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

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for magnetic resonance imaging (MRI) of the right and left hip and/or MRI of the left knee. Findings:  The physician reviewer found that this patient has an established history of longstanding left knee pain that has persisted after ACL repair. Per the chart notes, the patient presented multiple times in 2018 regarding these symptoms. Three years later, the patient experienced an acute traumatic event resulting in left knee and bilateral hip pain. The patients provider has recommended MRI studies of the bilateral hips and left knee. The American College of Radiology (ACR) states that in the event of acute hip pain after trauma, x-rays are the first, most appropriate step. If the x-ray is negative, an MRI can then be considered to evaluate abnormalities not visualized on x-ray. Similar recommendations are provided for knee pain after trauma with x-rays given the highest recommendation level of 9 out of 9. Given that the patient has a prior history of surgery and pain in the left knee, the ACR recommendations for chronic knee pain may be reviewed as this may be a case of acute on chronic pain. However, the recommendations are consistent to suggest that the initial imaging after trauma should be radiography. MRI is superior to x-rays in the evaluation of the soft tissues, but it is not superior to x-rays in all respects, particularly in providing a relative quick assessment for fractures and joint effusions. Furthermore, providers correlate findings on x-ray with MRI making the two studies complimentary and additive in providing information regarding joint injury (George, et al.). At this time, first-line imaging with radiographs has not been performed. Thus, the requested MRI of the right and left hip and MRI of the left knee are not medically necessary for this patient.Final Result: The reviewer determined that the requested services are 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 radiology with subspecialty certification in diagnostic radiology 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

A 63-year-old female has requested a Lap-band procedure for treatment of her obesity. Findings:  Two physician reviewers found that according to well-accepted criteria for weight loss surgery, patients with a BMI between 35 and 40 must have significant co-morbidities in order to be considered appropriate candidates for weight loss surgery. This patient has a BMI of 35. The patient also has a history of diabetes mellitus which is considered a significant weight related co-morbid condition. This patient was an appropriate candidate for weight loss surgery. The Lap-band procedure is a well-accepted weight loss method. It is accepted by the American Society of Bariatric Surgeons and the Society of American Gastrointestinal Endoscopic Surgeons as a suitable weight loss procedure in this patient population.
Appeal type: Medical Necessity
Decision: Upheld

A 61-year-old female enrollee has requested MRI of the thoracic spine for evaluation of her degenerative disc disease with peripheral neuropathy. Findings:  The physician reviewer found that although the patient has pain, there is no documentation in the chart to suggest a thoracic spine dermatome. The records do not document evidence of any red flags to support an indication for a thoracic spine MRI such as neurological deficit, history of cancer, infection, or equivocal radiologic finding requiring detailed imaging for clarification. Further, there is no electromyography (EMG) in the records detailing a thoracic dermatome abnormality. In the absence of a conservative trial of physical therapy and given the lack of red flags, there is no clinical indication for MRI of the thoracic spine. Thus, the requested diagnostic procedure is not medically necessary for evaluation of this patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient is a male with a history of chronic left knee pain. The patient has degenerative changes of the left knee joint, which have been managed by viscosupplementation injections with good long-term pain and activity levels and reduction in the use of over-the-counter medications and assistive devices.  The provider noted that Euflexxa was preferred due to risk of synovitis. The orthopedic report indicated that the patient had tricompartmental changes of the left knee, worse at the patellofemoral compartment. The left knee examination documented normal alignment, joint line anterior retropatellar tenderness to palpation, unchanged range of motion, normal strength, and no instability. The diagnosis was left knee tricompartmental osteoarthritis. In January, the left knee examination documented tenderness to palpation over the joint line and retropatellar regions, unchanged range of motion, normal strength, and no instability. The treatment plan included Euflexxa injections.a  study found with 33,243 participants, hyaluronic acid was found to be better than injected placebo or injected corticosteroids (Bannuru, et al.). The authors concluded that hyaluronic acid was the best pharmacologic intervention for knee osteoarthritis. In addition, the American Medical Society for Sports Medicine recommends hyaluronan acid for appropriate knee osteoarthritis patients, based on a very large network . Evidence based medical peer-reviewed literature supports the use of viscosupplementation injections for the treatment of pain in patients with significantly symptomatic osteoarthritis of the knee. Moreover, repeat viscosupplementation has been found to be safe and effective and allow for delay of total knee replacement, and more effective than corticosteroid injections.In this case, the patient has been diagnosed with osteoarthritis of the left knee. He has worsening left knee pain and functional impairment in mobility that has failed to respond adequately to conservative treatment, including corticosteroid injections. Prior viscosupplementation have reportedly provided good long-term pain relief and allowed him to continue with higher-level activities. Therefore, the requested Euflexxa injection to the left knee is medically necessary for 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 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. Findings:  The physician reviewer found that Findings:  The physician reviewer found that
Appeal type: Medical Necessity
Decision: Upheld

