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

A 53-year-old male enrollee has requested a left total hip arthroplasty for treatment of his arthritis of the left hip.  Findings:  The physician reviewer found that total hip replacement is recognized as an effective procedure for the relief of pain and improvement of function in the hip. This reconstructive procedure is indicated in patients with a failure to respond to conservative management. Although evidence of osteoarthritis on x-ray is a necessary indication for the operation, the severity of radiographic stage does not correlate with postoperative outcome. More important are the severity of the pain and the degree of interference with daily activities.  In this patients case, there is a lack of documentation of any conservative management, with no documentation of the patients response to medications, therapy, or assistive devices. The presence of osteoarthritis in the left hip is noted on x-ray, but there is no documentation of any findings on examination.  Based upon the submitted documentation, a left total hip arthroplasty is not medically indicated.
Appeal type: Medical Necessity
Decision: Upheld

A 36-year-old male enrollee has requested for an electromyography for evaluation of his toe pain. Findings:  The physician reviewer found that no evidence is presented to suggest a clinical diagnosis such as focal mononeuropathy, polyneuropathy or lumbar radiculopathy,
Appeal type: Urgent Care
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for emergency medical services. Findings:  The physician reviewer found that the medical services provided were not necessary for treatment of an emergency medical condition. In this case, the patient sustained a right hamstring injury playing tennis in 2016. The patient failed to improve with extension physical training, medications, ice, and platelet-rich plasma injections. The patient had reportedly plateaued at 50% of normal performance level. Clinical examination findings were consistent with evidence of high-grade partial tearing of the right hamstrings with retraction of the lateral fibers. The patient underwent right proximal hamstring repair, right amniopatch allograft patch, and sciatic neurolysis. There is no evidence that the surgery performed was emergent, as the patients injury had been present for six months and findings of hamstring tearing were documented three months prior to surgery. Therefore, the services provided are not considered emergency medical services. Thus, the patient did not receive emergency medical services on the date of service at issue. Final Result: The reviewer determined that the patient did not receive emergency medical services on the date of service at issue. 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

The patient is a 34-year-old woman with a history of diabetes mellitus type 2, which appears to date back to at least May 2004, as the patient was on metformin at that time. It is possible that she might have gone through a pregnancy on insulin at that time. It appears that some time after delivery, she was given Avandia and metformin. She apparently took Avandia from May 2005 through April 2006. It is unclear whether she was given Avandamet concurrently. Because of weight gain and edema, Avandia was discontinued. In May 2006 the patient was begun on Byetta and metformin. She lost 18 pounds over 2 months. Her A1c in June 2006 was 5.5%. Her endocrinologist recommends continuation of Byetta, apparently to further increase weight loss. The patients current medications and blood sugar control are not documented in the records provided.At issue is this case is whether Byetta is medically necessary for treatment of the patients medical conditionIt appears the onset of the patients diabetes predates September 2004. It seems that her blood sugars were in good control on Avandia and/or Avandamet.  However, because of an unspecified weight gain and edema, Avandia was discontinued, and she was begun on Byetta and metformin.  There is no documentation beyond an August 2006 glucose of 157 mg/dL to indicate her glycemic response to treatment.  The patient states that she has lost 18 pounds on her new regimen. Her physician asserts that Avandia was discontinued because she developed weight gain and edema. It is not known whether the patients subsequent weight loss was achieved by the Byetta or the metformin. The submitted evidence does not demonstrate the patient experienced a lack of controlled blood sugars on metformin alone. As such, the medical necessity of Byetta has not been established. For the reasons set forth above, I have determined the requested medication is not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested authorization and coverage for Omnitrope injection 10 mg/1.5 mL cartridge.The U.S. Food and Drug Administration (FDA) has approved somatotropin (HGH) to treat ISS, defined as a standing height below -2.25 SDs without identifiable cause. Standard of pediatric endocrine care for suspected growth disorders includes brain magnetic resonance imaging (MRI) with and without gadolinium contrast and standard provocative testing for endogenous growth hormone release. In this case, the patient has not met the FDA-approved indications or generally accepted indications for somatotropin. The patients height is within two SDs of the mean for his age and sex. Based on BA of 12 years and 6 months and height of 140.6 cm, the patients predicted adult height is within the normal range for North American men. The patients growth velocity was normal prior to initiation of HGH therapy. Therefore, the requested Omnitrope injection 10 mg/1.5 mL cartridge is not medically necessary for treatment of the patients medical condition.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: The reviewer is board certified in pediatrics with sub-specialty certification in pediatric endocrinology 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

