of a thyroid scan and uptake performed in December 2003 were normal. In addition, the results of thyroid UF3 performed in December 2001, and again in January 2004, were normal. A request has been made for a thyroid scan. The Health Plan has denied the request on the basis that a thyroid scan is not medically necessary for evaluation of the patients medical condition.The patient has a multiplicity of symptoms. The patients symptom complex is not characteristic of thyroid dysfunction. In addition, all studies of the patients thyroid have been normal including physical exam. She has minimally suppressed TSH with normal free T4, ultrasound, and UF3. Thus, there is no evidence that a thyroid scan is medically indicated. Therefore, I have determined that the requested thyroid scan is not medically necessary for evaluation of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/ Case Summary:  The enrollee requested coverage for SPECT scan for cognitive changes. The medical records indicate the enrollee was diagnosed with migraine without aura and major depressive disorder.  A clinical note indicated that the enrollee was seen in the office for a neurological evaluation.  A CT of the brain was showing moderate frontal lobe atrophy.  The enrollee indicated she had a herniated nucleus pulposus at the L3-4 with some cognitive changes at work and numbness and tingling of the extremities.  The enrollee had an MRI of the brain that showed mild to moderate frontal lobe atrophy.  She had neuropsychiatric testing that showed there were no deficits at all.  The repeat neuropsychiatric testing was also normal.  Upon review of the MRI, the enrollee did have some degree of atrophy of the frontal and anterior temporal lobes.  The possibility of frontotemporal neurodegenerative issues were discussed with the enrollee.  They indicated there was a need for repeat neuropsychiatric testing, as well as a SPECT scan.  There is no consensus statement that indicates SPECT is useful for the diagnosis of frontotemporal dementia. Also, when compared with PET, SPECT has a lower  diagnostic  accuracy and is inferior in its ability to separate healthy controls from patients with true dementia. SPECT has not been shown to have definite diagnostic benefit. The documentation indicates that the enrollee previously had an MRI that did show some degree of atrophy to the frontal and anterior temporal lobes and previously underwent neuropsychiatric testing that was normal.  There was no clear rationale for additional imaging studies as the enrollees condition was noted to be stable with no current signs or symptoms.  Final Result: Three of the three reviewers determined that the requested services are not likely to be more beneficial than any available standard therapy for treatment of the enrollees medical condition. Credentials/Qualifications: Three reviewers are board certified in Neurology 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: Upheld

A 27-year-old female enrollee has requested physical therapy for rehabilitation following anterior cruciate ligament (ACL) reconstruction. Findings:  The physician reviewer found that the submitted clinical evidence does not demonstrate the physical therapy services the patient received during the period at issue were medically necessary. The patient had 16 PT sessions over a two month period and she had weakness and functional limitations mostly with descending stairs. By this point in time therapy was directed toward strengthening and proprioception. After the number of PT sessions the patient had participated in, the stated goals could reasonably have been achieved with a daily home exercise program.