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

Nature of Statutory Criteria/Case Summary:   An enrollee has requested magnetic resonance imaging (MRI) of the thoracic and lumbar spine for evaluation of her back pain. Findings:  The physician reviewer found that upon review of the submitted documentation, an MRI of the thoracic and lumbar spine is medically necessary in ruling out or describing anatomical changes such as a thoracic level intervertebral disc herniation or other acute soft tissue changes following the patient's history of pain. Studies show that an MRI has a meaningful impact on clinical decision making in cases of ongoing musculoskeletal pain and is capable of ruling out significant diagnoses. In the presence of mid back pain, thoracic disc herniation may be effectively ruled in or out by MRI imaging of the thoracic and lumbar spine (Cannada). As discussed in the article by Wood and colleagues, incidental MRI findings of structural changes at the thoracic level need to be interpreted with reference to the patient's clinical history and examination. In spite of the need to interpret the MRI in reference to documented incidental disc protrusions at the thoracic level, the study is still valuable and indicated in this patient. Also, additional diagnoses referencing soft tissue changes in the face of negative x-ray examination have the potential of being diagnosed through MRI imaging. All told, an MRI study supplementing the clinical and x-ray examinations for this patient is medically necessary for the treatment of her back pain. Final Result: The reviewer determined that the requested MRI of the thoracic and lumbar spine is medically necessary for evaluation of the patients medical condition. Therefore, the Health Plans denial should be overturned.  Credentials/Qualifications: The reviewer is board certified in 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: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the Prometheus Anser IFX diagnostic testing. Findings:  The physician reviewer found that the testing at issue was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Monitoring patients on infliximab with measurement of infliximab levels and antibodies to infliximab continues to be an area of intense investigation. In general, infliximab levels correlate inversely with disease activity. However, there are a lack of controlled data which have identified the optimal drug level and the issue remains speculative. In addition, the American Gastroenterological Association indicates that there is low quality of evidence in support of reactive measurement of infliximab drug levels. For the reasons provided, the Prometheus Anser IFX diagnostic testing performed was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Final Result: The reviewers determined that the testing at issue was 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: Physician reviewers are board certified in internal medicine with sub-specialty certification in gastroenterology 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: Medical Necessity
Decision: Overturned

The parent of a four-year-old female enrollee has requested  speech therapy for treatment of the enrollees speech delay.  Findings:  The physician reviewer found that in the relevant medical literature, Nelson and colleagues concluded that speech and language development is considered to be a useful indicator of a childs overall development and cognitive ability. Moreover, the authors commented that young patients with speech and language delays tend to have more difficulties with written language. The authors warn that in some cases these problems may lead to lower IQ scores that may persist into young adulthood. From this detailed account, it is clear that speech and language delay in young children can result in substantial long-term consequences. This patient is a young child with a history of mild receptive language delay and moderate to severe expressive language delay, with residual mild deficits despite improvements made with speech therapy. Her skills remain below those of her peers despite intervention. These deficits negatively impacted her ability to communicate effectively with children and adult caregivers; thus the speech therapy services provided to this patient have been established to have been medically necessary.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient is a 29-year-old transgender female who has been diagnosed with gender dysphoria. Findings:the provider noted that gender affirming surgery is medically necessary for the patient. The records noted that the patient had been treated with estrogen and spironolactone. The patients breasts had developed but were small and in the range of at 32-34 A cup. The patient has requested authorization and coverage for bilateral breast augmentation. The Health Plan denied the request and reported the requested services are not medically necessary for the treatment of this patient. At issue in this case is whether bilateral breast augmentation is medically necessary for the treatment of the patients medical condition. The Health Plan denied the request for bilateral breast augmentation due to the patient having developed breast tissue with hormone therapy. The presence of breast growth due to estrogen treatment does not negate the patient's gender dysphoria. The World Professional Association for Transgender Health (WPATH) Standards of Care for the Health of Transsexual, Transgender, and Gender-Nonconforming People states that the expected maximum effect of hormones on breast growth is two to three years. The patient has been treated with hormone therapy since 2013. WPATH also states that the criteria for breast surgery for an adult includes well-documented gender dysphoria, capacity to consent, and that any co-occurring medical and mental illnesses are reasonably well-controlled. Gender affirming/confirming treatments and surgical procedures have proven to be beneficial and effective for patients with transsexualism or gender dysphoria (WPATH). The medical evidence supports the requested services in this clinical setting. Therefore, bilateral breast augmentation 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 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

