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

Nature of Statutory Criteria/ Case Summary:  The enrollee requested coverage for the medication Nutropin AQ Nuspin. The enrollee has been diagnosed with hypothyroidism due to Hashimotos thyroiditis, osteopenia of the lumbar spine and both hips, and idiopathic short stature (ISS). She takes Synthroid. Her insulin growth factor 1 (IGF1) level was 445. A bone age study reported normal skeletal age for her chronological age. She was 59.2 inches tall and weighs 113 pounds, 12 ounces. The mid-parental target height is 65.9 inches. Her pediatric endocrinologist has recommended growth hormone therapy with Nutropin injections. The pediatric endocrinologist reports growth hormone deficiency is a sub-normal condition, possibly caused by the childs under responsiveness to the growth hormone she is producing, even if the amount she is secreting is clinically normal. Treatment of ISS with growth hormone is supported by randomized controlled trials and consensus guidelines. The Food and Drug Administration approval for this indication is for non-growth hormone-deficient short stature. This is defined by a height standard deviation score less than or equal to -2.25, and associated with growth rates unlikely to permit attainment of adult height in the normal range, in pediatric patients whose epiphyses are not closed and for whom diagnostic evaluation excludes other causes associated with short stature that should be observed or treated by other means. The patient does not have a pretreatment height less than or equal to -2.25 standard deviations. The patient does not meet idiopathic short stature criteria and the request for Nutropin AQ Nuspin does not meet any nationally accepted criteria for use of growth hormone.Final Result: The reviewer determined that the requested service is not medically necessary for the treatment of the enrollees medical condition.Credentials/Qualifications: The physician reviewer is board certified in pediatric endocrinology 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 similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has history of gender dysphoria. The provider noted that the patient was diagnosed with gender dysphoria and she has been on hormone therapy. She has a history of anxiety and depression, which were worsened by gender dysphoria. The patient relates much of her continued gender dysphoria to her facial features not aligning with her identified gender.  The patient has requested authorization and coverage for facial feminization surgeries. The Health Plan has denied this request and reported that the requested services are not medically necessary for the treatment of this patient. According to researchers, medically necessary gender affirming/confirming surgical procedures include certain facial plastic reconstruction procedures. Researchers noted that other surgeries or procedures that may be necessary to resolve gender dysphoria and allow transgender women to navigate the world as women includereconstructive facial feminization surgery.   In this patients case, the records document anxiety and depression that are worsened by gender dysphoria. There is support for the requested services in this clinical setting. Therefore, the requested services 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 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: An enrollee has requested authorization and coverage for magnetic resonance imaging (MRI) of the knee.The American College of Radiology guidelines state that MRI is indicated for non-traumatic knee pain when pain is persistent and radiographs are non-diagnostic. It is not indicated before complete physical examination and radiography, or for the following conditions: severe degenerative joint disease, inflammatory arthritis, stress fracture, osteonecrosis, or chronic regional pain syndrome. (American College of Radiology). Matar and colleagues noted, The management of patients with knee pain is non-operative both for degenerative meniscal tears and degenerative joint disease in its initial stages. Magnetic resonance imaging has little added value in the management of middle-aged and elderly patients with degenerative disease. Failure to respond to non-operative measures warrants orthopedic assessment with radiographic studies and counselling on managing degenerative joint disease both non-operatively and operatively. (Matar, H., et al.). In this case, the patient is noted to have had a mechanical fall in November 2020, resulting in left knee pain. The patient reported clicking in the joint and noted that the knee felt loose. The records noted a prior history of knee pain October 2019, with reported diagnosis of meniscus tear. Per the records, the patient was treated conservatively in October 2019, with no imaging performed. Examination of the left knee revealed lateral joint line tenderness, normal range of motion, and no ligamentous laxity with varus or valgus stress. The patient did not tolerate McMurrays maneuver. The patient was noted to have been prescribed meloxicam on 1/25/21; however, the records dated do not document 3/1/21 benefits with this medication. There are no x-rays provided or noted to have been completed. There is limited documentation of any trial and failure of conservative care modalities provided for review. Advanced imaging is not indicated without failure of conservative treatment and non-diagnostic x-rays. There is no compelling rationale presented or extenuating circumstances noted to support the medical necessity of this request as an exception. Therefore, the requested MRI of the knee is not medically necessary for the evaluation of the patients medical condition.Final Result: The reviewer determined that the requested service is 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 internal medicine with subspecialty certification in orthopedic surgery and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

