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

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for magnetic resonance imaging (MRI) of the left shoulder (CPT 73221). Findings:  The physician reviewer found that patients x-rays were consistent with calcific tendinitis. The patients provider recommended an MRI scan for further diagnostic purposes and treatment planning. Disease of the rotator cuff is a common cause of shoulder pain and dysfunction in adult patients. In this case, the patients calcific tendinitis has persisted for at least six months. The standard of care is arthroscopic removal of the calcific deposit and repair with a suture bridge technique if the deposit removal leaves a full thickness defect. The anatomy and physiology of the rotator cuff is complex and unique in each patient. Diagnostic imaging with MRI provides valuable information about the nature of the injury, which is critical to planning surgical intervention. For these reasons, the requested MRI of the left shoulder (CPT 73221) is medically necessary for this patient. Final Result: The reviewer determined that the requested services are medically necessary for evaluation of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer 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: Experimental/Investigational
Decision: Overturned

A 41-year-old female enrollee has requested for Botox injections for treatment of her migraine headaches. Findings:  Three physician reviewers found that Botox is not a first-line therapy for migraine headache, there is ample medical literature supporting its use for this condition. Additionally, she has previously had marked benefit on a trial of Botox. As this patient has already been given adequate trials of traditional therapies, treatment with a different agent such as Botox is clinically appropriate.
Appeal type: Medical Necessity
Decision: Upheld

A 44-year-old male has requested coverage for past substance abuse sub-acute residential rehabilitation for treatment of his alcohol dependence.  Findings:  The physician reviewer found that the submitted documentation fails to establish the medical necessity of the services at issue.  This patient completed two days of supervised detoxification treatment without any evidence of decompensation or medical instability.  The medical records noted no previous chemical dependency treatment.  In this clinical setting, the patient could have been treated safely and effectively in an outpatient setting.  Direct admission to a residential rehabilitation program is not considered generally accepted standard of practice.  Evidence-based therapies, such as individual therapy, group counseling, and office-based pharmacotherapy, show consistently therapeutic outcomes and can be offered in an outpatient setting.  This patients medical records do not reflect psychiatric or medical instability that required treatment in a 24-hour clinical setting under a physicians care.  The clinical notes do not reflect safety concerns requiring treatment in the substance abuse sub-acute residential treatment setting.  All told, substance abuse sub-acute residential treatment was not medically indicated in this patients case.
Appeal type: Medical Necessity
Decision: Upheld

A 45-year-old female enrollee has requested OrthoVisc injections for the treatment of her knee pain. Findings:  The physician reviewer found that this particular patient has a long and complicated orthopedic history relative to her right foot, cervical spine and right shoulder.  She also has ongoing right knee symptomatology.  While the patient is noted to have degenerative changes in the right knee, there is no documentation that the patient has tried and failed an appropriate course of conservative treatment.  The patients current degree of symptomatology and limitations are also unknown.  Hyaluronan injections such as the Orthovisc injections requested are generally prescribed for documented knee osteoarthritis in patients who have failed to respond to other standard forms of conservative treatment.  These treatments would include physical therapy, activity modification, routine dosing of anti-inflammatory medications and an intra-articular cortisone injection.  Therefore, without knowledge of her current functional limitations and without evidence that the patient has attempted an appropriate course of conservative treatment, the request for OrthoVisc injections cannot be recommended at this time.
Appeal type: Medical Necessity
Decision: Overturned

A female enrollee requested Avastin for medical treatment of her ovarian cancer.  Findings:  The physician reviewer found that Phase II studies with Avastin have shown promise in patients with platinum-refractory disease which is the case here (Cannistra, et al; Burger, et al; Monk, et al).  The evaluation of the original course of treatment appears incomplete and the patient warrants a trial of Avastin as supported by the medical evidence (Aghajanian, et al). Therefore, the request for Avastin 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 trigger point injections for treatment of the enrollee, who has been diagnosed with trigeminal neuralgia. Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested services.  Trigger points are taut muscle bands which when pressed have a characteristic pattern of radiation.  A diagram showing the pattern of radiation is the standard procedure for documenting the trigger point.  In this patients case, there is no documentation of where her trigger points are and the pattern of radiation from those points. Further, there is a lack of support in the peer-reviewed literature for trigger points as therapy for trigeminal neuralgia.  The current medical evidence does not support the requested services in this clinical setting. 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 anesthesiology with sub-specialty certification in pain medicine and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

