Persius/imr-appeals huggingface dataset:
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary:   An enrollee has requested digital breast tomosynthesis for evaluation of her medical condition.  Findings:  Two physician reviewers found that breast tomosynthesis is a technique that was developed several years ago as a problem solving adjunct to routine mammography.  Applying the same basic concept as computed tomography (CT) scanning, the logic is that by separating the various layers of breast tissue, one can better detect abnormalities.  However, in this patients case, she apparently had a routine screening mammogram and an abnormality was detected.  Per the records, she was evaluated with breast tomosynthesis examination at that time.  She was then recalled, and had a repeat tomosynthesis exam shortly thereafter.  One of the primary arguments supporting the use of tomosynthesis is that this technology lessens the incidence of callbacks.  The initial tomosynthesis was warranted.  However, there is a lack of support for the repeat tomosynthesis shortly thereafter.  Thus, the digital breast tomosynthesis in question was not likely to have been of greater benefit than other methods of evaluating this patient.  Final Result: Two 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:  All three reviewers are board certified in diagnostic radiology and are actively practicing. All three reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

A 56-year-old female enrollee requested authorization and coverage of the medication fosamax (70 mg) for the treatment of osteopenia in the lumbar spine.  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 medication is medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned

The parent of two-year-eleven-month-old female enrollee has requested speech therapy, occupational therapy, and physical therapy services for treatment of the enrollees developmental disabilities. Findings:  The physician reviewer found that global developmental delay is defined as a significant delay in two or more of the following developmental domains: gross/fine motor, speech and language, cognitive, social/personal, and activities of daily living. It involves a profile that is associated with age-specific deficits in adaptive and learning skills. Those deficits are evident in comparison with the skills obtained by same-aged peers (Shevell, et al.). Speech therapy is indicated with any delay greater than 25% (Feldman & Messick). Physical and occupational therapies are standard modalities for children with significant delays in gross and fine motor skills and cognitive functioning. The main goal of treatment is to enhance the level of functioning. This patient has delays in speech and gross motor skills with fine motor and cognitive delays. Appropriate services including speech, physical and occupational therapies are medically necessary and promote adaptive skill development and independence (Wolraich, et al.)
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for bilateral reduction mammoplasty.The submitted documentation supports the medical necessity of the services at issue. Researchers report that reduction mammoplasty has a positive impact on a range of symptoms associated with macromastia, including greater improvement in back pain, neck pain, and poor posture, even with lower volume resections and regardless of body surface area-calculated adjustments. Likewise, the American Society of Plastic Surgeons (ASPS) guidelines on reduction mammoplasty note that reduction mammoplasty has been shown to improve quality of life. The guidelines further note that evidence is inconclusive on whether increased body mass index is associated with increased risk of complications. Researchers note that while many insurance carriers continue to deny coverage for reduction mammoplasty unless a minimum weight of 500 grams of breast tissue per breast is resected during surgery, a distinct cohort of women who are clinically appropriate candidates may not meet this criterion. In this case, the patient had a prior breast reduction with inadequate tissue removal to relieve her symptoms of neck and back pain, and with complications that resulted in significant scarring of the breasts. The records noted that 1,083 grams were removed from the right breast, and 1,130 grams were removed from the left breast specimen. Therefore, bilateral reduction mammoplasty was medically necessary for the treatment of this patient. The California reconstructive surgery statute requires health insurers to cover reconstructive surgeries, defined as surgery performed to correct or repair abnormal structures of the body caused by congenital defects, developmental abnormalities, trauma, infection, tumors, or disease to do either of the following: (1) to improve function; (2) to create a normal appearance, to the extent possible. In this case, the records document an abnormal structure of the body caused by macromastia and complications from prior breast reduction surgery. The bilateral reduction mammoplasty was performed to relieve symptoms of macromastia and managed significant cutaneous scarring as a result of complications of the prior breast reduction surgery and provided a significant improvement in the appearance of the patients breasts. Therefore, the bilateral reduction mammoplasty was reconstructive in nature for the treatment of this patient. Final Result: The reviewer determined that the bilateral reduction mammoplasty was medically necessary for treatment of the patients medical condition and was reconstructive in nature. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in plastic 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 right knee Orthovisc injections. The current medical evidence supports the requested services in this clinical setting.  This patient presents with significant right knee pain that is limiting activities of daily living. Clinical examination findings are consistent with right knee osteoarthritis. The peer-reviewed literature supports the use of viscosupplementation injections for the treatment of pain in patients with osteoarthritis of the knee. Repeat viscosupplementation injections have been found to be safe and effective. Given the previous response and to assist in delaying total knee replacement, repeat viscosupplementation injections are indicated. Therefore, the requested right knee Orthovisc injections are medically necessary for the treatment of this patient. 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
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for a knee scooter. Ciufo and colleagues note that the knee scooter is a commonly used mobility device in the setting of unilateral below-knee immobilization to manage lower extremity injuries and elective surgery. The authors continue that the knee scooter assists patients in maintaining independence, performing daily activities, and returning to work, concluding that there was a statistically significant decrease in volumetric flow rate in subjects using a knee scooter device with a flexed knee. In a comparative study of patients using a wheeled walker verses patients using axillary crutches, Kocher and colleagues concluded that wheeled knee walkers provided increased assisted ambulation and had a lower rating of perceived exertion than axillary crutches on level surfaces in healthy participants. In this case, the patient is post-surgical right ankle repair of bone cysts and arthrotomy. Given current medical literature supporting the use of a knee scooter as safe and effective, the patients comorbidities and the providers recommendation, the requested equipment is medically indicated. Therefore, a knee scooter is medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested equipment 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 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

