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

Nature of Statutory Criteria/Case Summary: An enrollee has requested magnetic resonance imaging (MRI) of the knee for evaluation of her medical condition.Findings: The physician reviewer found that the submitted documentation and relevant literature demonstrates the medical necessity of the requested services. MRI of the knee as recommended by the treating orthopedist is indicated to determine whether an arthroscopic debridement of the joint is likely to be beneficial versus a more extensive procedure such as total knee arthroplasty. The utilization of both x-ray and MRI is a standard approach in making an appropriate clinical decision as to whether a meniscal debridement or removal of loose bodies may provide a likely benefit and follows the standards of care. In addition, MRI in the face of degenerative osteoarthritic conditions is indicated in order to assess not only the joint surfacing but also the adjacent subchondral bone to rule in or out occult fractures or bone marrow bruises with bone marrow MRI changes. Given the above, MRI of the knee has been established as medically necessary for treatment of the patients medical condition.Final Result: The reviewer determined that the requested services are medically necessary for evaluation of the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The physician 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

A 53-year-old female enrollee has requested lumbar fusion for treatment of her spondylolisthesis of L4-5.  Findings:  The physician reviewer found that this patient has chronic back pain and her pain generator has not been adequately identified. She has abnormal findings on studies, but none of them correlate to her various symptoms. In addition, her imaging studies show no motion with flexion and extension views. Further, she has no evidence of instability, rapidly progressive neurologic condition, recent trauma, fracture, infection, tumor, or cauda equina syndrome, which may be an indication for spinal fusion according to the medical literature. Thus, the proposed spinal fusion is not medically necessary for treatment of this patients medical condition.
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 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 case, considering the asymmetry and dense nature of her breasts, an initial breast tomosynthesis was indicated.  Following the original study, it was recommended the patient have additional views as well as a sonogram.  The sonogram did demonstrate several benign appearing nodules and cysts.  However, there is a lack of support for a requested second breast tomosynthesis.  While the first tomosynthesis was indicated due to the heterogeneously dense nature of her breasts and the asymmetry, the second breast tomosynthesis was not likely to have been more efficacious than other methods of evaluating this patient. Final Result: Two reviewers determined that the services at issue were 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 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: Medical Necessity
Decision: Upheld

A 64-year-old male enrollee, with an extended history of back and cervical pain, has requested authorization for axial decompression therapy with the DRX-9000. Findings:  The physician reviewer found that the transient reduction of disc pressure has never been definitively shown to correlate with long-term relief of low back pain. There is no convincing evidence that this treatment modality is efficacious. Axial decompression therapy is not the standard of care in managing degenerative back discomfort.
Appeal type: Medical Necessity
Decision: Upheld

A 55-year-old male enrollee has requested for a liver transplant for treatment of his hepatocellular carcinoma. Findings:  The physician reviewer found that the medical records document this noncompliance with liver transplant requirements.   Although his diagnosis of liver cancer should give him priority in receiving a donor liver, his active drug use and noncompliance should exclude him from listing.
Appeal type: Medical Necessity
Decision: Upheld