A fifty year-old female who complains of neck pain is requesting reimbursement for lumbar and cervical MR imaging.Reviewers Findings:  The reviewing physician found that there is no information regarding the duration of the patients symptoms or whether there was a trial of medication and/or physical therapy. Conservative therapy should be attempted before performing an MRI of the lumbar spine.  The reviewing physician found that the Health Plan denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for maxillomandibular advancement surgery for treatment of the enrollees obstructive sleep apnea (OSA). Findings:  The physician reviewer found that this patient has been diagnosed with severe OSA. Surgical intervention focused at site specific obstructions is ideal. Maxillomandibular advancement has been shown to improve posterior airway space and also to increase the stability of the lateral pharyngeal wall, countering its tendency to collapse. A study reported a 100% success when maxillomandibular advancement was combined with a genial advancement. The author concluded that maxillomandibular advancement is highly successful and safe. Maxillomandibular advancement has also been reported to be an effective first-line treatment for severe OSA. Final Result: The reviewer determined that the requested surgery 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 oral and maxillofacial surgery and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

A 56-year-old male enrollee requested authorization and coverage of 60 Imitrex per month.  The Health Plan denied the request indicating that the requested prescription is not medically necessary for treatment of the enrollees migraine headaches.One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer upheld the Health Plans denial on the basis that the requested prescription is not medically necessary.
Appeal type: Medical Necessity
Decision: Upheld

The patient is a 42-year-old female who was diagnosed with breast cancer in 2004. In November 2004, she underwent a right mastectomy. The pathology revealed multifocal invasive and in situ ductal carcinomas  high grade. Eight of fifteen axillary nodes were positive. Estrogen and progesterone receptors were positive and HER2 was negative. Various scans were negative for metastatic disease. Thereafter, the patient elected to undergo Light Beam Generator therapy, intravenous immune support therapy, and sauna treatments. All of these treatments were denied by the Health Plan.Light Beam Generator therapy is allegedly utilized for restoring lymph flow. There is no scientific evidence demonstrating its effectiveness in any cancer-related situation. Similarly, intravenous immune therapy and sauna treatments are of no known clinical benefit in the treatment of breast cancer. Scientific evidence supports adjuvant chemotherapy for this patient. Because there is no evidence supporting the use of the therapy at issue for treatment of the patients condition, I have determined the therapy at issue was not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Prothrombin (Factor II) G20210A gene mutation testing (CPT 81240). Stroke is caused by one of several pathophysiologic processes involving the blood vessels of the brain. The process may be intrinsic to the vessel, as in thrombosis seen in a hypercoagulable state. Stroke evaluation involves brain imaging, cardiac testing, and laboratory studies. The records provided for review document that this patient underwent a comprehensive neurological evaluation and patent foramen ovale closure. Despite the exhaustive work-up and medical evaluations, the patient sustained a subsequent stroke and etiology remained cryptogenic. Coinciding with the patients brain ischemia there was diagnosis of unprovoked pulmonary embolism. Ischemic strokes in a patient under 50-years of age and coinciding pulmonary embolism supports suspicion for an underlying hypercoagulability as the etiology of the ischemic events. This patient has undergone comprehensive evaluation and continues to have ischemic events with coinciding evidence of hypercoagulability. Obtaining laboratory studies to evaluate the presence of hypercoagulable etiologies, specifically testing for Prothrombin (Factor II) G20210A gene mutation, is supported by the medical literature. Given these findings, the requested Prothrombin (Factor II) G20210A gene mutation testing (CPT 81240) is likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Findings:  Three of the three physician reviewers found the requested Prothrombin (Factor II) G20210A gene mutation testing (CPT 81240) is likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the requested services are likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: Physician reviewer 1 is board certified in neurology with subspecialty certification in vascular neurology and is actively practicing. Physician reviewer 2 is board certified in medical oncology with subspecialty certification in hematology and is actively practicing. Physician reviewer 3 is board certified in internal medicine with subspecialty certifications in medical oncology and hematology and is actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for Orthovisc injections. This patient has chronic left knee pain and imaging evidence of advanced patellofemoral arthritis and mild tibiofemoral arthritis. A review of the current medical literature pertaining to viscosupplementation reveals mixed results. Although viscosupplementation may relieve knee pain in some individuals with osteoarthritis, it is not known which individuals will benefit.  Different studies have tried mixing hyaluronic acid with corticosteroids, platelet-rich plasma, and other agents to make it more effective. The current evidence does not support viscosupplementation as standard treatment for osteoarthritis of the knees. Viscosupplementation can only be recommended in patients with a history of lasting benefit from prior injections and in carefully selected cases where the options are limited. In this patients case, her options are limited. She has tried and failed other conservative treatments, with the alternative being a total knee arthroplasty. Therefore, Orthovisc injections were medically necessary for the treatment of this patient.Final Result: The reviewer determined that the services at issue were medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The 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: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for OxyFast 5 mg/5 mL (3,000 mL total), Dilaudid 8 mg (180 mg total), and Ketamine 150 mg/mL (60 mL total). This patient presents with a history of chronic pain related to CRPS and cyclic vomiting syndrome. He has attempted several forms of conservative non-opioid treatment modalities including plexus block injections, physical therapy, appendectomy, and cholecystectomy. The provider documented that the patients regimen of OxyFast, Dilaudid, and Ketamine has been managing his symptoms as a bridge to more sustainable treatment in the form of an intrathecal pain pump. The patients urine toxicology screens and Controlled Substance Utilization Evaluation System (CURES) reports have been consistent with therapy. In addition, there has been no evidence of adverse drug reactions or aberrant behavior identified. The Centers for Disease Control and Prevention (CDC) guidelines state that, nonpharmacologic therapy and nonopioid pharmacologic therapy are preferred for chronic pain. Clinicians should consider opioid therapy only if expected benefits for both pain and function are anticipated to outweigh risks to the patient. The American Society of Regional Anesthesia and Pain Medicine state that, For CRPS, there is moderate evidence supporting ketamine infusions to provide improvements in pain for up to 12 weeks. This patients treatment plan includes weaning off of high-dose narcotic therapy with placement of an intrathecal pain pump. In the interim, continuation of his medication regimen is supported for treatment of his CRPS and cyclic vomiting syndrome. For these reasons, the requested OxyFast 5 mg/5 mL (3,000 mL total), Dilaudid 8 mg (180 mg total), and Ketamine 150 mg/mL (60 mL total) are medically necessary for treatment of this patient. Final Result: The reviewer determined that the requested medications 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 anesthesiology with subspecialty certification in pain management 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