An enrollee has requested authorization and coverage for Botox injections. Findings:  The physician reviewer found that the request for Botox injections is not medically necessary for treatment of the patients medical condition. The patient presents with headaches, however it is not clear as to whether she has migraine or tension-type headache. She reports improvement after receiving Botox injections, but there are no records provided demonstrating the paradigm used or the dosage amount. The records also do not indicate if she has had headaches 15 or more days a month for over three months which would support the diagnosis of chronic migraine. In addition, there is a lack of documentation showing that the patient has tried other preventive treatment therapies for migraine such as beta blockers, anticonvulsants or tricyclic antidepressants. All told, the request for Botox injections are not supported as medically necessary for the treatment of this patients medical condition. Final Result: The reviewer determined that the requested service 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 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 45-year-old female who presented with symptomatic varicose veins.  There is no documentation of any complications such as bleeding, ulceration, or thrombophlebitis. The patients primary care provider prescribed compression stockings in April 2006 as well as analgesics. No follow-up visit is documented; it is unknown if the compression stockings were successful in treating the patients symptoms.  The patient has requested authorization for a consultation with a vascular surgeon. The Health Plan denied this request based upon a determination that the consultation is not medically necessary.Compression therapy is the appropriate first line treatment for venous insufficiency.   A referral to a vascular surgeon is warranted when complications of varicose vein disease are present or conservative management (compression stockings) fails to adequately control the patients symptoms.  Neither complications nor failure of conservative therapy have been documented in this case.  Therefore, I have determined the requested service is not medically necessary for evaluation of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld

A thirty-three year-old male with right shoulder pain is requesting authorization for an MRI of the shoulder.Reviewers Findings:The reviewing physician found that the patient requires further workup before an MRI is appropriate.  The physician concluded that the Health Plan denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement and prospective authorization and coverage for residential treatment center (RTC) services. Per the American Society of Addiction Medicine (ASAM) criteria, this patient meets Level 3.5 criteria for Clinically Managed High-Intensity Residential Services. ASAM criteria focuses on six dimensions to determine the appropriate level of care including: (1) intoxication and withdrawal potential; (2) biomedical conditions; (3) emotional, behavioral and cognitive conditions; (4) readiness to change; (5) relapse, continued use, or continued problem potential; and (6) recovery environment. For dimension 1, the patient presents with mild to moderate withdrawal as per CIWA scoring. The patient meets the criterion for dimension 2, the records document bleeding esophageal varices that are fragile and require close medical monitoring. In addition, she has required three intensive care unit (ICU) admissions in the past four years for treatment of substance-related medical complications. Dimension 3 is met, as the patient has comorbid PTSD as well as symptoms of depression and anxiety. For dimension 4, the provider noted that the patient is willing but not yet able or ready for change as evidenced by her reduced ability to attend to activities of daily living. The patient continues to blame external factors. The patient satisfies dimension 5, as she demonstrates impulsive behavior and mood instability as well as varying commitment to treatment. For dimension 6, the patient has shown impulsivity in the context of tending towards social isolation in remote locales. The providers noted that the patient continues to require further monitoring until stabilized, given her tendency to relapse. The patient requires a safe and stable living environment in order to develop her recovery skills and qualifies for ASAM Level III treatment similar to what patient has received at the current facility. Given the severity of the patients illness, the RTC services were and are medically necessary for treatment of this patient. Final Result: The reviewer determined that the services at issue were and 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 psychiatry with expertise in addiction 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

