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

Nature of Statutory Criteria/Case Summary: An enrollee has requested computed tomography or magnetic resonance imaging for the evaluation of the enrollees localized swelling on her left leg. Findings: The physician reviewer found that there is support for the requested MRI of the knee but not a CT scan, in this clinical setting. An MRI examination may be indicated if the patient has not responded to a trial of conservative treatment. Patients with persistent or recurrent unexplained pain after three to six weeks of conservative treatment may require MRI for further evaluation. The standard practice is generally to obtain baseline plain x-rays such as was performed in this case. However, plain x-rays are of only limited value as the menisci and ligaments are not visible on plain x-rays. In this particular patient, her referring provider did not recommend that an MRI or CT scan was indicated. Her physical examination did not support a meniscal tear or a ligamentous injury or tear, and her provider was not recommending an intervention. However, it was reported that this patient may also have been diagnosed with pes anserinus bursitis. MRI will generally demonstrate fluid in the bursa, and generally, there is very little fluid in a normal bursa.  To that end, MRI would be helpful and could conceivably avert an arthroscopic procedure. Therefore, the requested MRI is medically necessary for evaluation of this patient but a CT scan is not medically indicated.Final Result: The reviewer determined that a portion of the requested services are medically necessary for evaluation of the patients medical condition. Therefore, the Health Plans denial should be partially 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: Medical Necessity
Decision: Overturned

The patient is a 61-year-old female with profound congenital bilateral hearing loss.  She has undergone cochlear implantation to her right ear and gained benefit from the device.  Hearing from the left ear, which was initially the better hearing ear, has declined over time and there is now no useful hearing obtained through the use of a hearing aid. The patient has requested authorization for left-sided implantation with the goal of binaural hearing.  The Health Plan has denied her request based upon a determination that a second cochlear implant is not medically necessary.When a patient with hearing loss presents for evaluation, the standard of care is to fully evaluate and to derive options toward lessening this deficit.  When the hearing loss involves both ears and is so severe as to impair activities of daily living and communication, the accepted recommendation is to (hearing) aid both ears for optimum function.  This case is analogous except that the type and extent of the hearing loss is such that it cannot be improved with the use of hearing aids. There is increasing recognition in the current literature of the substantial benefit of bilateral cochlear implantation in helping to return and/or to allow a patient to lead a more productive and functional life.  Despite the right cochlear implant, the patient in this case is still limited in her ability to fully participate in functional communication and a second cochlear implant is likely to significantly improve her communication and listening skills.  Therefore, I have determined the requested device is medically necessary for treatment of the patients medical condition. The Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Upheld

A 60-year-old female enrollee has requested for use of a continuous passive motion machine for treatment of her post total knee replacement. Findings:  The physician reviewer found that postoperative progress notes do not include any documentation of problems with range of motion. Additionally, physical therapy postoperative records do not document the patients full functional ability. The physical therapy records document her pain complaints, yet do not document her strength or motion ability.
Appeal type: Medical Necessity
Decision: Upheld

The parents of an 11-year-old male have requested growth hormone (GH) therapy with Humatrope for treatment of short stature.   Findings:  The physician reviewer found that a diagnosis of GH deficiency appears improbable given his normal IGF-1 levels and his growth at the 20th percentile. The patient would not qualify for GH therapy under the FDA guidelines for idiopathic short stature.
Appeal type: Experimental/Investigational
Decision: Overturned

