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

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for the magnetic resonance imaging (MRI)of the enrollees lumbar radiculopathy status post lumbar fusion. Findings:  The physician reviewer found that while the patient continues to report low back pain and right radicular symptoms the provided records do not document an adequate trial of conservative management after the removal of the lumbar screws from the patients prior fusion. The provider indicates that anterior lumbar interbody fusion (ALIF) has been considered since the patient has not significantly improved following the screw removal. However, the patient does not have a history of fever to indicate infection, or neurological deficit or other red flag to support an indication for immediate imaging with MRI. Overall, the criteria for the lumbar spine MRI rendered was not medically necessary for evaluation of this patients medical condition absent a trial of conservative management. Final Result: The reviewer determined that the diagnostic procedure at issue was not medically necessary for evaluation of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in diagnostic radiology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld

 A 47-year-old female enrollee requested magnetic resonance imaging (MRI) of the breast (CPT  77058) for medical evaluation of the enrollees left breast swelling.  Findings:  Two physician reviewers found that applying the American College of Radiology (ACR) guidelines, the requested breast MRI is not likely to be more beneficial for evaluation of this patients medical condition than available standard therapies. The records do not indicate the patient is at high or intermediate risk categories. The mammogram report states the breasts are average density and there is no documentation of a family history of breast cancer. Screening breast MRI is recommended in patients at high risk for breast cancer on the basis of family history. All told, the requested breast MRI is not supported as likely to be more beneficial for evaluation of this patients medical condition than any available approach.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary:  The parent of an enrollee has requested fusionless spine surgery (pediatric spinal tethering for treatment the enrollees medical condition.    Findings:  Two physician reviewers found that fusionless spine surgery (pediatric spinal tethering) is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. There is a lack of sufficient support in the peer-reviewed literature for the requested services in this clinical setting. According to Samdani and colleagues, vertebral body tethering offers a fusionless treatment option for skeletally immature patients with adolescent idiopathic scoliosis. However, the study concluded that longer term follow-up of this cohort will reveal the true benefits of this promising technique. Moreover, anterior of posterior fusion scoliosis surgery remains the gold standard scoliosis procedure at this time. In sum, there is a lack of long-term outcomes data to determine the safety and efficacy of fusionless scoliosis surgery. In addition, complications and long-term outcomes remain unknown.   Final Result: Two reviewers determined that the requested services are not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld.  Credentials/Qualifications: One reviewer is board certified in pediatrics and is actively practicing. Two reviewers are board certified in orthopedic 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 21-year-old female enrollee has requested reimbursement for single proton emission computed tomography (SPECT) for evaluation of psychiatric conditions.  Findings:  Three physician reviewers found that current literature does not support the use of SPECT in the diagnosis and treatment of major depression, anxiety or agoraphobia. There are no multi-centered, researched-based, studies showing the usefulness of SPECT for this application. SPECT is still considered an investigational and experimental diagnostic procedure according to the latest literature and community standards of psychiatric practice.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary:  The parent of an enrollee has requested psychiatric residential treatment center (RTC) services for treatment of the patients behavioral health condition.   Findings:  The physician reviewer found that the residential treatment center services were not and are not medically necessary for treatment of the patients medical condition. The patient had previous treatment at a program where, according to his therapist at the program, he made good gains, and developed insight, was motivated, and made progress. The recommendation was made that he not return home to live with his family immediately, so that he could consolidate the gains already made. The suggestion was made for him to attend a residential treatment program or a therapeutic boarding school. There is a difference between the two settings. A residential treatment program is required to provide nursing/medical treatment 24 hours each day, seven days a week. A therapeutic boarding school provides structure and some treatment during the day, but only limited supervision at night. Based on the documentation submitted for review, the patient continued to have a positive attitude and did not require 24 hour nursing or medical care.  In sum, the patient could have been safely treated at a lower level of care such as a therapeutic boarding school with outpatient therapy.  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 with sub-specialty certification in child and adolescent psychiatry and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