The parent of a 13-year-old male enrollee has requested coverage for a dynamic adjustable ankle extension/flexion device (Dynasplint for treatment of his Achilles tendon contracture.)  Findings:  Two physician reviewers found that the patient presented to orthopedics with a complaint of bilateral foot pain. He was diagnosed with pes planus and prescribed physical therapy and cast immobilization. He developed a rash from the casting and found the physical therapy to be ineffective. The patient has also been assessed with Achilles tendon contracture. An MRI was suspicious for a left second metatarsal fracture. The orthopedic provider recommended a Dynasplint for passive stretching.  The Dynasplint is not likely to be more beneficial for this patient than conservative physical therapy care consisting of manual stretching and heating.  There is no evidence in the peer-reviewed literature that Dynasplint offers a better functional outcome as compared to standard modalities. Additionally, the documentation shows that the patient demonstrated normal ankle range of motion (ROM) when examined and subsequent exams by additional providers revealed active ROM of the patients ankles of neutral and passive ROM of -10 through 20 degrees. Based upon the evidence provided, there is an absence of evidence of significant contracture that would require treatment.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary:  An enrollee has requested a peripheral bone density test for evaluation of her osteoporosis.  Three physician reviewers found that the testing at issue was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Fractures are the most dangerous aspect of osteoporosis and can lead to acute and chronic pain. While primary osteoporosis, which occurs with aging and accelerates at menopause, is the most common cause of osteoporosis, there are numerous secondary causes of osteoporosis as well. Hyperparathyroidism, as such, can lead to severe osteoporosis associated with a catabolic destruction of the skeleton with bone loss, brown tumors, bone cysts, and subperiosteal bone resorption of the phalanges. Because the catabolic action of parathyroid hormone predominantly occurs in cortical bone, greatest reduction in BMD is typically found at the distal 1/3 radius. Therefore, it is important for patients with hyperparathyroidism to be screened for osteoporosis. As such, the testing at issue was likely to be a more beneficial for evaluation of the patients medical condition than standard medical therapy.  Final Result:  Three reviewers determined that the testing 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: All three reviewers are board certified in endocrinology and metabolism and are actively practicing. All three reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld

A 64-year-old female enrollee has requested the Esteem hearing implant and associated anesthesia services for treatment of her hearing loss. Findings:  Three physician reviewers found that in this patients case, the superior efficacy of the services at issue has not been established.  The current medical literature has not demonstrated the superior effectiveness of the Esteem hearing implant in this clinical setting.  Additionally, the Esteem device has a high complication rate.  All told, the Esteem hearing implant and associated anesthesia services were not likely to have been of greater benefit than other treatment options.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for proton beam radiation therapy for treatment of his prostate cancer. Findings:  Three physician reviewers found that currently, there is insufficient clinical data to discern whether treatment with proton beam radiation therapy offers a clinical benefit compared to conventional radiation therapy techniques in the treatment of prostate cancer.  Researchers evaluated the comparative effectiveness of intensity modulated radiation therapy (IMRT), proton beam radiation therapy, and conformal radiation therapy for prostate cancer.  In the comparison between IMRT and proton beam radiation therapy, IMRT patients had a lower rate of gastrointestinal morbidity. There were no other significant differences regarding toxicities between IMRT and proton beam radiation therapy.  The National Comprehensive Cancer Network guidelines indicate that no clear benefit of proton beam radiation therapy has been demonstrated over standard treatment with photons and IMRT technique.   Final Result: The 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: Reviewers 1, 2, and 3 are board certified in radiation oncology and is 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

A 60-year-old female enrollee is requesting cognitive rehabilitation (speech therapy) twice per week for eight weeks, including an evaluation for treatment of her dysnomia, status post evacuation of a subdural hematoma.  Findings:  Two physician reviewers found that this patients records document that the patient has experienced a mild brain injury and has requested coverage for cognitive rehabilitation with speech therapy. To date, there is a lack of available scientific evidence demonstrating the proposed therapy results in cognitive improvements in this patient population. The relevant literature does not support routine application of cognitive rehabilitation, especially for patients with mild deficits, as is the case with this patient. At this time, the proposed modality has not been proven in studies to confer significant benefit in this setting and it is not expected to have any significant impact on this patients cognitive deficits beyond counseling or daily activity.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary:  An enrollee has requested a referral to a neurologist for treatment of her medical condition.  Findings:  The physician reviewer found that the current medical evidence does not support the requested services in this patients case.  Intermittent explosive disorder (IED) is considered a psychiatric disorder which is characterized by a wide variety of aggressive outbursts.  Per the medical evidence, this disorder is often characterized by recurrent episodes of serious assaultive acts or destruction of property due to a failure to resist aggressive impulses.  Treatment for this disorder is typically by psychiatry, with recommendations including cognitive behavioral therapy and medications.  Treatment by neurology for this psychiatric diagnosis is not medically necessary, as it is a psychiatric diagnosis, with defined diagnostic criteria and treatments.  All told, the requested referral to a neurologist is not medically indicated for the 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 neurology 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 33-year-old female with size 42DD breasts who complains of back pain. She is seeking breast reduction surgery to relieve her back pain. She has had normal x-rays of the thoracic spine and is noted to have a body mass index (BMI) of 31.9. The Health Plan has denied authorization for the requested procedure and has recommended weight loss prior to consideration of surgery.The Health Plans denial should be upheld. There is no photographic evidence demonstrating shoulder grooving and clinical notes do not document shoulder grooving. In addition, there is no evidence the patient has attempted and failed conservative therapy such as weight loss. Without such evidence there is no indication that breast reduction surgery is indicated for this patient. Therefore, I have determined the requested procedure is not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld

A 43-year-old female has requested suction-assisted lipectomy (liposuction) for treatment of lymphedema.  Findings:  The physician reviewer found that this condition represents an abnormal structure of the body, and this condition may be due to surgical trauma.  The reviewed records document response to lymphedema therapy.  In this patients case, the requested surgery will not improve function beyond what the conservative therapy has done.  Liposuction will not create a normal appearance, as it currently appears normal after the response to conservative therapy.  Therefore, the requested services are not reconstructive in nature.Presently, no cure exists for lower extremity lymphedema.  Medical management consists of compressive garments and regimens.  Surgical intervention is reserved for a patient with significant morbidity, such as recurrent cellulitis or functional impairment, who has failed conservative therapy.  Surgical treatment can either reestablish lymphatic connections or remove tissue.  Excisional procedures include staged subcutaneous resection and/or liposuction.  In this patients case, the reviewed records do not document significant morbidity after conservative therapy.  There is no documentation of recurrent cellulitis, rashes, or skin breakdown after the completion of conservative treatment.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for a stem cell injection to the right knee. Current medical literature does not support the use of injection of stem cells or hyaluronic acid following total knee arthroplasty as an effective method of diminishing residual pain. In this case, the patient underwent right total knee arthroplasty for painful end-stage osteoarthrosis the previous year. Visit notes reported that the patient received a PalinGen SportFlow injection, described by the manufacturer as an amniotic tissue allograft containing cellular components, cytokines, growth factors and extracellular matrix proteins that are naturally found in amniotic tissues. Amniotic fluid derived injections do not contain live cells. There is a lack of scientific evidence on the efficacy of hyaluronic acid and/or of amniotic tissue allografts for the treatment of residual pain in this clinical setting. Therefore, the stem cell injection to the right knee was not likely to have been more beneficial for treatment of the patients condition than any available standard therapy.Findings:  Two of the three physician reviewers found the stem cell injection to the right knee  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 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: Medical Necessity
Decision: Overturned

A 14-year-old female enrollee requested authorization and coverage of scar revision surgery for the treatment of scars.  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 overturned the health plans denial on the basis that the requested surgery is 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 stereotactic body radiation therapy for treatment of the enrollee who has a history of lung cancer. Findings:  The physician reviewer found that The requested services are not medically necessary for treatment of this patients medical condition. SBRT, delivering high fractional doses in 4-5 fractions, is an established approach for the treatment of discrete lesions from cancer. SBRT systems use fiducials, bony anatomy or external markers as a coordinate system to map the delivery of radiation to increase the precision and accuracy of radiation delivery. SBRT can be considered in select patients with oligometastatic bone metastases. Gerszten and colleagues and Harel and Zach outlined commonly accepted indications to include patients with good performance status, life expectancy greater than six months, no more than two contiguous sites involved and no direct cord compression. The most recent American Society of Radiation Oncology (ASTRO) model SBRT coverage policy states that SBRT for metastatic lung, liver, adrenal, and kidney lesions is medically necessary when the patients performance status justifies aggressive treatment, and for those whose tumor burden can be completely targeted with acceptable risks.  Bone metastases are discussed in this model policy as follows: SBRT has been demonstrated to achieve durable tumor control when treating lesions in vertebral bodies or the paraspinous region, where extra care must be taken to avoid excess irradiation of the spinal cord when tumor-ablative doses are administered. There is an important clinical distinction between the status of patients described above and a patient with widely metastatic disease for whom palliation is the major objective. In one setting, a patient with limited metastatic disease and good performance status is treated with the intention of eradicating all known active disease or greatly reducing the total disease burden in a manner that can extend progression free survival. For such a patient, SBRT can be a reasonable therapeutic intervention. However, in this patients case, the submitted documentation does not indicate that the ASTRO model policy criteria has been met as she has widespread disease. Therefore, SBRT 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 radiation oncology 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.