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

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for breast reduction surgery. Cabral and colleagues noted that patients with increased breast size experience symptoms such as pain in the neck, shoulders and lumbar spine, headache, intertrigo in the inframammary fold, difficulty in performing daily activities, paresthesia in the hands (due to weight on the anterior chest wall and compression of the brachial plexus), difficulty in exercising, low self-esteem, and body dissatisfaction. This patient presents with complaints of back pain and her bra straps digging into her shoulders due to her heavy breasts. The records provided for review do not document shoulder grooving on physical examination, and shoulder grooving is not visible in the photographs received for review. In addition, the records do not document chronic neck or back pain due to weight of the breasts, intertrigo unresponsive to medical management, thoracic kyphosis, upper extremity paresthesia, headache, or congenital breast deformity. There is no report of the proposed resection of breast weight. Per the American Society for Plastic Surgeons (ASPS), at least two documented quality of life signs are needed to support an indication for breast reduction surgery. In the absence of this documentation, the requested breast reduction surgery is not medically necessary for treatment of this patient. The California reconstructive surgery statute requires health insurers to cover reconstructive surgeries, defined as surgery performed to correct or repair abnormal structures of the body caused by congenital defects, developmental abnormalities, trauma, infection, tumors, or disease to do either of the following: (1) to improve function; (2) to create a normal appearance, to the extent possible. Based on the available documentation, the patient complains of back pain from pressure of her bra straps. The patient has comorbid scleroderma and fibromyalgia that required multiple pain medications. There is a lack of evidence that the patients pain or function is attributed to her breasts and that her function would be improved with breast reduction surgery. Moreover, based on the available documentation and photographs, the appearance of the patient is not abnormal. The requested surgery would not provide a more than minimal improvement in the appearance of the patient. For these reasons, the requested breast reduction surgery is not reconstructive in nature for this patient. Final Result: The reviewer determined that the requested services are not medically necessary and not reconstructive in nature for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in plastic surgery and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

A 63-year-old female enrollee requested authorization and coverage for Botox injections.  The health plan has denied this request indicating that the requested injections are not medically necessary for treatment of the enrollees recurrent acute headaches.One physician reviewer performed a medical necessity Independent Medical Review.  The physician reviewer overturned the health plans denial on the basis that the requested Botox injections are medically necessary.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested magnetic resonance imaging (MRI) of the chest (with and without contrast) for evaluation of the enrollees mass lesions and localized swelling on his chest. Findings: The physician reviewer found that there is a lack of support for the requested services in this clinical setting. The American College of Radiology (ACR) has established the appropriateness criteria in the category of chronic chest pain where it is unlikely that the pain is cardiac but where pleural disease is a consideration. Per the ACR guideline, MRI has the next to lowest appropriateness rating (2 out of 9). The medical studies and guidelines do not support that MRI of the chest will contribute to the diagnosis or management of the patients medical condition. In this patients case, the areas of the costochondral junctions were specifically evaluated. The laboratory workup, including studies to evaluate for rheumatologic diseases, was negative. This patient has multifocal, aligned, and symmetric symptoms for as long as two years. This clinical presentation, as noted by the referring physician, is not suggestive for occult malignancy. The likelihood that these multifocal masses are neoplastic is low. The best means to evaluate these types of signs and symptoms is through a CT scan of the chest which the patient underwent in June 2016. For these reasons, the requested coverage for magnetic resonance imaging (MRI) of the chest (with and without contrast) is not medically necessary for evaluation of this patient.Final Result: The reviewer determined that the requested services are not medically necessary for evaluation of the patients medical condition. Therefore, the Health Plans denial should be upheld.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

