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

The parent of an enrollee has requested authorization and coverage for the medication Nutropin AQ Nuspin. The submitted documentation does not support that the requested medication is medically necessary at this time. Medical literature shows that FDA approved indications for growth hormone for pediatric patients include growth hormone deficiency, growth failure associated with chronic kidney disease, idiopathic short stature, and short stature associated with Turner syndrome. Researchers state that accurate measurement of height and weight using standardized techniques is a fundamental component of pediatric medical visits. They state that calculation of height velocity over time enables comparison with standardized growth charts to identify potential deviations from normal. In this case, however, there is insufficient evidence of poor growth in the medical records provided. The submitted documentation records only two heights for the patient, taken three months apart, and no records of a prior growth chart. This limited information does not permit a determination of whether the patient has poor growth velocity. Calculating growth velocity based on only two measurements that are taken three months apart is insufficient evidence for poor growth. Therefore, while the patient may be demonstrated to meet the criteria in the future, the submitted documentation is not sufficient at this time. Under these circumstances, Nutropin AQ Nuspin is not medically necessary to treat the patients medical condition at this time.Final Result: The reviewer determined that the requested medication 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 pediatrics, with subspecialty certification 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 a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

A 44-year-old male enrollee has requested Provigil for the treatment of his shift work sleep disorder. Findings:  The physician reviewer found that the patient has a history of anxiety and depression. In addition to these diagnoses, he also suffers from shift work sleep disorder and is bothered by excessive sleepiness and difficulty sustaining attention. Provigil has been beneficial in this regard and its continued use is medically appropriate.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for digital breast tomosynthesis for the enrollees routine breast cancer screening. 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 particular patient, her breasts were initially described as being heterogeneously dense. It is specifically those patients who have dense breasts that can benefit most from breast tomosynthesis.  The ability to separate out the overlapping structures enables the possibility of demonstrating an otherwise occult tumor.  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 physician reviewers are board certified in diagnostic radiology 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

A 59-year-old male enrollee has requested for physical therapy services, including electrical and passive modalities for treatment of his left shoulder rotator cuff tear. Findings:  The physician reviewer found that therapy is usually performed for four to six weeks which graduates into a home program.  However, to be approved, it should also include an exercise program for stretching and strengthening.  There must be active treatment rather than solely passive modalities. It appears that this individual did have an exercise program. Therapy would be appropriate for four to six weeks, three times weekly, with a diagnosis of impingement syndrome. Electrical stimulation, if part of an active treatment program, would be appropriate.  Modalities may include, but are not limited to, cryotherapy, hydrotherapy, electrical stimulation and thermotherapy.
Appeal type: Experimental/Investigational
Decision: Upheld

A 62-year-old male enrollee has requested an addition of Avastin to chemotherapy for treatment his metastatic melanoma. Findings:  Three physician reviewers found that in this patient condition, the primary goal is to maximize palliation and achieve pain control. This patient has many comorbid conditions, making him poor performance status (i.e., ECOG 4). Boasberg and colleagues note that an abstract from the American Society of Clinical Oncology (ASCO) supports the use of Avastin in advanced metastatic melanoma. However, it did not involve patients with the same performance status as this patient and therefore is not applicable to this patients clinical situation. In fact, given the patients history of hypertension as well as various surgeries and wound complications, Avastin could potentially worsen the hypertension or cause fatal hemorrhage or wound dehiscence. The use of this drug in this patient remains unproven in terms of potential benefit and toxicity.
Appeal type: Medical Necessity
Decision: Upheld

A 48-year-old female enrollee has requested sacroiliac joint injections for the treatment of her back pain. Findings:  The physician reviewer found that in this particular patient, a neurosurgical consultation identifies the thoracolumbar spine as the primary source of pain. This appears to be an accurate assessment based on the information provided. The neurosurgeon recommended instrumentation and fusion. Although the patients sacroiliac joints may contribute as an additional pain generator, they should not be considered the primary cause. Because of this patients specific clinical situation, sacroiliac joint injections are not likely to provide adequate relief and should not be considered medically necessary in her ongoing care. Since the patient declined surgical intervention, alternative methods including physical therapy and kinesiotherapy (emphasizing pool therapy and isokinetic exercise) would have been appropriate alternatives to ongoing repeated needle injection therapies, particularly sacroiliac joint injections.
Appeal type: Experimental/Investigational
Decision: Overturned

