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

This patient is a 52-year-old female with persistent left shoulder pain and limited range of motion. The pain began when she wrenched her shoulder over one year ago.  There is apparently also a possibility of rheumatoid arthritis.  The patient has undergone conservative treatment including pain medication and a cortisone injection.  Her provider ordered an MRI of the left shoulder but authorization was denied by the Health Plan based upon a determination that it was not medically necessary.The patient gives a history of trauma to her shoulder and now has limited range of motion. While she does exhibit signs of a frozen shoulder, she could also have a rotator cuff tear. An MRI would be beneficial to rule out a torn ligament as the cause of her problems. As such, the requested MRI is medically appropriate and indicated in this setting. Therefore, I have determined the requested MRI is medically necessary for evaluation of the patients medical condition. The Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Overturned

A forty-four year-old male who underwent an audiometric evaluation is requesting authorization for a follow up evaluation of his hearing.Reviewers Findings:  The reviewing physician found that it is reasonable for the patient to undergo follow-up audiometric testing to compare with the previous results.  The reviewing physician found that the Health Plan denial should be overturned.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a 21-month-old female enrollee has requested coverage for speech therapy for treatment of the enrollees speech delay. Findings:  The physician reviewer found that the submitted documentation demonstrates the medical necessity of the requested therapy in this patients case.  As noted by Nelson and colleagues, speech and language development is considered by experts to be a useful indicator of a childs overall development and cognitive ability and is related to school success.  Per the authors, identification of children at risk for developmental delay or related problems may lead to intervention services and family assistance at a young age when chances for improvement are best.  Speech and language delay must be taken seriously in young children because the long-term consequences may be substantial.  As noted by Law and colleagues, children whose difficulties persist into primary school may have long-term problems concerning literacy, socialization, behavior, and school attainment.  These reviewers concluded that there is a positive effect of speech and language therapy interventions for children with expressive phonological and expressive vocabulary difficulties.  In this patients case, she demonstrates expressive language skills below those of her peers, limiting her ability to communicate effectively.  The current medical literature supports speech therapy in this clinical setting.  All told, the requested speech therapy is medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Overturned

A 64-year-old male has requested coverage for blepharoplasty, upper eyelid (CPT 15823) and canthoplasty (CPT 67950) for treatment of his visual field loss secondary to eyelid droop.  Findings:  The physician reviewer found that based on the records provided for review, this patients eyelids constitute an abnormal structure of the body. Specifically, there is dermatochalasia and upper eyelid ptosis of both upper eyelids as documented in the providers notes and confirmed with photographs. These are developmental abnormalities in this patients case as he has developed functional loss of vision as a result of the excess skin of the upper eyelids and of the structures that keep the eyelid at a normal level. These anatomic structures are considered two separate conditions that require different treatments (Older). As noted by Nahai and Behr, upper lid ptosis should always be recorded. If present, it is pointed out to the patient and plans are discussed to correct it at the time of blepharoplasty.  As such, lid ptosis and redundant eyelid tissue can both cause functional problems that are addressed with different procedures. The medical documentation support that this patient has a combination of the two factors: redundant skin of the upper eyelid; and ptosis of the eyelid. The procedures for these two conditions are distinct and each is a separate attempt to improve the patients functional visual field. For these reasons, the requested surgery is reconstructive as it was primarily recommended to improve function and will create a normal appearance to the extent possible as a secondary result.  In summary, the blepharoplasty and ptosis codes should be approved as separate procedures as each is reconstructive in nature and therefore medically necessary. However, there is inadequate support for the canthoplasty, which is generally associated with the lower eyelids and not reconstructive or medically necessary in this patients care.
Appeal type: Medical Necessity
Decision: Overturned

The representative of a 49-year-old male enrollee has requested Botox injections for the treatment of the enrollees condition. Findings:  The physician reviewer found that the patients spasticity is refractory to medications. Botox can be used in selected patients with multiple sclerosis with localized, medically refractory spasticity. The requested Botox therapy is medically appropriate for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned

A 55-year-old female enrollee has requested authorization for Orthovisc injections for treatment of her degenerative joint disease.  Findings:  Three physician reviewers found that repeat series of viscosupplementation (Orthovisc) have been found to be moderately efficacious in those patients who previously had a favorable response to this treatment. The available literature supports repeat injections as long as benefit is achieved. Alternative treatment for end-stage osteoarthritis in the knee would be total joint replacement, which is a significant surgery, not without its own limitations and complications including possible revision and replacement surgery especially in a young patient such as this patient. As long as benefit is being realized from the Orthovisc injections, continuation of yearly injections is appropriate as a stop-gap measure to delay total knee replacement surgery as long as possible.
Appeal type: Medical Necessity
Decision: Upheld