The patients parent has requested authorization and coverage for 23 hours per week of direct applied behavioral analysis (ABA) services. The Behavior Analyst Certification Board (BACB) highlights that treatment intensity is influenced by variables, including the number, complexity, and intensity of behavioral targets and the clients own response to treatment. Based on the submitted treatment plan, this patient is engaging in low rates of challenging behaviors that are not severe in nature. The number of goals requested also does not require additional hours. Although problem behaviors are also targets, these issues are addressed as the opportunities arise. Moreover, the patient is making considerable progress, meeting 50% of the goals since the previous reporting period. According to medical literature medically necessary ABA services are required to meet the essential health needs of the patient; consistent with the diagnosis of the condition for which they are required; consistent in type, frequency, and duration of treatment with scientifically based guidelines as determined by medical research; required for purposes other than the convenience of the provider or the comfort of the patient; and rendered in the least intensive setting that is appropriate for the delivery of health care. Based on these guidelines, the patient does not meet criteria (c), as based on the treatment plan, the number of goals and severity of behavior do not warrant a more intensive level of service. All told, the requested 23 hours per week of direct ABA services are 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 a licensed B.C.B.A. board certified in psychology 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 27-year-old male enrollee requested authorization and coverage of the medication provigil for the treatment of neuropothy and myopothy.  The health plan denied the enrollees request indicating that provigil 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 medication is not medically necessary.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Invokana for treatment of the enrollees diabetes. Findings:  The physician reviewer found that the request for Invokana has not been established as medically necessary for treatment of the patients medical condition. Invokana and Jardiance are members of a relatively new class of diabetes medications, subtype 2 sodium-glucose transport protein (SGLT2) inhibitors. The primary mechanism of action of this group of agents involves decreasing renal glucose reabsorption, which results in enhanced urinary glucose excretion, thereby leading to reductions in plasma glucose and hemoglobin A1C concentrations. While there have been no head to head trials of the SGLT2 inhibitors, both Invokana and Jardiance appear to have similar efficacy in terms of glycemic control, weight reduction, and blood pressure lowering. In this case, the documentation does not show failure of treatment Jardiance. Given the similar efficacy of the Health Plans formulary alternative, the request for Invokana has not been established as 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 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: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for magnetic resonance imaging (MRI) with sedation for evaluation of the enrollees cervical spine lesion. Findings:  The physician reviewer found that the documentation submitted for review supports a medical indication for MRI with sedation. The American College of Radiology (ACR) Appropriateness Criteria has devised multiple variants under the category of myelopathy.  The variant most closely matching this patient is described as sudden onset or slowly progressive. Under this variant, MRI is considered the most appropriate imaging study. Moreover, the request for MRI with sedation is clinically indicated. In general, MRI can be performed on non-sedated patients, however there are occasional patients who need sedation. Most of these patients can be managed with sedatives such as limited doses of Valium, but there are also some patients who require more substantial sedation. In this case, given the patients constellation of progressive symptoms and providers recommendation for MRI with sedation, the requested diagnostic procedure is medically necessary for evaluation of the patients medical condition. Final Result: The reviewer determined that the requested diagnostic 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 diagnostic radiology 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 47-year-old male enrollee requested authorization and coverage of L5-S1 discectomy and placement of an SB Charite III intervertebral spacer. The Health Plan denied the request indicating that the requested procedure is considered experimental for treatment of the enrollees degenerative disc disease.Three physician reviewers performed an experimental/investigational Independent Medical Review. All three physician reviewers concluded that the requested procedure is not likely to be more beneficial for treatment of the enrollee's medical condition than any available standard therapy. Because all three physician reviewers concluded that the requested surgery is not likely to be more beneficial for treatment of the enrollee's medical condition than any available standard therapy, the Health Plans denial has been upheld.
Appeal type: Experimental/Investigational
Decision: Upheld

A 32-year-old female enrollee requested the AmniSure test (evaluate amniotic fluid protein for medical evaluation of her pregnancy. Findings:  Three physician reviewers found that most cases of premature rupture of membranes can be diagnosed on the basis of the patients history and physical examination consisting of visualization of amniotic fluid passing from the cervical canal and pooling in the vagina. First-line testing includes a basic pH test of vaginal fluid (Nitrazine) or arborization of dried vaginal fluid. Based on the records reviewed, this patient underwent AmniSure testing in lieu of standard testing. Therefore, the AmniSure test (evaluate amniotic fluid protein) was not likely to have been more beneficial for evaluation of the patients medical condition than any available standard therapy.
Appeal type: Medical Necessity
Decision: Overturned