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for residential treatment center services for treatment of the enrollees behavioral health condition. Findings:  The physician reviewer found that there is sufficient support for the services at issue in this clinical setting. Per the medical records provided, the patient has a longstanding history of difficulties with impulse control, aggression, and emotion regulation. The patient met with a child psychologist starting at age and had an Individualized Education Plan starting in school with placement in a highly structured classroom with an aide. Prior to admission to the residential facility, the patient ran away from home several times and was failing classes at school.  The patient was admitted for ten days to an inpatient facility after he engaged in self-injurious behavior via cutting on his face and arms and posted these images on social media with a message about being depressed. The patient was documented as not willing to participate in treatment during the hospitalization. Upon admission to the residential treatment facility, the patient was described as angry, irritable and guarded.  The patient was placed on 1:1 precautions.  The patient was documented as displaying angry, impulsive, and aggressive behavior and physically assaulted a staff member.  The patient was described as anxious, tearful, and overwhelmed with significant rigidity.  The American Academy of Child and Adolescent Psychiatrys (AACAP) Child and Adolescent Service Intensity Instrument (CASII) was developed to help determine the appropriate level of service intensity for behavioral health treatment for youth. The CASII utilizes dimensions that are relevant to the patients clinical status when determining appropriate level of service intensity.  Based on the patients clinical history provided and documentation as outlined above, the patient met CASII criteria for non-secure 24 hour psychiatric monitoring. The patients clinical status, in addition to current medical literature, support that the treatment at the residential level of care.  Therefore, residential treatment center services were medically necessary for 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 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: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for trigger point injections. . Findings:  The physician reviewer found that a review of treatments and management of myofascial pain, Urits and colleagues noted that studies that compared trigger point injection effectiveness against a control with some therapeutic value, such as dry needling or saline trigger point injection, all found that local anesthetic trigger point injection was not a significantly better treatment even if it did result in patient improvement from baseline pain. The authors further noted that studies suggest that while both topical and trigger point injection treatments may be effective in treating patient pain from myofascial pain syndrome, the less invasive nature and lower risk of adverse effects of topical treatment make it a better initial therapeutic route than local anesthetic trigger point injection. Weller and colleagues note that stretching and physical therapy are the mainstays of myofascial pain syndrome management, and that pharmacologic management of myofascial pain is generally indicated as the first-line therapy for patients in whom physical therapy and other noninvasive techniques are either  contraindicated or have failed. The authors further noted that a recent systematic review and meta-analysis found dry needling to be superior to sham or no treatment both immediately and for four weeks postintervention but did not demonstrate a significant difference compared with alternative interventions for myofascial trigger point derived myofascial pain syndrome. In this case, the patient reports upper back pain localized to the midline between the scapula.  There is no indication of recent attempts to treat suspected myofascial pain with physical therapy or a stretching program. Given that the evidence in current medical literature supporting trigger point injections is limited by studies with small sample sizes that are underpowered and a  lack of longitudinal data to demonstrating superiority over noninvasive treatment methods, the requested services are not medically indicated. Therefore, trigger point injections are not medically necessary for the treatment of this patient.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: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement and prospective authorization and coverage for wearable cardioverter defibrillator vest services for treatment of the enrollees dilated cardiomyopathy. Findings:  Two physician reviewers found that the benefits of wearable cardiac defibrillators have been the subject of intensive study. However, the device has not been proven to be of substantial benefit for patients with newly diagnosed cardiomyopathy. Guidelines from the Heart Rhythm Society (HRS) and the American College of Cardiology (ACC) do not support use of the wearable cardioverter defibrillator in this patients clinical setting. Permanent ICD placement is recommended after a waiting period of 45-90 days, but a wearable cardiac defibrillator has not been proven beneficial for use in the interim. Based on these findings, the wearable cardioverter defibrillator vest services provided were not and are not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Final Result: The reviewers determined that the services at issue were not and 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: Reviewers 1, 2 and 3 are board certified in internal medicine with sub-specialty certification in cardiovascular disease 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 female enrollee requested speech therapy at the frequency of two times per week (one hour per session) for treatment of the enrollees mixed receptive-expressive language disorder and autism spectrum disorder.  Findings:  The physician reviewer found that speech therapy is medically indicated for children with autism spectrum disorders (Myers and Johnson). This patient has been diagnosed with autism. Given that she has made progress with two hours of speech therapy per week thus far, a reduction in services would be detrimental for this patient. For the reasons provided, it is medically necessary for this patient to have speech therapy at the frequency of two times per week (one hour per session).
Appeal type: Medical Necessity
Decision: Overturned