The patient is a 35-year-old female three years post gastric bypass for morbid obesity. She underwent an abdominoplasty with rectus plication in 2003. The patient wishes to undergo revision of the abdominal wall in the upper portion where there remains excess tissue. The Health Plan has denied authorization for the requested procedure on the basis that it is cosmetic in nature and not medically necessary.Clinical information from the operating surgeon and photographs of the patient show an obese female with scars from a prior procedure. These materials fail to indicate evidence of medical necessity for the proposed procedure. There is no evidence of a functional impairment. Based upon the information provided, it appears the requested procedure is cosmetic and not reconstructive in nature. Therefore, I have determined that the requested procedure is not medically necessary for the treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for a colonoscopy. Findings:  The physician reviewer found that American Gastroenterological Association Institute (AGA), and American Society for Gastrointestinal Endoscopy (ASGE) guidelines note that the interval for follow-up repeat screening colonoscopies depends on the findings at the baseline colonoscopy and subsequent colonoscopies. Wilkins and colleagues report that screening colonoscopies performed in accordance with guidelines can prevent colorectal cancer. In this case, pathology findings from a colonoscopy showed one tubular adenoma. In this clinical setting, a repeat colonoscopy is recommended after five years for follow-up of the polyp. Therefore, a colonoscopy is medically necessary for the evaluation of this patient.Final Result: The reviewer determined that the requested service 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 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: Upheld

A 62-year-old male enrollee requested bi-weekly therapy for medical treatment of the his behavioral health condition.  Findings:  The physician reviewer found that the medical documentation submitted for review does not support bi-weekly therapy as the patient has not optimized the therapeutic interventions currently available to him. The status of pharmacotherapy is not clear; psychotropic medications are commonly used in conjunction with psychotherapy to address the biological aspects of an anxiety condition such as panic disorder.  The record indicates that he was not being treated with a U.S. Food and Drug Administration (FDA) approved daily medication for panic disorder.  The patient has been in therapy for eight years and the American Psychological Association states that the large majority of people who suffer from an anxiety disorder are able to reduce or eliminate their anxiety and return to normal functioning after several months of appropriate psychotherapy. The patient also completed an evidence-based therapy for panic disorder, via weekly sessions of adequate duration.  There is a lack of adequately powered studies in the medical literature that supports improved outcomes for bi-weekly versus monthly sessions for patients with panic disorder.  Documentation does not demonstrate that he has regularly followed up with the psychologists recommendations of anxiety skills group, panic drop-in group and couples communication class. In addition, the patients psychologist has not recommended more frequent sessions. In regards to the frequency of therapy, monthly psychotherapy sessions are medically necessary for this patient as this treatment plan represents treatment consistent with good medical practice. Therefore, the request for bi-weekly therapy is not medically necessary for treatment of the patients behavioral health condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested general anesthesia for a dental procedure in an outpatient surgery center for treatment of the enrollees dental condition. Findings: The physician reviewer found that the patient meets medical necessity criteria for general anesthesia in an operating room setting for his dental procedure. General anesthesia is often employed to facilitate extensive dental treatment particularly in younger pediatric patients, such as this patient, who do not have the psychological or emotional maturity required to cooperate in an office setting. The combination of an inability to cooperate and a need for an extensive dental procedure makes general anesthesia an appropriate treatment modality for pediatric patients. Because dental restoration under general anesthesia does not require cooperation from the child it is a very efficient treatment modality. It can usually be completed in one procedure. In this case, the patient has met the criteria as outlined in the medical record: use of in office conscious sedation was not feasible based on the medical needs of the patient. For these reasons, administration of general anesthesia in an outpatient surgery center setting is medically necessary and appropriate in this case.  Final Result: The reviewer determined that the requested service is medically necessary for treatment of the patients dental condition. Therefore, the Health Plans denial should be overturned.  Credentials/Qualifications: The physician 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: Experimental/Investigational
Decision: Overturned

A thirty-six year-old male diagnosed with grade III anaplastic astrocytoma is requesting authorization for magnetic resonance spectroscopy (MRS).  The patient has also had radiation therapy and is receiving ongoing chemotherapy.  (MRS) has been utilized previously for this patient.  Reviewers Findings:The reviewing physicians found that anaplastic astrocytoma is a life-threatening disorder and that the request is medically indicated for a patient such as this one for optimal treatment. MRS is not considered experimental or investigational in this instance and is superior to other diagnostic modalities in its ability to discern the metabolic pattern of an active tumor.  Therefore, the Health Plan denial should be overturned.
Appeal type: Medical Necessity
Decision: Upheld