A female enrollee requested an eight-week course of Harvoni 90/400 mg for medical treatment of her hepatitis C virus, genotype 3a.  Findings:  Three physician reviewers found thatreview of the submitted documentation fails to establish the medical necessity of the requested medication. Harvoni is not indicated for the treatment of HCV, genotype 3. According to the American Association for the Study of Liver Diseases (AASLD) and Infectious Diseases Society of America (IDSA) recommendations for treatment of HCV, the combination of sofosbuvir and weight-based ribavirin for 24 weeks is the preferred treatment regimen for patients with genotype 3 infection. For these reasons, the requested medication is not medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for facial Botox injections. Mehta and colleagues note that temporomandibular disorders (TMD) are associated with substantial morbidity, affecting quality of life and work productivity, and that the goals of TMD management are to alleviate pain and to improve jaw function and quality of life. The authors further explain that standard noninvasive management includes self-care and education, physical therapy, occlusal splints, behavioral therapy, and adjunctive pharmacotherapy, while for patients with TMD symptoms refractory to noninvasive management, treatment options may include trigger point muscle injections, botulinum toxin injections, intra-articular injections, or, in some patients, surgery such as arthrocentesis, arthroscopy, arthroplasty, or temporomandibular joint (TMJ) reconstruction. Awan describes botulinum toxin (Botox) as an exotoxin produced from Clostridium botulinum that blocks the release of acetylcholine from the cholinergic nerve end plates resulting in inactivity of the muscles or glands innervated. In a review of the current evidence pertaining to Botox use in non-cosmetic head and neck conditions, the author reported findings showing evidence of the efficacy of Botox in the treatment of TMJ disorders. Abdi explains that complex regional pain syndrome (CRPS) remains a relatively mysterious chronic pain disorder, characterized by pain in an area that is disproportionate in time or degree to the usual course of any known trauma or other lesion. The author notes that a multidisciplinary approach is suggested for the management of CRPS, with appropriate interventions including physical therapy, occupational therapy, pharmacotherapy, psychosocial and behavioral therapy, and, for patients with refractory pain, trigger/tender point injections and regional sympathetic nerve block. The author does not mention Botox as a typical treatment modality for CRPS. In this case, the patient has a TMJ disorder and CRPS that developed after double jaw surgery, and the provider has recommended a trial of Botox into the masseter muscles to address the patients TMJ disorder. Given that current medical literature supports the efficacy of  Botox in TMJ disorders, the requested services are medically indicated. Therefore, facial Botox injections 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 neurology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Acthar gel.Findings: A research team was formed to comprised of rheumatologists, neurologists and dermatologists to establish a multidisciplinary treatment consensus to standardize patient care for patients with polymyositis (PM) and dermatomyositis (DM). According to their treatment consensus, the first line treatment for polymyositis is glucocorticoids for remission induction. According to the consensus statement, immunosuppressants can be given to patients who are resistant to glucocorticoids. Immunosuppressants are also useful to assist with the tapering of glucocorticoids. Under the consensus statement, immunosuppressants which can be utilized for the treatment of polymyositis include tacrolimus, cyclosporine, CellCept, methotrexate and azathioprine. IVIG can be used in refractory cases, and biologic agents such as rituximab can also be utilized.In this case, the patient had demonstrated ongoing polymyositis symptoms manifested by flares of muscle weakness, increased creatine kinase (CK), inflammatory arthritis and mechanics hand. Based upon the submitted documentation, the patient has been unable to taper and discontinue prednisone due to these symptoms. Records also reflect that the patient attempted and failed to respond to several immunosuppressants/steroid sparing agents including cyclosporine, tacrolimus, CellCept, and methotrexate. The patient also developed an infusion reaction when attempting rituximab therapy for polymyositis. The patient has been on IVIG with continued polymyositis symptoms and has been unable to taper off prednisone. There is no indication in the submitted records, however, that the patient has utilized azathioprine, which was supported by the consensus statement, as a steroid sparing agent in the treatment of their polymyositis. Furthermore, the use of Acthar Gel is not supported by the consensus statement. There is very limited data to support the use of Acthar Gel in the treatment of polymyositis. Accordingly, the requested Acthar gel is not medically necessary for the patients medical condition.Final Result: The reviewer determined that the requested medication is not medically necessary for the patient's medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is board certified in internal medicine, with subspecialty certification in rheumatology, 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 authorization and coverage for gene testing. Findings:  The physician reviewer found that the patient has a history of longstanding shoulder winging and a first degree relative with facioscapulohumeral muscular dystrophy (FSHD). On examination, the patient reported shoulder weakness. The patient described symptoms that were consistent with a diagnosis of FSHD.  The patients provider requested genetic testing to ensure the patients diagnosis and guide clinical treatment. There is sufficient support in the medical literature for the efficacy of the requested services in this clinical setting. Genetic testing is the gold standard and is considered standard of care when diagnosing FSHD. This patients provider would need to obtain the correct diagnosis for this patient in order to guide management, provide therapeutic options, give proper counsel, and to arrange for the most appropriate multisystemic disease monitoring. Furthermore, gene testing could end the diagnostic work-up for this patient if tested negative. But if the patient tested positive, additional etiologies for the patient's symptoms could be explored. Gene testing would significantly improve the ability to effectively manage this patient. If the patient has FSHD, arrangements for hearing, cardiac, and visual disease monitoring would be different than if FSHD is not present.  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: the physician reviewers are board certified in neurology 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: Experimental/Investigational
Decision: Upheld

A 51-year-old male enrollee has requested surgery using the LINX procedure for treatment of his laryngopharyngeal reflux.  Findings:  Two physician reviewers found that treatment with fundoplication is supported with numerous studies and clinical data demonstrating the efficacy and durability of the procedure. However, evidence on the LINX procedure remains premature with the best data coming from a cohort series published by Ganz and colleagues. There is a paucity of scientific data that the LINX procedure is as efficacious or superior compared to hiatal hernia repair with fundoplication. An appropriately randomized, controlled, comparative clinical trial including optimal medical therapy or traditional hernia repair with fundoplication has not been performed. All told, the requested LINX procedure is not likely to provide this patient with an improved health outcome when compared with standard therapies.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/ Case Summary: This is a patient with idiopathic short stature (ISS). The patient underwent a growth hormone stimulation test with L-dopa and Inderal that peaked at 17 and 5.5. At issue is whether the Humatrope for ISS is medically necessary to treat the patients medical condition. Growth hormone in the treatment of ISS is supported by randomized controlled trials and consensus guidelines. Federal Drug Administration approval for this indication is for non-growth hormone-deficient short stature, defined by height standard deviation 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. This patient has a pretreatment height less than or equal to -2.25 standard deviations. The patients height velocity is not adequate to allow a height in the normal range. Other causes of short stature have been ruled out. The patient meets nationally accepted criteria for the use of growth hormone for ISS.  Final Result: The reviewer determined that the requested service is 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: Upheld