A 56-year-old female enrollee has requested computer-aided detection (CAD), including computer algorithm analysis of magnetic resonance imaging data for lesion detection/characterization (CPT code 0159T) for evaluation of her right breast cancer. Findings:  Three physician reviewers found that there has been some debate in the literature concerning the efficacy of CAD streaming in the interpretation of breast MRI. Overall, the technique has gained considerable popularity among radiologists over the past few years. While CAD cannot replace the expertise of a radiologist in the interpretation of this complex examination, it has been repeatedly demonstrated that the use of CAD improves the efficiency of the reading radiologist and provides another set of eyes in the interpretation of the study. While some radiologists interpret this exam without CAD streaming, providers who use it find it very valuable in much the same way that CAD assistance helps in the interpretation of digital mammography. Thus, although the use of CAD is not absolutely necessary for the interpretation of breast MRI, it is a useful diagnostic adjunct and is no longer considered investigational for this indication.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the genetic testing. The National Comprehensive Cancer Network (NCCN) testing guidelines recommend BRCA testing for this patient, since she has a first or second degree relative with breast cancer under the age of 45. However, what is being requested is the MyRisk panel that includes BRCA within it but also a variety of other suspected risk genes. Though many of these other gene mutations are of interest, there is a lack of data demonstrating that these findings are significant to be support a basis for clinical decision making. Such broad testing is not included in the guidelines from the major organizations such as American Society of Clinical Oncology (ASCO). Therefore, BRCA but not the remainder of the myRisk panel testing would be of possible clinical benefit to this patient. Thus, the BRCA1 and BRCA2 portions of the genetic testing performed was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.One reviewer found that the genetic testing performed was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Final Result: Two of the three reviewers determined that a portion of the genetic testing performed was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be partially overturned.Credentials/Qualifications:  One reviewer is board certified in internal medicine with sub-specialty certification in medical oncology and is actively practicing. One Reviewer is board certified in internal medicine with sub-specialty certification in medical oncology and is actively practicing.  One Reviewer is board certified in internal medicine with sub-specialty certification in medical oncology 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 authorization and coverage for a panniculectomy for treatment of the enrollees medical condition. Findings:  The physician reviewer found that the medical documentation does not support that the patient has evidence of a significantly overlapping abdominal pannus. There is evidence of rashes but the only conservative management documented is baby powder. No other treatments were documented including medicated powders, antifungal treatment or antibacterial treatment. In addition, primary care evaluations did not document any history of rashes or dermatologic treatment. Finally, the photographs and evaluation by the requesting surgeon only note evidence of a small overhanging abdominal pannus.  Based on the entirety of the documentation submitted, a clear functional deficit that has failed standard dermatologic treatment and is associated with a significantly overhanging pannus have not been adequately defined. Final Result: The reviewer determined that the requested procedure is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.  Credentials/Qualifications: Physician reviewer number one 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

A 44-year-old male enrollee has requested  for residential treatment services for treatment of her substance dependence.  Findings:  The physician reviewer found that the patients risk of complicated withdrawal and the risk of relapse due to withdrawal and depression supported the need for treatment in a structured setting such as residential care. The admission report also indicated that the patient engaged in violent/suicidal behaviors when intoxicated. Progress notes show that withdrawal from alcohol and Vicodin was the initial concern. Criteria I, II, and V of the American Addiction Medicine Patient Placement Criteria for Adult Residential Treatment were met in this case.
Appeal type: Medical Necessity
Decision: Overturned

The parents of a 19-year-old female enrollee requested reimbursement for residential treatment services the enrollee received from 6/21/01 to 6/29/01. The Health Plan denied the request indicating that residential treatment services were not medically necessary for treatment of the enrollees medical condition from 6/21/01 to 6/29/01.One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer overturned the Health Plans denial on the basis that the services at issue were medically necessary.
Appeal type: Medical Necessity
Decision: Upheld

A 57-year-old male enrollee has requested proton beam radiation therapy for treatment of his prostate cancer. Findings:  The physician reviewer found that proton radiation is indicated over standard radiation techniques in patients with chordomas and chondrosarcomas of the base of skull and spine. However, proton radiation does not have significant proven advantages over modern conformal techniques such as image-guided intensity modulated radiation therapy (IMRT) in the treatment of prostate cancer. While anecdotal data suggests increased fatigue with IMRT, it also reveals more patients experience late rectal bleeding with proton therapy. Zietman and colleagues concluded that IMRT has superior bladder dose distributions when compared to proton radiation. Moreover, there is a paucity of evidence supporting protons over conventional therapy in terms of potency preservation. While there may be some benefit in less integral dose to the pelvis with proton beam therapy, this alone does not indicate that proton beam therapy is standard treatment for prostate cancer. In addition, this patients records do not specify that the protons will be significantly dose escalated beyond that of IMRT.
Appeal type: Medical Necessity
Decision: Upheld

A 41-year-old male enrollee requested medical transportation services to his long distance provider for all appointments related to the treatment of the enrollees medical condition.  Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested services.  Neck and back pain are common complaints that result in many physician visits, with sequelae that have the potential to range from minor symptoms to incapacitation.  In this case, the records indicate that the patient has had various symptoms involving the neck and back, as well as the abdomen.  He has undergone imaging studies, but there are no objective indications that he has any impairment that would preclude travel by regular means such as a bus, subway, train, or passenger automobile.  There is a lack of support for the requested services in this clinical setting.  All told, the requested medical transportation services to the patients long distance provider for all of his appointments are not medically indicated in this case.
Appeal type: Experimental/Investigational
Decision: Upheld