The patient is a 34-year-old man who sustained an injury to his knee requiring an ACL reconstruction. Postoperatively, the treating surgeon ordered a continuous passive motion (CPM) device, which the patient obtained and utilized. The Health Plan has denied coverage for the CPM device on the basis that it was not medically necessary.Many surgeons believe CPM therapy is useful in gaining and maintaining motion following surgery. It is a matter of physician preference. Numerous studies have shown benefit with CPM. The device has been utilized for more than 20 years for a number of different reasons.In the case of this patient, the device was felt to be of benefit following the patients ACL reconstruction. Furthermore, there are no significant risks posed by use of a CPM machine. A CPM machine was medically reasonable and indicated for the patients successful postoperative rehabilitation. Therefore, I have determined that the device at issue was medically necessary for treatment of the patients medical condition. Accordingly, the Health Plans denial should be overturned.
Appeal type: Experimental/Investigational
Decision: Overturned

A 27-year-old female enrollee requested authorization and coverage of osteochondral autograft transfer with medial malleolar osteotomy of the left ankle. The Health Plan denied the request indicating that the requested procedure is investigational for treatment of the enrollees ankle pain.Three physician reviewers performed an experimental/investigational Independent Medical Review. Two of the three physician reviewers concluded that the requested procedure is likely to be more beneficial for treatment of the enrollee's medical condition than any available standard therapy. One physician reviewer 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 two of the three physician reviewers concluded that the requested procedure is likely to be more beneficial for treatment of the enrollee's medical condition than any available standard therapy, the Health Plans denial has been overturned.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the gene testing for evaluation of the enrollee who has a history lymphoma. Findings:  The physician reviewers found that Follicular helper like T cell lymphoma is a newly described entity seen mostly in elderly males. It is rare and treatment has not been clearly defined. Currently, there is a lack of standard therapies that exist. Although the precise events driving angioimmunoblastic T cell lymphoma (AITL) oncogenesis are not fully understood, several molecular anomalies have been described in AITL. These molecular anomalies can help further characterize the tumor as well as guide therapy. Multiplexed genotype testing, such as with FoundationOne Heme, allows an entire panel of genotypes of interest to be queried at a single time from a single tissue sample instead of doing the tests sequentially one by one. This is the most tissue efficient approach, particularly when dealing with small tumor samples. For these reasons, genetic testing was likely to be more beneficial than any available treatment option for the evaluation of this patients medical condition. Final Result: Two of three reviewers determined that the services at issue were likely to have been 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 number one, two, and three are board certified in internal medicine with sub-specialty certification in medical oncology and 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

The patient is a male diagnosed with cannabis use disorder, Accutane induced psychotic disorder, and rule out bipolar II disorder. The patient endorsed using cannabis and alcohol use. The patient was prescribed Accutane for acne and was noted to have withdrawal symptoms including psychosis. The patient was treated at the residential treatment level of care from. He was started in an intensive outpatient program (IOP). The patients provider noted the patient appeared paranoid and suspicious of others. At issue in this case is whether IOP treatment from was and/or is medically necessary for the treatment of the patients medical condition. The Child and Adolescent Level of Care Utilization System (CALOCUS), developed as a collaboration between the American Academy of Child and Adolescent Psychiatry and the American Association of Community Psychiatrists, is a level of care assessment tool used by behavioral health managers and clinicians to support accurate level of care recommendations. The six dimensions of CALOCUS include risk of harm, functional status, comorbidity, recovery environment, resiliency and treatment history, and acceptance and engagement. For risk of harm, the patients score is 2 due to past suicidal ideation and substance use. For functional status, the patients score is 3 due to substance use with recent gains in functioning achieved while participating in structured treatment. For comorbidity, the patients score is 3 due to the patients previous paranoia and hallucinations. For recovery environment level of stress, the patients score is 2 due to a potential for exposure to substance use as his sibling is involved in substance use. For recovery environment level of support, the patients score is 2 due to parental involvement in treatment. For resiliency and treatment history, the patients score is 2 due to previous treatment at the residential level of care, and abstinence from drug and alcohol use. For acceptance and engagement, the patients score is 2 due to participation in treatment. For acceptance and engagement of the caretaker, the score is 2 due to parental support and involvement in treatment. The patients composite CALOCUS score is which corresponds to high intensity community based services. Therefore, IOP treatment was and is medically necessary for this patient. Final Result: The reviewer determined that the requested services 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 subspecialty 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

A 63-year-old female enrollee has requested repeat Synvisc injections for treatment of the enrollees knee pain. Findings:  The physician reviewer found that the patient has documented degenerative changes and the initial series of Synvisc resulted in improvement. There is no contraindication for repeat Synvisc injections based on the evidence provided. The patient is likely to benefit from another series of Synvisc injections at this time.
Appeal type: Medical Necessity
Decision: Overturned