A 31-year-old male enrollee has requested for either peripheral subcutaneous target stimulation or spinal neurostimulator pulse generator for treatment of his chronic back pain. Findings:  Three physician reviewers found that the available peer reviewed medical literature supports the use of PNS in patients with chronic back pain, which has been refractory to other treatments. The patient has had chronic pain status post a motor vehicle accident. He is not a surgical candidate. He has been through a number of conservative therapies with little relief, including as noted above: injections, physical therapy, acupuncture, psychotherapy, and medication therapy including narcotics. The patient did complete a psychological evaluation and has obtained clearance for spinal cord/peripheral nerve stimulation. Thus, the patient is an appropriate candidate for PNS, which is likely to be more efficacious than standard interventions. Consistent with the relevant scientific literature, a treatment plan documenting the specific location of the patients pain should be obtained prior to proceeding with PNS.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for digital breast tomosynthesis for evaluation of the enrollees risk for breast cancer. Findings:  Three physician reviewers found that 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, by separating the various layers of breast tissue, one can better detect abnormalities. This particular patient was noted to have breasts that are described as being heterogeneously dense. While one could make the argument that the patients mammogram has not changed since the last study, it is specifically the patients who have dense breasts that can benefit most from tomosynthesis. The ability to separate out the overlapping structures enables the possibility of demonstrating an otherwise occult tumor. Final Result: Three reviewers determined that the diagnostic procedure 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: All three physician reviewers are board certified in diagnostic radiology 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: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested eating disorder intensive outpatient program services for treatment of the enrollees behavioral health conditions.  Findings: The physician reviewer found that although comprehensive psychiatric and eating disorder specialty services are indicated, the medical records do not demonstrate the medical necessity of intensive outpatient programming.  There was evidence of a plateaued therapeutic response in context of relative medical stability and the absence of an acute psychiatric syndrome.  The care plan noted no physical symptoms, pending laboratory studies or clinical interventions.  The patient elected to discontinue one of her psychotropic medications.  Despite struggling with ongoing binging and purging, she was mostly compliant with her meal plan in program.  Her caloric intake was 1500 to 2000 kcal, which aligned with the recommended intake of 1650 to 1800 kcal.  The patient was 92% of her ideal weight, and her body mass index was in the normal range.  The termination summary noted moderate improvement with improved insight and awareness of her eating disorder.  Considering the treatment history and patient status as described in the termination summary and most recent treatment review note, intensive outpatient program services would not be reasonably expected to improve the patients condition while effective services, including but not limited to psychiatric care, nutritional counseling, mentoring, and individual, family and group therapies, could be safely delivered in the outpatient setting.  Thus, eating disorder intensive outpatient program services were not and are not medically indicated for the treatment of this patient.Final Result: The reviewer determined that the services at issue were not and 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 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:  An enrollee has requested a power wheelchair/power gurney for treatment of his multiple osseous deformities and severe scoliosis.  Findings:  The physician reviewer found that the submitted documentation establishes the medical necessity of the requested power wheelchair. According to the medical literature, The benefits of power-mobility devices are reported to include improved quality of life, an increased sense of freedom and improved self-esteem. Power mobility can benefit specific individuals. The determination of who will benefit is a matter of clinical judgement more than of adherence to criteria defined by the literature. In this case, the patient has profound deficits of functional mobility for which he depends on the modified power wheelchair that has been requested.  He has been using a power wheelchair for most of his life. He can use a power wheelchair safely and his abode can accommodate the device. Therefore, based on the clinical documentation submitted, a power wheelchair/power gurney is medically necessary for treatment of the patients medical condition.   Final Result: The reviewer determined that the requested equipment 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 physical medicine and rehabilitation with sub-specialty certification in neuromuscular medicine and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