The patient is a 17-year-old male with an extensive history of mental illness, behavioral problems, and chemical dependence. He has had two acute inpatient psychiatric admissions. He had intensive outpatient treatment, partial hospitalization treatment, outpatient therapy, and has been diagnosed as having depression, polysubstance dependence, and possible post-traumatic stress disorder (PTSD). He was admitted to a residential treatment facility in August 2005 due to combative behavior at home, running away, and failing outpatient treatment. The primary goals to be addressed were his family conflict, chemical dependence, and self-isolating, self-destructive behavior. The patient was evaluated at the residential treatment facility, received family therapy, medical management, and individual treatment. The patient adjusted well to the structure of the facility, and was engaged and involved in his treatment. The patient has not been suicidal, homicidal, psychotic, aggressive or out of control.At issue in this case is whether residential treatment services after August 2005 were/are medically necessary for treatment of the patients behavioral health problems.After a detailed review of the submitted clinical records there is no documentation in the patients progress notes, session notes, call logs, and notes by the psychiatrist, demonstrating that the patient was aggressive or not in control of his behavior as of August 2005. There is no evidence that the patient was psychotic or unable to care for himself as of that time. Furthermore, the patient was not actively suicidal or homicidal or at any imminent or immediate risk of harming himself or others.The session notes as well as progress notes are devoid of any information that would support the need for continued stay in the residential treatment facility beyond August 2005. The patient could have been treated at a less intensive level of care as of that date. Therefore, I have determined the services at issue were/are not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld

A 50-year-old male enrollee has requested the prescription medication Malarone for his malarial prophylaxis. Findings:  The physician reviewer found that the patient sought prophylaxis against malarial disease several weeks in advance of his travels. The recommended prophylactic treatment for malarial disease in that region of the world is either doxycycline or Malarone started prior to travel and continued during the travel period. Doxycycline is a formulary medication under the Health Plan. The patient does not appear to have an adverse history or allergy to doxycycline. While he did require prophylactic treatment against Malarial disease while traveling to the above named areas of the world, the formulary medication doxycycline is an acceptable and equivalent medication option. Treatment with Malarone appears to have been a matter of preference, not a medical necessity.
Appeal type: Medical Necessity
Decision: Upheld

The parent of a five-month-old female enrollee has requested Synagis for treatment of the enrollees prematurity to protect against respiratory syncytial virus (RSV).  Findings:  The physician reviewer found that the American Academy of Pediatrics (AAP), the Centers for Disease Control (CDC), and the American Committee on Immunization Practices, have invested a substantial amount of resources into determining which infants would most likely benefit from treatment with palivizumab (Synagis). The current recommendations are based on the evidence that demonstrates which children are most likely to be hospitalized with RSV. The majority of infants who are hospitalized with RSV have multiple risk factors, including prematurity and lung disease and/or heart disease. This patient does have a history of moderate prematurity but she does not have any other risk factors such as chronic lung or heart disease. Moderate prematurity alone is a risk factor when it is associated with being younger than three months old during the RSV season and having an exposure that would substantially increase the likelihood that the infant will be exposed to RSV. This patient was four months old at the start of RSV season and although she has a twin sister at home, her sister does not represent an increased risk for exposure to RSV. Therefore, there is no clinical indication for her to receive Synagis and the requested vaccination is not supported as medically necessary.
Appeal type: Medical Necessity
Decision: Overturned

A 59-year-old female enrollee has requested acupuncture services for the treatment of her condition. Findings:  The physician reviewer found that the patient may have had eight prior acupuncture treatments for the same above complaints. A request by the patient's primary care physician for acupuncture treatment was denied as being not medically necessary or a benefit of the Health Plan. The use of acupuncture for the treatment of this patient's condition is a viable method of treatment and may be of benefit to the patient. Because the Health Plan does not indicate a recommended alternative service at this time, and the patient's primary care physician is requesting the acupuncture treatment, a course of eight visits at a frequency of twice a week could be considered.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested breast tomosynthesis for evaluation of her medical condition. Findings: Two 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. However, in this particular patient, there were no problems to be resolved. Specifically, the patient did not have dense breasts, she did not have a mass, there were no palpable lumps, and she did not have suspicious calcifications. A routine mammogram would have been sufficient. Tomosynthesis has not been shown to provide significant increased value in patients who do not have dense tissue that could obscure an abnormality, especially when there have been no changes when compared to prior studies over 12 years. Thus, in this clinical setting, the use of the digital breast tomosynthesis was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.  Final Result: Two reviewers determined that the diagnostic procedure 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: All three physician reviewers are board certified in diagnostic radiology and are actively practicing. All three reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the corneal collagen cross-linking. Keratoconus is caused by a structural abnormality in the collagen of the cornea, wherein the cornea becomes progressively misshapen over time. Eventually, this may develop into failure of the cornea, with intractable edema and permanent loss of vision. The classic treatment for keratoconus-induced visual decline is a corneal transplant, which places patients at risk for significant complications. Corneal collagen cross-linking has been studied extensively and is now considered part of the standard of care for patients with progressing keratoconus. As compared to a corneal transplant, corneal collagen cross-linking has little to no risk. In this patients circumstance, the use of corneal collagen cross-linking was indicated to address the patients progressive condition. Accordingly, the corneal collagen cross-linking was likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.One reviewer found that the corneal collagen cross-linking was not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: Two of the three reviewers determined that the services at issue were 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:  One reviewer is board certified in ophthalmology and is actively practicing. One Reviewer is board certified in ophthalmology and is actively practicing.  One Reviewer is board certified in ophthalmology and is actively practicing.  All three reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.