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for   laboratory services. Testing for specific genetic mutations was indicated for this patient given her history of retinal artery occlusion and retinal vein occlusion. Although they are listed as separate diagnoses, it is considered a singular clinical entity with different implications for treatment and comorbidity. There is evidence in the medical literature that laboratory investigation for hypercoagulability is recommended in the setting of combined retinal artery and retinal vein occlusion (Sengupta and Pan; Parchand; Desai, et al.). Given this support, the laboratory services were likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Findings:  Three of the three physician reviewers found the laboratory services were likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the services at issue were 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: Physician reviewers 1, 2, and 3 are board certified in ophthalmology and are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld

A 42-year-old male enrollee has requested lumbar artificial intervertebral disc and spinal fusion (spinal disc replacement, dual level L4-5, L5-S1) for treatment of his back pain. Findings:  Three physician reviewers found that the requested services are not likely to be more effective for this patient than other available options. There is a lack of long term studies in the peer-reviewed literature documenting the superiority of disc replacement surgery compared to other modalities. The article by De Kleuver and colleagues notes, There is no evidence that disc replacement reliably, reproducibly, and over longer periods of time fulfils the three primary aims of clinical efficacy, continued motion, and few adjacent segment degenerative problems. Total disc replacement seems to be associated with a high rate of re-operations, and the potential problems that may occur with longer follow-up have not been addressed. For the reasons provided, the requested services are not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.
Appeal type: Medical Necessity
Decision: Overturned

The patient has requested authorization and coverage for Euflexxa injections in both knees. Evidence from systematic reviews and randomized controlled trials indicate that although viscosupplementation may relieve knee pain in some patients with osteoarthritis, data has not established which patients will benefit. Guidelines from the American Academy of Orthopedic Surgeons (AAOS) indicate that the data on safety and efficacy of viscosupplementation remain inconclusive. As such, the AAOS does not currently recommend viscosupplementation as standard treatment for osteoarthritis of the knees. Viscosupplementation is reserved for patients with a history of lasting benefit from prior injections and in cases where the remaining options are limited. In this case, the patients treatment options are limited. The patient has tried and failed conservative treatments. The patients remaining treatment options include a total knee arthroplasty in the presence of moderate patellofemoral arthritis but no tibiofemoral arthritis or viscosupplementation. The patient underwent a series of viscosupplementation in 2018, and the provider has repeatedly recommended additional Euflexxa injections since that time due to its long-term efficacy. All told, the requested Euflexxa injections in both knees are medically necessary for treatment of this patient.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.
Appeal type: Medical Necessity
Decision: Overturned

A 36-year-old female enrollee has requested custom molded orthotics, cast supplies, application of short leg splint, and follow-up podiatry visit for treatment of the enrollees plantar fasciitis. Findings:  The physician reviewer found that this patients heel pain has not resolved with use of nonsteroidal anti-inflammatory medications and over-the-counter arch supports.  She has partially responded to a local steroid injection and medial arch strapping.  In this clinical setting, given the biomechanical pathology, the current medical evidence supports custom molded orthotics.  The use of custom molded orthotics is an established treatment for overpronation and heel pain.  In this patients case, the requested custom molded orthotics and follow-up podiatry visit are medically indicated.  However, cast supplies and application of short leg splint are not medically necessary.  The progress notes do not support the need for a short leg splint or cast supplies.  All told, the submitted documentation demonstrates the medical necessity of a portion of the requested services.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Euflexxa injection series in the right knee. Per the medical literature, although viscosupplementation may relieve knee pain in some individuals with osteoarthritis, it is not known as to which individuals will benefit. The current evidence is limited, and guidelines from organizations such as the American Academy of Orthopedic Surgeons indicate that the evidence is not conclusive. 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 a history of relief from prior injections. The patient has tried and failed other conservative treatments, with the alternative being a total knee arthroplasty. Given the patients limited options and based on the current medical literature, the requested services are medically indicated. Therefore, Euflexxa injection series in the right knee is medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested service 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 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.