A 50-year-old male enrollee has requested transcranial magnetic stimulation (TMS) therapy for treatment of the enrollees major depressive disorder.  Findings:  Two physician reviewers found that in the relevant clinical studies, Schutter and colleagues reported that TMS was found to have a moderate effect on patients with treatment resistant depression. In addition, George and colleagues showed that TMS was significantly more likely than sham treatment to produce remission in patients with treatment resistant depression. Further, Avery and colleagues provides evidence that TMS is a safe and effective treatment for major depressive disorder. Thus, although relatively new, TMS is an effective treatment supported in the medical literature and approved by the FDA for the treatment of treatment resistant major depressive disorder. However, this patients records do not document an adequate trial and the outcome of a second selective serotonin reuptake inhibitor (SSRI). Moreover, the patient has not reportedly undergone a trial of electroconvulsive therapy (ECT), both of which are likely to be more beneficial than TMS therapy for his condition.
Appeal type: Medical Necessity
Decision: Upheld

A 33-year-old female enrollee has requested Roux-en-Y bariatric surgery for treatment of her obesity. Findings:  The physician reviewer found that this patient is obese, but the records provided for review do not document morbid or clinically severe obesity as she has a BMI that is less than 40. Although the patients BMI is greater than 35, there is no evidence of the presence of any serious weight-related co-morbid conditions such as hypertension or diabetes. The patient is on no medications for asthma and reportedly is treated with Pepcid for GERD, and these conditions appear to be medically controlled. Applying the National Institutes of Health (NIH) consensus guidelines, the requested bariatric surgery is not medically necessary for this patient without documented morbid or clinically severe obesity or serious weight-related co-morbid conditions.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary:  An enrollee has requested Lyrica for treatment of her medical condition. Findings:  The physician reviewer found that Lyrica is medically necessary for treatment of the patients medical condition. There is sufficient support in the evidence based literature supporting the requested services. Lyrica has been utilized off-label for many neuropathic pain syndromes. There is significant literature regarding the use of Lyrica in neuropathic pain other than diabetic neuropathy and post herpetic neuralgia. Lyrica is widely used by both headaches specialists and multiple sclerosis specialists to treat the conditions presented in this case. Finally, the medical records support an excellent response to the patients chronic migraine with the treatment of Lyrica. Given these facts, Lyrica is supported as medically necessary for treatment of this patients medical condition.  Final Result: The reviewers determined that the requested medication is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.  Credentials/Qualifications: The reviewer is board certified in 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

A 23-year-old female enrollee has requested bilateral endoscopic lumbar sympathectomy for treatment of her hyperhidrosis.  Findings:  The physician reviewer found that a review of the available medical literature on endoscopic lumbar sympathectomy for the treatment of hyperhidrosis suggests that the procedure is of unproven efficacy and safety. Rieger and Pedevilla performed bilateral lumbar sympathectomies on 8 patients and at 3- to 8- month follow up, the anhidrosis persisted in all cases. However, about 62% of the patients reportedly experienced minor compensatory sweating of the torso, and 50% had postsympathectomy neuralgia. The authors noted that while the procedure appears to be effective, there is also evidence of a significant complication rate. Loureiro and colleagues performed a randomized study of 30 female patients with persistent plantar hyperhidrosis treated with thoracic sympathectomy. The authors concluded that, the endoscopic retroperitoneal lumbar sympathectomy diminishes plantar sweat and improves the quality of life of women with plantar hyperhidrosis. However, about half of the patients develop increased compensatory hyperhidrosis in other areas of the body.
Appeal type: Medical Necessity
Decision: Upheld