The patient is a 24-year-old female with a body mass index (BMI) of 46.5. Her comorbid conditions include hypercholesterolemia and hypertension. The patient has obtained psychiatric clearance for weight loss surgery. She wishes to undergo gastric bypass with duodenal switch. The Health Plan has denied this request indicating the patient does not medical necessity criteria for weight loss surgery. The patient is an appropriate candidate for surgical intervention to treat her morbid obesity. There is more than substantial data in the literature to support the use of duodenal switch to accomplish this goal. The literature shows that duodenal switch has a superior long-term outcome when compared to Roux-en-Y gastric bypass. Consequently, duodenal switch is an accepted and medically necessary procedure for this patients medical condition. Furthermore, there is no scientific evidence demonstrating that structured diet or exercise plans have been successful in the treatment of the morbidly obese. In fact, the Swedish obesity study identifies that even though there may be reduction or resolution of some symptoms with diet and exercise, surgery has the longest and best long-term outcome for the morbidly obese.Based upon the information set forth above, I have determined that the requested procedure is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has been diagnosed with morphea of the right breast. The patient initially developed a lesion on the right breast. A biopsy performed revealed an inflamed sinus tract. The physical examination findings included a large geometric plaque with scarring and lichenification on the right breast. No areas of erythema, drainage, nodules, or open ulcers were noted. The provider noted that there were no signs of infection or inflammation.The patient has requested authorization and coverage for tacrolimus 0.1% ointment. The Health Plan denied the request and reported the requested medication is not medically necessary for the treatment of this patient. At issue in this case is whether tacrolimus 0.1% ointment is medically necessary for treatment of the patients medical condition. Cantisani and colleagues reported that morphea, also known as localized scleroderma, is a fibrosing disorder of the skin that may also affect the underlying muscle and connective tissue. The authors noted that even when spontaneous remission occurs, the residual damage created by previously active disease (pigment change, atrophy, contracture, limb length discrepancy) may be severe. Researchers reported that no consistent recommendations exist for the treatment of morphea. The authors noted that phototherapy, methotrexate/systemic corticosteroids, calcipotriene, and topical tacrolimus have the most evidence for efficacy in morphea. Topical treatment with tacrolimus 0.1% is effective for superficial dermal or dermal-limited (single plaque) lesions. In this case, physical examination findings included a large geometric plaque with scarring and lichenification on the patients right breast. No areas of erythema, drainage, nodules, or open ulcers were noted. Per the records, there were no signs of infection or inflammation. The medical evidence supports the requested medication in this clinical setting. Therefore, tacrolimus 0.1% ointment is medically necessary for 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 dermatology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

A 48-year-old female enrollee has requested a surgical procedure to remove a growth (right eye) for treatment of her pterygium of the right eye.  Findings:  The physician reviewer found that the submitted documentation fails to establish the medical necessity of the requested procedure. Pterygium is an abnormal growth of the conjunctiva onto the corneal surface. It is associated with chronic sun exposure, dust exposure and dry climates. Pterygium surgery is indicated when the pterygium impinges on the visual axis, interfering with vision. In this patients case, the provider noted the growth to be 1.75 mm, which is not extensive enough to interfere with the visual axis. As such, the requested surgery is not clinically indicated. Based on the documentation submitted for review and the peer-reviewed literature cited above, the requested procedure is not medically necessary for treatment of the patients medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld

A 62-year-old female has requested radiofrequency neurolysis for treatment of her low back pain.  Findings:  Two physician reviewers found that the patient has chronic low back pain, diagnosed as sacroiliitis. She is status post an L5-S1 discectomy fourteen years ago, an artificial disc replacement nine years ago L5-S1 and a spinal fusion procedure five years ago. She has undergone treatment with medications, physical therapy and sacroiliac (SI) joint injections. The SI joint injections were noted to provide 80% relief of the patients pain, with the pain relief lasting for only one day. The requested SI joint radiofrequency neurolysis is not likely to be more beneficial for treatment of the patients sacroiliitis than any other available standard therapies. The literature suggests that benefit from this procedure may be limited and there is a paucity of evidence demonstrating the safety and efficacy of the requested procedure. The study by Hanson and colleagues concluded that evidence is limited regarding the following: the accuracy of provocative maneuvers in the diagnosis of SI joint pain, the therapeutic value of intra-articular SI injections, and for the use of radiofrequency neurotomy in managing chronic SI joint pain. All told, the requested radiofrequency neurolysis remains investigational.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the surgery performed by an out-of-network provider for treatment of the enrollees right upper lobe lung nodule suspicious for non-small cell lung cancer.Findings:  The physician reviewer found that the submitted documentation and relevant literature fails to demonstrate the medical necessity of the services at issue. There is a lack of compelling evidence in the peer-reviewed literature to suggest robotic minimally invasive technique is superior to video-assisted thoracic surgical lobectomy. A study found that robotic lobectomy and wedge resection have longer operating times without any differences in adverse events. In this case, in-network providers were available to perform the procedure, including a minimally invasive procedure without utilizing the robotic technique. 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 physician revieweris board certified in thoracic 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.