The spouse of a deceased female enrollee has requested skilled nursing facility care for treatment of her metastatic breast cancer.  Findings:  The physician reviewer found the submitted documentation supports the medical necessity of the services at issue.  In this patients case, skilled nursing facility care was medically indicated and consistent with generally accepted guidelines. The submitted records document several issues which required daily skilled nursing, which included monitoring of fluid intake, changing the dressings on skin ulcers, assistance up and out of bed, evaluation for frequent dyspnea, and management of a urinary tract infection.  Skilled nursing facility care was medically appropriate in this clinical setting.  This patient had advanced metastatic cancer and resulting symptoms.  In this case, the daily nursing care recognized acute dyspnea that required hospital admission. Paracentesis was subsequently performed, and the patient was transferred back to the skilled nursing facility after this admission.  All told, skilled nursing facility care was medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for positron emission tomography (PET) scan for evaluation of the enrollee, who is being treated for hemangiopericytoma. Findings:  The physician reviewer found that there is sufficient support in the medical literature for the requested services in this clinical setting. One advantage of PET scan, as opposed to other cross-sectional imaging such as MRI and CT is that PET scan enables an evaluation of the entire body as opposed to the focal nature of MRI and CT.  Unsuspected additional occult lesions are more easily detected by PET. Hemangiopericytomas of the breast are very rare.  The uncertainty is clear in the referring providers note.  Hemangiopericytomas can occur anywhere in the body.  They originate in the walls of capillaries, and are more commonly seen in the head and neck.  In addition, as noted in the European Sarcoma Networks practice guidelines, A biopsy may underestimate the tumour malignancy grade. Therefore, when pre-operative treatment is an option, radiological imaging (including positron emission tomography, PET) may be useful, in addition to pathology, in providing the clinician with information that helps to estimate the malignancy grade (i.e., necrosis).  In one study, it was noted that, The accurate diagnosis of HPC [hemangiopericytoma] depends on the appropriate histological and immunohistochemical examination.  Surgical resection is the treatment of choice and due to scarcity of cases and unpredictable biological behavior of these tumors long term follow-up may be warranted. All told, a careful, thorough pre-operative evaluation is reasonable, especially in view of the need for long term follow-up.  A baseline PET scan could potentially be invaluable, as it would be for any other soft tissue sarcoma. For all these reasons, PET scan is medically necessary for evaluation of this patient. Final Result: The reviewer determined that the requested procedure 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 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: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for carpal tunnel surgery. Conservative treatment for carpal tunnel syndrome is preferred for mild and short-term carpal tunnel syndrome. Both surgical and conservative interventions have a role in treating carpal tunnel syndrome. The authors noted that nonsurgical treatment is more effective and safer than surgical treatment, but there was no significant improvement in function, symptoms, or neurophysiological parameters. Overall, nonsurgical treatment is recommended as the optimal choice for carpal tunnel syndrome and surgical release is reserved for patients who have failed conservative treatment. This patient presents with complaints of bilateral hand pain with numbness and tingling primarily in the second through fourth fingers, right greater than left. She has documented functional difficulty with activities involving fine manipulation of the fingers. Clinical examination findings demonstrated intact sensation with positive right Tinels sign. There is electrodiagnostic evidence of mild left and moderate right carpal tunnel syndrome. Conservative treatment has included activity modification, non-steroidal anti-inflammatory drugs (NSAIDs), and a right wrist brace. However, the records do not document a thorough orthopedic evaluation and failure of maximal conservative treatment. Therefore, this requested carpal tunnel syndrome is not medically necessary for treatment of this patient. 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 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

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for anesthesia services. Findings:  The physician reviewer found that for this patient, there is no documentation of clinical findings that would support the need for anesthesia services. The patient had an (ASA) preoperative physical status classification score of 1 which indicated low preoperative risk. Intravenous sedation, performed by a non-anesthesiologist and non-certified registered nurse anesthetist, is well supported in both clinical practice and in the medical literature. Therefore, given a low preoperative physical status classification score of 1, the anesthesia services administered were not medically necessary. 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 anesthesiology 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 53-year-old male enrollee has requested a bilateral knee MRI for evaluation of his knee pain. Findings:  The physician reviewer found that the results of the patients examination combined with his treatment history do not support the need for an MRI study to further evaluate the cause of his pain. X-ray evaluation was essentially normal and there is no history of locking of the knee joint. A trial of physical therapy has not been attempted. In sum, MRI is not appropriate at this juncture.
Appeal type: Medical Necessity
Decision: Overturned

A 24-year-old female enrollee has requested reimbursement for extended care residential program services for treatment of the enrollees alcohol dependence and depression.  Findings:  The physician reviewer found that the records provided did not document the patients severity of illness and her level of functioning in a multidimensional assessment, which would justify residential treatment center level of services. The American Psychiatric Association (APA) Clinical Practice Guidelines state, residential treatment is indicated primarily for individuals who do not meet clinical criteria for hospitalization, but whose lives and social interactions have come to focus exclusively on substance use and who currently lack sufficient motivation and/or substance-free social supports to remain abstinent in an ambulatory setting. In this patients case, the daily routine and social organization of her college experience were likely contributing to her heavy alcohol use. Once the patient left school to pursue treatment, she had a dramatic change in environment and was motivated for care with good family support. Further, based upon the documentation provided, the patient had not been trialed on less restrictive interventions prior to pursuing treatment at a residential level of care. However, considering that the patient had been drinking daily she was at risk for alcohol withdrawal; thus inpatient detoxification was indicated. The record states that the patient was on detoxification medications and her vital signs had stabilized on a specific date.  Accordingly, as of the follwing day, the patient was appropriate for partial hospitalization or intensive outpatient level of care with community support programming. In conclusion, the services provided from up until detoxification were medically necessary and the services provided afterward were not medically necessary.