A 57-year-old female enrollee has requested for continued Botox injections for treatment of her cervical dystonia. Findings:  The physician reviewer found that Dystonia has been defined as a painful condition in which neck muscles contract involuntarily, causing the head to twist or turn to one side. Sometimes the contractions are sustained and other times the neck muscles spasm, causing a repetitive, jerky movement of the head. Treatment for cervical dystonia usually involves botulinum toxin injections. Therapy may take several cycles to be optimized, usually starting with low dosing and selectively increasing dose, or changing which muscles are treated to fine tune results.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for cryoablation of the metastatic tumor at the right chest wall. In a peer-reviewed medical literature reported on percutaneous ablation of musculoskeletal metastases. The authors noted that this treatment modality may result in significant pain palliation, prevention of morbidity from skeletal-related events, and local tumor control. The authors concluded that this minimally invasive approach has unique advantages compared with surgery or radiation therapy. In addition, `many studies have shown that percutaneous ablation of a painful bone metastasis can significantly and sustainably reduce symptoms. Thus, the literature does support the use of cryoablation for bone metastasis for the purpose of palliating bone pain and local tumor control. Given this support, the requested cryoablation of the metastatic tumor at the right chest wall is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.One reviewer found that the requested cryoablation of the metastatic tumor at the right chest wall is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: Two of the three reviewers determined that the requested services are likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications:  One reviewer is board certified in diagnostic radiology and is actively practicing. One Reviewer is board certified in diagnostic radiology and is actively practicing.  One Reviewer is board certified in diagnostic radiology and is actively practicing.  All three reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary:  An enrollee has requested substance abuse residential treatment center services for treatment of his behavioral health condition.  The physician reviewer found that the submitted documentation fails to establish the medical necessity of the services at issue.  The patient did not have severe withdrawal symptoms. He was not suicidal, homicidal, or psychotic. His hypertension was stable, and although he rated his depression and anxiety at high levels he did not require 24-hour supervision. He was willing to enter treatment and aware of the need to develop coping mechanisms. He had multiple episodes of substance abuse treatment with multiple relapses, making his risk for relapse high. He resided in sober living so his environment was safe. His alcohol use had adversely affected emotional, social, and vocational aspects of his life. Given all of these factors and carefully considering American Society of Addiction Medicine (ASAM) placement criteria, residential level of care was not medically necessary in this clinical setting. The patient could have been safely and effectively managed at a lower level of care, such as IOP (intensive outpatient) level of care. Thus, the services at issue were not medically necessary for treatment of the patients medical condition. 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 reviewer is board certified in psychiatry with sub-specialty certification 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: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for laparoscopic LINX procedure. Findings:  The physician reviewer found that the LINX reflux management system has been U.S. Food and Drug Administration approved for patients with gastroesophageal reflux disease as defined by abnormal pH testing, and who continue to have chronic gastroesophageal reflux disease symptoms despite maximal medical therapy for the treatment of reflux. It is important to conduct appropriate patient selection before anti-reflux procedures. Pertinent to this patients case, the pathophysiology of reflux induced lung injury includes the effects of aspiration and local immunomodulation in the development of pulmonary decline and histologic rejection, as reflective of allograft injury supports an association between GERD and allograft injury, encouraging a strategy of early diagnosis and aggressive reflux management in lung transplant recipients to improve transplant outcomes.  The patient has acid reflux as based on pH recording. However, there is neither documentation that the patient is aspirating nor documentation to indicate that she is medically refractory to acid blocker drugs to warrant LINX implantation or other antireflux surgeries at this time. As such, the submitted record has not demonstrated the superior efficacy of the laparoscopic LINX procedure over available methods of treating this patients medical condition. Final Result: Two of the three reviewers determined the requested procedure is 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 internal medicine with sub-specialty certification in gastroenterology 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 45-year-old female has requested a referral to a high level orthopedic center for leg surgery services for the treatment of a leg injury.  Findings:  The physician reviewer found that this is a very specialized treatment and only limited orthopedic surgeons have the knowledge and expertise to manage the soft tissue contractures, especially in the presence of a free flap and significant prior skeletal trauma. It is doubtful that any typical soft tissue lengthening procedure would be a reasonable option in light of the prior free flap that was placed and the significant soft tissue and bony trauma. Most physicians do not use the Ilizarov frame and therefore, are not competent in this area. It has not been demonstrated that the Health Plan has an orthopedic surgeon who has expertise with using an Ilizarov frame.