A 56-year-old male has requested a custom left knee brace for treatment of his left knee osteoarthritis.  Findings:  The physician reviewer found that the medical literature with respect to the clinical effectiveness of knee orthoses in the setting of knee arthropathy is limited.  A Cochrane review in 2005, for instance, found limited evidence based on one study in a meta-analysis that supported bracing for knee arthritis.  This was limited to subjects with medial knee involvement.  There were no recommendations for lateral or generalized knee involvement.Per a 2009 review by Beaudreuil and colleagues Few high-level studies of bracing for knee osteoarthritis were foundShort- and mid-term follow-up indicates that valgus knee bracing decreases pain and disability in medial knee osteoarthritis, appears to be more effective than knee sleeves, and improves quality of life, knee proprioception, quadriceps strength, and gait symmetry, and decreases compressive loads in the medial femoro-tibial compartment. However, results of response to valgus knee bracing remain inconsistent; discomfort and side effects can result. Thrombophlebitis of the lower limbs has been reported with the braces. Braces, whatever kind, are infrequently prescribed in clinical practice for osteoarthritis of the lower limbs.The medical literature with respect to knee bracing in the treatment of knee osteoarthritis is limited and does not support the efficacy of the requested orthosis.  Additionally, the current clinical practice guidelines do not support the use of the requested knee brace.  Further, the records provided for review do not support trials with standard conservative management such as activity modification, weight loss, acetaminophen or topical NSAIDs.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for fertility preservation services including: office visit (10);ultrasound (10); estradiol (10); progesterone (3); guided egg retrieval (1);  ultrasound guidance of oocytes (1); oocyte ID from follicular fluid (1);culture/fertilize oocytes (1); ICSI more than 10 oocytes (1); sperm isolation; complex prep (1); blastocyst culture (1); assisted hatching (1); embryo biopsy (1); embryo cryopreservation (1); specimen handing (4); phlebotomy (10) were medically necessary for treatment of this patient. Chemotherapy is a gonadotoxic treatment that can result in infertility. For reproductive aged patients with newly diagnosed cancer, it is within the standard of care to counsel them about their options for preservation of fertility. When appropriate, patients may undergo preservation of ovarian hormone production. Providers should discuss the risk of treatment-induced infertility as well as possible interventions to preserve fertility and hormone production prior to initiating gonadotoxic therapy, as was done in this case. Established techniques for fertility preservation include cryopreservation of embryos and oocytes, which is associated with the greatest likelihood of successfully generating offspring. This patient was recently diagnosed with osteosarcoma. She is of childbearing age and her provider recommended fertility preservation prior to undergoing treatment. Given this support, the fertility preservation services including: office visit (10);ultrasound (10); estradiol (10); progesterone (3); guided egg retrieval (1); ultrasound guidance of oocytes (1); oocyte ID from follicular fluid (1); culture/fertilize oocytes (1); ICSI more than 10 oocytes (1); sperm isolation; complex prep (1); blastocyst culture (1); assisted hatching (1); embryo biopsy (1); embryo cryopreservation (1); specimen handing (4); phlebotomy (10) were medically necessary for 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 reviewer is board certified in obstetrics and gynecology 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 50-year-old female enrollee has requested BRCA1 and BRCA2 gene testing for an evaluation of the enrollees medical condition. Findings:  The physician reviewer found that there are no other appropriate services offered by the Health Plan in lieu of the testing. Further, the patients clinical circumstances meet the criteria for coverage of the BRCA testing as set forth in the Health Plans own criteria. The Health Plans criteria are consistent with national practice standards and guidelines for the use of BRCA testing, as published by the National Comprehensive Cancer Network, and the U.S. Preventative Services Task Force. Patients with a history of breast cancer and a strong family history of breast cancer who are found to have a deleterious mutation in BRCA 1 or BRCA 2 genes may consider elective bilateral oophorectomy to reduce their risk of development of ovarian cancer.
Appeal type: Experimental/Investigational
Decision: Upheld

