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

Nature of Statutory Criteria/Case Summary: An enrollee has requested a collagen meniscus implant (CMI) for treatment of his medical condition.  Findings: Two physician reviewers found that there is a lack of support for the requested services in this clinical setting.  Clinical examination findings did not evidence positive meniscal signs, and there was no documentation of mechanical symptoms. There was imaging evidence of prior medial meniscectomy, and additional tearing could not be excluded. There was also imaging evidence of mild degenerative osteoarthritis, greatest in the medial compartment. There is no indication to support additional meniscal surgery at this time. Therefore, the requested services are not likely to be of greater benefit than other treatment alternatives.  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 physician reviewers are board certified in orthopedic surgery 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

Nature of Statutory Criteria/Case Summary:   An enrollee has requested actigraphy testing for evaluation of her sleep difficulties.   Two physician reviewers found that Taibi and colleagues noted that actigraphy offers an unobtrusive method for measuring sleep, but it appears to underestimate sleep disturbance, particularly at sleep efficiency levels below 73%, in older women with insomnia. Ancoli-Israel and colleagues reported that although actigraphy is not as accurate as polysomnogram for determining some sleep measurements, studies are in general agreement that actigraphy, with its ability to record continuously for long time periods, is more reliable than sleep logs which rely on the patients recall of how many times they woke up or how long they slept during the night and is more reliable than observations which only capture short time periods. Actigraphy can provide information obtainable in no other practical way. However, this patients records include complaints of sleep problem with otherwise normal exam and reported normal MSLT and polysomnogram. Based on current peer-reviewed publications, there is no indication that actigraphy would offer any new information from a diagnostic standpoint compared to the normal studies already performed. As such, the medical records do not support the addition of actigraphy as likely to have been more beneficial for evaluation of the patients medical condition than any available standard therapy.  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 internal medicine and 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: Overturned

A 34-year-old enrollee requested inpatient care for medical treatment of his behavioral health conditions.  Findings:  The physician reviewer found that the submitted documentation supports the medical necessity of the services.  This patient evidenced dramatic affective symptoms characterized by dysphoria, mood dysregulation and suicidality despite outpatient treatment.  Further complicating matters was his anxiety disorder.  Discharge would have been premature and inconsistent with good medical practice.  Per the medical records, the patient had not consolidated the treatment gains necessary to succeed in a less restrictive setting.  The hospital services were for active treatment.  The services were reasonably expected to improve the patients condition and prevent a more serious episode of illness.  All told, inpatient care was medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Overturned

The parents of a 17-year-old female enrollee requested authorization and coverage of residential treatment services. The Health Plan denied the request indicating that the requested services are not medically necessary for treatment of the enrollees behavioral health problems.One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer overturned the Health Plans denial on the basis that the requested services are medically necessary.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee requested a custom knee brace for treatment of her medical condition status post anterior cruciate ligament (ACL) reconstruction with allograft. Findings:  The physician reviewer found that it is medically necessary for this patient with stated XXX syndrome and clinical findings of generalized ligamentous laxity to have the protective benefits of a custom knee brace. This has been recommended for a period of one year after ACL reconstruction. The patient has XXX syndrome, which is characterized by a wide range of effects including variable musculoskeletal syndrome. Due to the documentation of a generalized ligamentous laxity combined with the stated XXX syndrome, it is prudent for this patient to have the benefit of ACL bracing during rehabilitation. Custom ACL bracing is not medically necessary in patients who do not have collagen disorders. In the medical literature, an evaluation of 820 skiers who had experienced ACL injuries and reconstruction was performed. Of the 820 patients, 257 of the skiers used functional bracing during skiing and 563 skiers did not. The authors reported a statistically significant increase in incidence of subsequent knee injury in non-braced skiers. Consistent with the current scientific data, it is medically necessary for this patient to have the requested custom knee brace for ACL bracing during rehabilitation. Final Result: The reviewer determined that the requested device 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