A 30-year-old female enrollee requested authorization and coverage of a hysterectomy. The Health Plan denied the request indicating that the requested procedure is not medically necessary for treatment of the enrollees abdominal pain.One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer upheld the Health Plans denial on the basis that the requested procedure is not medically necessary.
Appeal type: Experimental/Investigational
Decision: Overturned

The parent of a 17-year-old male enrollee requested positron emission tomography (PET) with computed tomography (CT), skull base to thigh (CPT code 78815) for evaluation of the enrollees Burkitts lymphoma.  Findings:  Two physician reviewers found that the diagnostic procedure at issue was likely to have been superior over other modalities.  PET/CT scans are an effective method of evaluating patients with lymphoma.  Per the current medical evidence, a minimum of three years surveillance with PET/CT is recommended in this clinical setting.  There is sufficient support for the diagnostic procedure.  Therefore, PET/CT, skull base to thigh (CPT code 78815 was likely to have been more efficacious than other available methods for evaluating this patient.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for a Dynasplint.  The Health Plan has denied this request indicating that the requested equipment is not medically necessary for treatment of the enrollees medical condition. The submitted documentation fails to demonstrate the medical necessity of the requested equipment. In this particular case, there is no documented evidence that this patient has undergone recent orthotic treatments. The records do not document home stretching exercises for the plantar fascia, physical therapy, local steroid injection to symptomatic painful heel area, over-the-counter orthotic therapy, or anti-inflammatory medications. All of the above-mentioned treatments are first-line standard of care treatments for plantar fasciitis. Dynasplint devices may be used to help alleviate significant painful contractures of multiple areas of the body, including the lower extremity, foot and ankle. However, Dynasplint devices are not considered first-line treatment for painful plantar fasciitis. All told, the requested Dynasplint is not medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested equipment 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 podiatry 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 authorization and coverage for bi-level positive airway pressure (BPAP) machine. Findings:  The physician reviewer found that based on the current medical literature and the presented clinical records, the BPAP machine to be provided is medically necessary for evaluation of the patients medical condition. The patient presents with mild obstructive sleep apnea and development of central apneas while undergoing standard CPAP titration. The patient was switched to BPAP to complete titration with no further central apneas and AHI reduced to 0. The patient was initially having problems with BPAP compliance due to face mask issues, but she was appropriately treated with nasal pillows with chin strap. In this case, continued use of the BPAP machine is medically necessary based on polysomnogram findings with central apneas and compliance greater than 4 hours per night. For the reasons provided, the requested device is medically necessary for treatment of the patients medical condition. Final Result: The reviewer determined that the requested device is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The physician reviewer is board certified in internal medicine with sub-specialty certification in pulmonary disease and critical care 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 69-year-old male enrollee requested magnetic resonance imaging (MRI) of the knee for medical evaluation of the enrollees knee pain.  Findings:  The physician reviewer found that the current medical evidence does not support the MRI of the knee in this patients case.  Per the medical records, there were no red flags to indicate immediate MRI imaging.  There was no evidence of effusion, ligamentous laxity on physical examination, fever, or abnormal equivocal findings on plain films prior to the study.  National Imaging Associates guidelines do not support the diagnostic procedure at issue in this clinical setting.  All told, the MRI of the knee was not medically indicated for the evaluation of this patient.
Appeal type: Medical Necessity
Decision: Overturned

An 18-year-old female enrollee has requested for inpatient rehabilitation treatment for treatment of her bulimia.  Findings:  The physician reviewer found that this patient has had several previous hospital admissions for treatment of diabetic issues associated with her eating disorder. However, she has made substantive progress in the residential facility.This patient did require several additional days of residential treatment to more fully integrate her diabetic management with treatment of her bulimia. Her diabetes complicates her bulimia and without full recognition of this facet of the patients pathology, the gains she had made would be jeopardized.
Appeal type: Medical Necessity
Decision: Upheld

A 53-year-old female enrollee has requested Synvisc injections to her left knee for the treatment of her knee pain. Findings:  The physician reviewer found that this patient has osteoarthritis of the knee that is very painful.  Although she had tried several medications to reduce her symptoms, there is no evidence of any cortisone injections. A trial of cortisone injections prior to proceeding with Synvisc injections is medically reasonable and appropriate.