A 40-year-old female enrollee has requested gene testing for drug metabolism for evaluation of her behavioral health conditions.  Findings:  Three physician reviewers found that the current medical evidence does not support the services at issue in this patients case.  The American Psychiatric Association does not endorse the services at issue in this clinical setting.  In this patients case, there was a dearth of case-specific information about psychosocial stressors and past interventions or the specific type, setting and duration of psychotherapy.  Further, the circumstances, dosing and length of previous psychotropic medication trials were not discussed, while the record does not indicate that the patient had exhausted common pharmacologic strategies.  Based upon the peer-reviewed literature and current practice standards, it has not been demonstrated that the services at issue were likely to have yielded information that significantly influenced treatment decisions, improved the patients condition, prevented a more serious episode of illness or reduced morbidity.  Thus, gene testing for drug metabolism performed on the date indicated was not likely to have been of greater benefit than other available modalities.
Appeal type: Medical Necessity
Decision: Overturned

A 52-year-old male enrollee has requested therapeutic facet joint injections for treatment of his back pain.Findings:  The physician reviewer found that in evaluating the use of facet joints, Manchikanti and colleagues recommend proceeding with diagnostic blocks once or twice, followed by more permanent neurolytic treatment for moderate term control of pain. National interventional guidelines do not recommend more than three procedures in six months, or four in one year. Facet blocks, more frequently than every eight weeks, is too short of a time interval and do not provide for meaningful symptom relief. In this patients case, seven injections into the same level have been done in an 8-9 month span which exceeds the recommended standard of care.  The two diagnostic initial blocks, and the two injections done more than eight weeks are medically necessary. Further injections are not medically necessary for treatment of this patients condition.
Appeal type: Medical Necessity
Decision: Overturned

A 38-year-old female enrollee requested authorization and coverage of orthognathic surgery for the treatment of maxillary hypoplasia.  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 surgery is medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld

An eighty year-old male who has chest pain with exertion only is requesting authorization for EECP.  The provider reviewed the role of catheterization with the patient but the patient was reluctant to undergo the procedure.Reviewers Findings:  The reviewing physician found that EECP is not considered a proven substitute for standard medical therapy or revascularization. EECP is instead considered appropriate in those cases where the patient cannot be safely revascularized and medical therapy fails.  The reviewing physician found that the Health Plan denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld

A 39-year-old female enrollee has requested Provigil for the treatment of her extreme fatigue. Findings:  The physician reviewer found that Provigil is FDA approved for fatigue/somnolence associated with shift work disorder, sleep apnea and narcolepsy. The literature also suggests a benefit for patients with fatigue related to multiple sclerosis. There is no medical literature to indicate that Provigil is indicated for the treatment of chronic fatigue syndrome or fatigue of unknown etiology. It appears the patient is taking some sedating medications that may contribute to her symptoms. Chronic fatigue may also be a symptom of depression, and activating antidepressants such as Wellbutrin or Effexor may be more beneficial.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Orthovisc injections in both knees. An exhaustive review of the current medical literature pertaining to viscosupplementation reveals mixed results. Evidence from eight systematic reviews and six randomized controlled trials indicates that although viscosupplementation may relieve knee pain in some individuals with osteoarthritis, it is not known as to which individuals will benefit. Different studies have tried mixing hyaluronic acid with corticosteroids, platelet-rich plasma, and other agents to make it more effective. 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, there is a history of good results from prior Orthovisc injections. There is sufficient support for the requested services in this clinical setting. Therefore, Orthovisc injections in both knees 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.