A 37-year-old male enrollee has requested  E1800 Dynamic adjustable elbow extension/flexion device (Dynasplint) for treatment of his right elbow radial head fracture. Findings:  The physician reviewer found that the patient suffered a right elbow radial head fracture and underwent an open reduction internal fixation on the date indicated. The patient was treated with postoperative physical therapy and a Dynasplint. There was no mention of a postoperative elbow contracture. The patients physical examination on the subsequent date revealed 12 to 150 degree range of motion with full supination and pronation. There was no mention of a contraindication to traditional physical therapy and home exercise as opposed to static progressive stretching. Based on the clinical information received, the medical necessity for the requested Dynasplint device has not been established. All told, the requested device is not medically necessary for treatment of the patients medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested breast tomosynthesis for evaluation of her medical condition.  Findings: Two physician reviewers found that breast tomosynthesis was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. There is sufficient support in the peer-reviewed literature for the services at issue in this clinical setting. According to the study by Ciatto and colleagues, the addition of breast tomosynthesis reduces false positives and increases cancer detection when compared to two-dimensional mammography alone. Moreover, Detection rates, including those for invasive and in situ cancers, were 6.1 per 1000 examinations for mammography alone and 8.0 per 1000 examinations for mammography plus tomosynthesis (Skaane, et al). Given the support above, the services at issue were likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.  Final Result: Two physicians 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: All three physician 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

Nature of Statutory Criteria/Case Summary: The parent of a male enrollee has requested reimbursement for residential treatment center services for treatment of the enrollees behavioral health condition. Findings:  The physician reviewer found that based on the documentation submitted for review, residential treatment center services provided were medically necessary for treatment of the patients medical condition. In this case, the patient presents with diagnoses of ADHD, anxiety disorder and disruptive behavior disorder. He displayed aggressive and intimidating behavior towards his parents. He was treated with multiple lower level of care interventions including psychotherapists, psychiatrists and home-based therapeutic services. However, despite multiple therapies the patients behavior continued to deteriorate. In this clinical setting the structure of a 24-hour based residential treatment was medically necessary for the patient to develop therapeutic relationships and modeling types of behavior. In addition, the services provided were consistent and beneficial for treatment of the patients medical condition. Based on the documentation submitted for review, the services at issue were medically necessary for treatment of the patients medical condition. Final Result: The reviewer determined that the services at issue were 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 sub-specialty certification in child and adolescent 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: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for fabricated maxillary and mandibular interim prosthesis/stent provided. Findings:  The physician reviewer found that there is sufficient support for the services at issue in this clinical setting.  The patient sustained facial trauma with loss of multiple teeth. Restoration of his teeth with dental implants was appropriate.  The interim prosthesis/stent was required in order to place and restore the dental implants.  The current evidence supports the fabricated maxillary and mandibular interim prosthesis/stent for the treatment of this patient.  All told, fabricated maxillary and mandibular interim prosthesis/stent provided was medically necessary for the treatment of this patient. Final Result: The reviewer determined that the services at issue were medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The physician reviewer is board certified in oral and maxillofacial 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

A female enrollee requested a Quantum Edge power wheelchair for medical treatment of her hereditary spastic paraplegia.  Findings:  The physician reviewer found thatThis patient has mobility impairments due to her various conditions, but she has sufficient upper limb strength, coordination, and range of motion to propel an optimally fit manual wheelchair.  Additionally, the patient has multiple chronic conditions that would benefit from increased physical activity and exercise.  All told, the requested Quantum Edge power wheelchair is not medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld

The patient is a 61-year-old male with a long history of knee and lower back problems who was found to have a slightly elevated PSA in November 2004 (6.09) and again in December 2004 (6.13). Prostate biopsy on 1/11/05 was negative for metastatic disease. Assuming the prostate felt benign on digital rectal examination, the stage of this cancer would be T1c and based on Partin's Tables the cancer would have a 75% chance of being organ confined. Thus, it represents a cancer potentially curable by surgical removal. The patient has requested coverage for a robotic-assisted laparoscopic radical retropubic prostatectomy. The open surgical approach is a well-established treatment with good long-term results with regard to both survival and complications. Robotic-assisted laparoscopic prostatectomy is relatively new, and while short-term results are comparable, long-term data, especially with regard to survival, is not yet available. While there is no medical objection to the robotic-assisted laparoscopic approach, to date there is insufficient data to demonstrate its superiority to other procedures. The alternatives offered by the Health Plan are medically reasonable and appropriate treatment options for this patient. There is no medical justification for a robotic-assisted laparoscopic radical prostatectomy in this case. Therefore, I have determined that 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 55-year-old male enrollee, who underwent left total hip arthroplasty, has requested authorization for a referral to the Texas Nerve and Paralysis Institute or a similarly qualified specialist for nerve decompression consultation and treatment. Findings:  The physician reviewer found that there is no role for operative intervention in the treatment of sciatic nerve injury following total hip arthroplasty. The injury is typically a stretch injury. There is no benefit in a referral to the Texas Nerve and Paralysis Institute or a consultation with a nerve decompression specialist. A plan of conservative treatment, watchful waiting and serial EMGs is consistent with the recognized standard of care for this type of nerve injury.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for prenatal genetic tests.Findings:  Two of the three physician reviewers found that testing for common recessive genetic disorders in pregnancy allows patients to make important medical decisions. If the patient is positive for a particular mutation, then testing for their partner may be offered. This allows for eliminating the potential to have an affected offspring with a serious genetic disorder. In this case, the services at issue revealed that the patient was a carrier for Fanconi anemia type C. Carrier testing is supported by the American College of Obstetricians and Gynecologists. Thus, prenatal genetic tests were likely to have been of greater benefit than other methods of evaluating this patient.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 reviewer 1 is board certified in clinical biochemical genetics and is actively practicing. Physician reviewer 2 is board certified in clinical genetics and genomics and is actively practicing. Physician reviewer 3 is board certified in obstetrics and gynecology 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

Nature of Statutory Criteria/Case Summary:   An enrollee has requested the Life Vest wearable cardioverter for treatment of her cardiomyopathy. Two physician reviewers found that placement of a prophylactic defibrillator is not recommended until a period of time, about 40 days after myocardial infarction has elapsed, where continued severe left ventricular dysfunction is documented to persist in spite of appropriate treatment. Placement of a prophylactic defibrillator (wearable or implantable) before this time has not been demonstrated to improve patient outcomes. Studies assessing the efficacy of prophylactic defibrillators early after diagnosis of myocardial infarction and reduced ejection fraction of 35% or less before ventricular function has had a chance to recover have not demonstrated improved outcome. A prophylactic wearable external defibrillator is indicated only if accepted criteria for an implantable defibrillator are met and an implantable defibrillator could not be placed, needed to be significantly delayed or required explantation. All told, the Life Vest wearable cardioverter defibrillator was not likely to have been more beneficial in treating this patients medical condition than standard modalities. Final Result: Two reviewers determined that the services at issue were 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 cardiology 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: Overturned

An 18-year-old male enrollee has requested ictal single photon emission computed tomography (SPECT) scan with video EEG monitoring for evaluation of his intractable epilepsy.  Findings:  Three physician reviewers found that the requested SPECT scan has been requested to localize the seizure focus, and if surgery is required, the provider will be able resect as little brain cortex as possible. As Goffin notes, Correct localization of the onset zone with the use of SPECT or PET is associated with a better surgical outcome. There are aspects of both SPECT and PET that are important. It is better to image the patient during a seizure (ictal imaging) as opposed to when the patient is not actively seizing (inter-ictal imaging). One will generally stop seizure medications, and have the tracer readily available to inject as soon as the seizure activity appears. Since the half-life of 99mTc (used for SPECT scans) is six hours and the half-life of 18FDG (used for PET) is less than two hours, it is easier to perform a SPECT scan. There is further literature that suggests that SPECT is actually preferable to PET. Desai and colleagues reported that ictal subtraction SPECT appears to be more sensitive than interictal PET in this patient population. This preference for SPECT over PET is confirmed by Kim and Mountz who noted that SPECT has the practical capacity to image blood flow functional changes that occur during seizures in the routine clinical setting. In conclusion, this patient is being treated in a dedicated epilepsy center that can effectively utilize SPECT scanning to help localize the seizure focus as well as possible. A SPECT scan, if obtained during an active seizure, should help in the decision making regarding the patients future treatment. Therefore, the requested services are likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.
Appeal type: Medical Necessity
Decision: Overturned

A 62-year-old female enrollee has for laparoscopic biliopancreatic diversion with duodenal switch (LBPD/DS) bariatric surgery for treatment of her morbid obesity. Findings:  The physician reviewer found that there is no data available that shows that nutritional deraignment after the LBPD/DS operation is more prevalent or more serious than what is encountered with the gastric bypass operation.  In fact, there is a large body of scientific evidence that shows superior short and long-term outcomes with the LBPD/DS when compared to the gastric bypass or the laparoscopic gastric banding procedures.