A 49-year-old male enrollee has requested for lumbar spinal fusion at L5-S1 for treatment of her back and leg pain.  Findings:  The physician reviewer found that there has not been any defined lumbar radiculopathy, or sciatic localizing symptoms or signs. Nor has there been any substantiating medical data implicating or conclusively showing that the L5-S1 level is his pain generator. In addition, there is no documentation of any instability, angulation, tumor, or infection. Thus, the indications for fusion as published by Bambakidis and colleagues and the Milliman Criteria for lumbar fusion have not been satisfied in this case.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested Harvoni for treatment of her hepatitis C.  Findings: The physician reviewer found that  according to the most recent joint guidelines issued by the American Association for the Study of Liver Diseases and the Infectious Diseases Society of America, all patients with chronic hepatitis C should be treated except those with limited life expectancy due to non-liver-related conditions.  This applies regardless of fibrosis stage or viral load.  The guidelines support Harvoni for treatment-naive patients with hepatitis C, genotype 1 infection.  Patients with viral load of less than 6,000,000 IU/mL can be treated with Harvoni for eight weeks.  These guideline recommendations are based on multiple randomized clinical trials.  All told, the requested Harvoni is medically indicated for the treatment of this patient. Final Result: The reviewer 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 internal medicine with sub-specialty certification in gastroenterology 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 52-year-old woman who underwent left unicompartmental knee replacement in June 2005 due to medial compartment degenerative joint disease. She began using the continuous passive motion (CPM) machine in the immediate postoperative period, as prescribed by her orthopedic surgeon, to assist with her rehabilitation. She is now requesting reimbursement for the rental cost of the device. The Health Plan denied her request based upon their determination that the CPM machine was not medically necessary following the patients partial knee replacement surgery. A CPM device is the standard of care for postoperative rehabilitation following knee replacement. Patient compliance is high and many surgeons find that patients regain their range of motion faster and have better pain control with the device. Regardless of whether the patient underwent total or unicompartmental knee replacement, immediate mobilization of the joint is imperative. Therefore, I have determined the device at issue was medically necessary for treatment of the patients medical condition. The Health Plans denial should be overturned.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for microvascular decompression surgery or treatment of the enrollee who has a history of facial pain. Findings:  The physician reviewer found that patients facial pain is attributable to a well known condition called trigeminal neuralgia. In trigeminal neuralgia, there is irritation of the trigeminal nerve, which provides sensation to the face. Oftentimes, the irritation is caused by pulsations of an artery that is contact with the trigeminal nerve. Treatment may include microvascular decompression or separation of the artery from the nerve when patients have not responded to medical therapy. In this patients case, he is documented to have facial pain that has not responded to medical treatment. In summary, the large body of medical evidence as well as standard practice patterns indicate that the patients trigeminal neuralgia will likely benefit from the requested microvascular decompression. As such, the requested microvascular decompression surgery is likely to be more beneficial when compared to the standard options for treating this patients medical condition.Final Result: Two of the three reviewers determined the requested services are likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications:  All three reviewers are board certified in neurological surgery 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: Experimental/Investigational
Decision: Upheld

A 49-year-old male enrollee has requested authorization and coverage for an IDET procedure. The Health Plan has denied this request indicating that the requested procedure is considered investigational for treatment of the enrollees low back pain. Findings:  Two physician reviewers found that Gibson and Waddell reported that there were three small randomized clinical trials of intradiscal electrotherapy (IDET), each using different protocols. The study by Barendse and colleagues randomized 28 patients to either IDET or placebo. At eight weeks, one in thirteen stimulated patients was judged to have achieved clinical success while two in fifteen control patients were judged to have achieved success. The Pauza study reported on a highly selected group of patients who were randomized to IDET or placebo. Results from 56 of the patients suggested that IDET resulted in significantly greater improvement in pain and disability, but this was a methodologically flawed study as an intention to treat analysis was not performed. The Freeman study randomized 57 patients with a 2:1 ratio to IDET or placebo and had a 96% follow-up. None of these patients met the pre-defined criteria for a clinically successful outcome. The authors concluded that there was no significant benefit from IDET over placebo. Finally, in a randomized trial comparing two durations of thermocoagulation rather than intervention versus control therapy, IDET was found to be ineffective. Gibson and Waddell concluded that the extremely poor results of Barendse and Freeman cast serious doubts on the highly selective, positive results reported by Pauza. A more recent review by Urrutia and colleagues also concluded that available evidence does not support the efficacy of this procedure for the treatment of discogenic low back pain. In light of these findings, the superiority of IDET over standard therapies in this setting remains unproven.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for an MRI of the cervical spine.The American College of Radiology (ACR) Appropriateness Criteria indicates that an MRI of the cervical spine is usually appropriate for patients with chronic cervical or neck pain. The addition of radiculopathy is a further justifiable indication of the cervical spine MRI. In the ACR recommendations, a distinction is made between patients with relatively acute or even chronic pain depending on whether there are any red flags. Red flags include such issues as infection, prior tumor, and unexplained weight loss. In this case, the patient had objective signs of degenerative change for many years, and now has evidence of radiculopathy (numbness and tingling). In this setting, it is medically appropriate to obtain an MRI of the cervical spine. The Health Plans denial noted six weeks of conservative therapy is necessary prior to the MRI of the cervical spine. The argument for delaying imaging studies for six weeks may be appropriate when one is only dealing with pain. While six weeks of conservative therapy is generally warranted, in this particular patient, considering the chronicity and well-documented degenerative change, the best and most efficacious means to evaluate the patient for a spinal stenosis, foraminal encroachment, or disc herniation is to obtain an MRI of the cervical spine. Thus, the MRI of the cervical spine is medically necessary for the evaluation of the patients medical condition.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 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

A 29-year-old male enrollee requested authorization and coverage of removal of a keloid scar. The Health Plan denied the request indicating that the requested scar removal is considered cosmetic in nature and 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 injections are reconstructive in nature and medically necessary.