A 38-year-old male enrollee has requested for artificial disc replacement surgery for treatment of his spinal stenosis.   Findings:  Three physician reviewers found that there is inadequate documentation in the peer-reviewed literature of randomized, long-term outcome studies to prove the effectiveness of artificial disc replacement when compared to standard surgical procedures and conservative measures for degenerative disc disease.  Most published studies consist of retrospective case series of small sizes and short-term uncontrolled retrospective studies.
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:  Three physician reviewers found that breast tomosynthesis was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. According to the study by Skaane and colleagues, 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. Thus, the addition of tomosynthesis allows better characterization of possible masses, spiculation, and architectural distortion. Moreover, there is sufficient support in the peer-reviewed literature for the use of tomosynthesis in this clinical setting. Therefore, the services at issue were likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Final Result: Three 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 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: An enrollee has requested reimbursement and prospective authorization and coverage for residential treatment center (RTC) level of care services for treatment of her eating disorder. Findings:  The physician reviewer found that per the American Psychiatric Association (APA) guidelines, services available for the treatment of eating disorders can range from intensive inpatient settings to RTC and partial hospitalization programs to varying levels of outpatient care. Pretreatment evaluation of the patient is essential for determining the appropriate treatment setting. Patient weight, rate of weight loss, cardiac function, and metabolic status are the most important physical parameters for making this choice. This patient was admitted status post bowel impaction due to prolonged food restriction combated with re-feeding and weighed 72% of her ideal body weight (IBW) on admission. She continues to have high levels of anxiety, eating disorder behaviors, and abnormal labs. In addition, the patient has demonstrated slower than expected improvement in symptoms. 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 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: The patient has requested reimbursement for inpatient behavioral health treatment level of care. The American Association of Community Psychiatrists Level of Care Utilization System (LOCUS) provides a reliable framework for determining the appropriate level of care for adults needing mental health treatment. Applying LOCUS guidelines, this patient met the criteria for inpatient behavioral health treatment level of care provided for a portion of her admission. On the first date of the Health Plans denial, the patient was at some risk of self-harm (score 2), given her disorganization. The patient demonstrated serious functional impairment (score 5) as she was unable to perform activities of daily living. The records document that she was disorganized and psychotic. The patient was unable to work and was non-compliant with her medications without support. The patient had a minor comorbidity (score 2) with documentation of a urinary tract infection. The patients recovery environment was highly stressful (score 4) as there was severe marital discord between the patient and her spouse. The patients recovery environment was minimally supportive (score 4) as her husband did not want her to return home and she had limited other familial support. A shelter was considered as a disposition option. The patient has exhibited poor response to treatment (score 4) as she has been hospitalized at least 30 times and was already treated as an inpatient in 2019. The patient was obstructive with treatment (score 3) as she has been non-adherent with treatment. This gives the patient a composite score of 24, which is consistent with medically monitored residence-based services, such as RTC. Based on a LOCUS score of 5 for functional status, the patient met the criteria for medically managed residence based services, such as inpatient behavioral health level of care. However, 11 days after admission, the patient showed improvement with mild functional impairment (score 2) as she was able to attend to her ADLs and constructive participation (score 2) in treatment. This gives the patient a composite score of 22, which is consistent with medically monitored community-based services. The provider noted that the patient was stable for discharge to a RTC. Given these findings, the inpatient behavioral health treatment level of care provided was medically necessary for treatment of this patient.Final Result: The reviewer determined that a portion of the services at issue was medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be partially overturned. Credentials/Qualifications: The reviewer is board certified in 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: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary:  An enrollee has requested a fetal aneuploidy trisomy risk test for evaluation of her pregnancy.  Three physician reviewers found that there is a lack of support for the services at issue in this clinical setting.  Per the American College of Obstetricians and Gynecologists (ACOG), indications for use of cell-free DNA testing include maternal age 35 years or older at delivery, fetal ultrasonographic findings indicating an increased risk of aneuploidy, positive test result for aneuploidy, history of prior pregnancy with a trisomy and parental balanced robertsonian translocation with increased risk of fetal trisomy 13 or trisomy 21.  This patient is under the age of 35 and meets none of the ACOG approved indications for the use of cell-free fetal DNA.  All told, a fetal aneuploidy trisomy risk test was not likely to be superior over other methods of evaluating this patient.  Final Result: Three reviewers determined that 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 obstetrics and gynecology 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: An enrollee has requested reimbursement and prospective authorization and coverage for residential treatment center (RTC) level of care services for treatment of the enrollees polysubstance abuse. Findings:  The physician reviewer found that the patient was admitted in active withdrawal with an elevated COWS score, which warranted admission. Although not suicidal, homicidal, or self-harming, she rated depression and anxiety as 10, and isolation as five to six, which also supported admission. The patients self-care was lacking in her disheveled presentation and reported high levels of stress. Thus, RTC was the best treatment option and was medically necessary. Treatment during these dates would afford the patient an opportunity to become more physically comfortable with less intense withdrawals, and increase the chances of compliance with medically assisted treatment with Subutex at a less restrictive level of care. However, RTC services after were not and are not medically necessary. For these reasons, RTC level of care services provided were medically necessary, but not thereafter. Final Result: The reviewer determined that a portion of the services at issue were medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be partially overturned. Credentials/Qualifications: The reviewer is board certified in psychiatry with sub-specialty certification in child and 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.