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for digital breast tomosynthesis. Findings:  Two physician reviewers found that the medical evidence supports the service at issue in this patients case.  Breast tomosynthesis provides advantages to radiologists interpreting mammograms.  This tomographic method often allows the reader to separate dense glandular elements from underlying mass/architectural distortion, resulting in a decrease in callbacks and increase in overall diagnostic accuracy and detection of small cancers compared to two-dimensional imaging alone.  Thus, the addition of tomosynthesis to the usual two-dimensional protocol was likely of greater benefit to the patient than had her examination been done using two-dimensional imaging alone. Final Result: The reviewers determined that the service at issue 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 overturned. Credentials/Qualifications: Reviewers 1, 2, and 3 are board certified in diagnostic radiology and is actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

The patient is a 63-year-old male with lower back pain secondary to osteomyelitis who was admitted to a skilled nursing facility after a hospital admission.  The patient had a physical therapy evaluation in April 2005. At that time the patient required minimum assistance for bed mobility, moderate assistance with transfers, and minimum assistance with ambulation. In addition, the patient required minimum assistance with toilet hygiene and maximum assistance with lower back dressing and bathing. After seven days of therapy, the patient required contact guard assistance with bed mobility, contact guard assistance with transfers, and contact guard assistance with ambulation. At this time the patient had not completed his rehabilitation course and was expected to continue to progress. He had not reached his functional potential and he was not independent or safe to be alone. The patient continued to receive therapy until May 2005. The Health Plan has denied reimbursement for the services the patient received after 5/5/05.The patient was denied continued rehabilitation therapy after seven sessions of physical and occupational therapy without achieving safe independent function. The patients coverage was denied before he completed his rehabilitation course. The clinical evidence demonstrates the patient was progressing with therapy and that there was an expectation he would continue to progress towards independence with continued therapy. The skilled therapy the patient received until 5/18/05 was medically necessary and appropriate. There is no indication this patient was at a custodial level of care during the dates of service in question.Based upon the information set forth above, I have determined the services at issue were medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Upheld

The patient is an 11-year-old male with a history of attention deficit hyperactivity disorder (ADHD), and inconsistent and erratic school performance. In 2005, the patient was tried on Strattera, apparently with good results. The patients parents have requested authorization and coverage to allow the patient to continue on Strattera. The Health Plan has denied coverage for Strattera on the basis the patient does not meet criteria for use of a second-line drug.At issue is whether Strattera is medically necessary for treatment of the patients medical condition.The Health Plans denial should be upheld. The submitted clinical information does not establish that Strattera is medically necessary for this patient. There is no evidence the patient has been tried on a long-acting stimulant or that use of a long-acting stimulant is contraindicated. As such, there are alternative therapies available that are likely to be beneficial for the patient. Therefore, I have determined that the requested medication is not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
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 is a technique that was developed several years ago as a problem solving adjunct to routine mammography.  Applying the same basic concept as computed tomography (CT) scanning, the logic is that by separating the various layers of breast tissue, one can better detect abnormalities.  This has been shown to be most useful in the evaluation of dense breasts.  In this patients case, there has been an interval change in her right breast when compared to multiple prior mammograms.  Breast tomosynthesis has been shown to better separate out superimposed tissues.  Areas of architectural distortion may be a sign of an invasive carcinoma.  In this patients case, breast tomosynthesis is likely to have been superior over other methods of evaluating this patient. Final Result: Three reviewer 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.