A 38-year-old female enrollee has requested psychoanalysis and medication management for treatment of her behavioral health problems. Findings:  The physician reviewer found that the patient had recalcitrant illness with diagnoses of bulimia nervosa, depression, and anxiety. She had been treated for many years by the same psychiatrist. The literature indicates that cognitive behavioral therapy (CBT) is an appropriate modality in this setting (Mitchell and colleagues). It is not clear from the records provided whether CBT was utilized by her psychiatrist in this case.The submitted evidence indicates the patient declined higher levels of care on numerous occasions. In addition, medication compliance appears to have been questionable. There is no clear medical record documentation that any of her medication regimens or therapies drastically stabilized her mood, anxiety or eating disorder symptoms. According to the legible parts of the records, it does appear that some degree of character pathology is present. Axis II character pathology could also explain why the patients medications have been ineffective in amelioration of her symptoms. Furthermore, the patient had been in treatment with her psychiatrist for many years; an enmeshed therapist-patient relationship often occurs in long-term intense psychotherapeutic relationships, especially with Axis II patients, and can impede therapeutic progress.In summary, there is inadequate evidence of therapeutic effect in this case. Based on the submitted treatment notes, which are mostly illegible, it has not been demonstrated that the patients past therapy was having a positive effect on her illnesses.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a 12-year-old female enrollee has requested Norditropin 15mg/1.5mL for treatment of the enrollees severe short stature. Findings:  The physician reviewer found that the treating physician reasonably requests a trial of GH therapy since this patients short stature without successful treatment would by any criteria be handicapping. Although the Health Plan originally indicated that growth hormone therapy was not medically necessary based on the clinical documentation provided, most recently the Health Plan has indicated that the specific GH requested (norditropin) is not medically necessary because there is no documentation of treatment failure or intolerance to Nutropin, Nutropin AQ, or Saizen, which are formulary medications. The use of GH is medically necessary for the treatment of this patient and this patient has already tried another Genotropin and had an adverse reaction but is tolerating Norditropin well. Thus, I concur that Norditropin is medically necessary for this patient on the basis of intrauterine growth restriction (IUGR) which did not catch-up, and on the basis of idiopathic short stature as the patients adult height prediction is well below the FDA cut-off for treatment.
Appeal type: Urgent Care
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the services on an emergent basis or urgent basis. Findings:  The physician reviewer found  a prudent layperson would not have sought immediate medical attention. Based on the records provided the patients presentation during the dates in dispute was not consistent with the above definition of an emergency medical condition. The patient presented with a long history of back pain. There is a lack of clinical documentation demonstrating that the patient presented with acute symptoms of sufficient severity such that the absence of immediate medical attention could reasonably be expected to result in placing the patients health in serious jeopardy. There is no documentation submitted showing the patients pain rating severity. In addition, acute intervention was not warranted. Based on the patients presenting complaints and symptoms, a prudent layperson in this circumstance would not reasonably believe he was suffering from a serious medical condition. In sum, the patient was not suffering from a serious medical condition that was likely to place the patients health in serious jeopardy, cause serious impairment to body functions or cause serious dysfunction to a body organ or part. Thus, the services did not meet prudent layperson criteria for emergency care.Further, it has not been established that criteria for urgently needed services were met on the date in dispute. The patient presented with a long history of cervical complaints. The records document multi-level central spinal and neural foraminal stenosis. However, there is a lack of documentation supporting that the services at issue were necessary to prevent serious deterioration of the health of the patient for which treatment cannot be delayed until the she returned to the Plans service area. Based on the documentation submitted for review a prudent layperson in a similar situation would not have believed urgent medical attention was necessary to prevent serious deterioration of ones health. In sum, based on the patients clinical presentation during the dates in dispute the patient did not meet prudent layperson criteria for urgently needed services.Final Result: The reviewer determined that the patients symptoms did not meet prudent layperson criteria for emergency care or urgently needed services. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in orthopedic surgery and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld

Findings:  The physician reviewer found that An enrollee has requested authorization and coverage for functional neuromuscular electrical stimulation ergometer (RT300-FES Therapy System). The records provided for review document that this patient sustained a complete mid-thoracic level traumatic spinal cord injury. The mainstay of rehabilitation and long-term management for this patient population focuses on functional restoration at a manual wheelchair level and on health maintenance including pain management, tone management, and preventive clinical care (Ong, et al.). In addition, active exercise and participation in educational, social, recreational, and vocational activities should be encouraged (Tweedy, et al.). However, there is a lack of support for use of a functional electrical stimulation cycle ergometer to provide a clinically meaningful benefit in this patients scenario. The available data published in the peer-reviewed literature have not demonstrated that use of a functional neuromuscular electrical stimulation ergometer improves cardiovascular, pulmonary, bony, or other health parameters (Nardone, et al.; Soleyman-Jahi, et al.). The device has not been found to promote neurological recovery beyond natural recovery in a clinically appreciable manner (Hofer and Schwab). Therefore, the requested functional neuromuscular electrical stimulation ergometer (RT300-FES Therapy System) is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Findings: Two of the three physician reviewers found the requested functional neuromuscular electrical stimulation ergometer (RT300-FES Therapy System) is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the requested device is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for laparoscopic anti-reflux surgery utilizing LINX Reflux Management System for treatment of the her gastroesophageal reflux disease (GERD).  Findings:  Three physician reviewers found that The peer-reviewed literature does not definitively support the conclusion that LINX is likely to be more beneficial in this case than standard treatment. There is a lack of randomized controlled trials comparing LINX with Nissen fundoplication or other surgical anti-reflux procedures. Adverse events, such as erosion through the esophagus, have been reported in the period after U.S. Food and Drug Administration (FDA) approval. Additionally, LINX is associated with severe dysphagia requiring endoscopic intervention. The American College of Gastroenterology guidelines for the management of reflux disease also state that more evidence is needed before LINX can be recommended. Final Result: The reviewers determined that the requested surgery is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: Reviewer 1, 2, and 3 are board certified in internal medicine with sub-specialty certification in gastroenterology 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: Experimental/Investigational
Decision: Upheld

A 64-year-old female enrollee has requested  radiofrequency ablation of the right sacroiliac (SI) joint for treatment of her low back pain and SI pain.  Findings:  Three physician reviewers found that radiofrequency ablation of the right SI joint is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. In this case, there were no provocative maneuvers reported on physical exam. The pain over the SI joint is described as right parasacral muscular tenderness, which could account for the pain independent of the SI joint. In addition, there are no supporting x-rays or imaging submitted for review. In sum, the documentation submitted for review does not support the use of radiofrequency ablation in the patient at this time. Therefore, the requested services are not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for methadone. The current guidelines do not support the use of long acting opioid therapy for chronic non-cancer pain. According to the Centers for Disease Control and Prevention (CDC) guidelines, methadone is not recommended as a first-line opioid for the treatment of non-cancer pain. The Federation of State Medical Boards (FSMB) guidelines state that the Continuation, modification or termination of opioid therapy for pain is contingent on the clinicians evaluation of (1) evidence of the patients progress toward treatment objectives and (2) the absence of substantial risks or adverse events, such as signs of substance use disorder and/or diversion. This patient has chronic neck and back pain with a history of Chiari malformation treated with surgical repair several years ago. Treatment has included high dose methadone for chronic pain. The patient was tapered off methadone and she was transitioned to Percocet. She states that Percocet has not been as effective for managing her pain as methadone. Her physical examination and MRI of cervical spine are unremarkable for any acute changes. She has a history of chronic depression and suicidal ideation, which has been exacerbated due to the recent loss of her pet. The presence of psychiatric comorbidities place the patient at higher risk for self-harm. As the risks of treatment outweigh the potential benefit, the requested methadone is not medically necessary for treatment of this patient. 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 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: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement and prospective authorization and coverage for supplemental oxygen and prospective authorization and coverage for an in-home sleep study. Findings:  The physician reviewer found that supplemental oxygen is used in the treatment of various clinical disorders, both respiratory and non-respiratory; relief hypoxia, treatment of pulmonary hypertension, polycythemia secondary to hypoxemia, chronic disease states complicated by anemia, cancer, migraine headaches, coronary artery disease, seizure disorders, sickle-cell crisis, and sleep apnea.  In this case, the documentation submitted for review does not support the need for supplemental oxygen.  The cardiac and respiratory examinations were unremarkable.  His oxygen saturation was 96%, and there was no documentation of abnormal laboratory studies or underlying comorbid conditions that would require oxygen.  Thus, the medical necessity for supplemental oxygen is not demonstrated.  The patient is requesting an in-home sleep study.  Home sleep apnea testing should only be used for the diagnostic evaluation of suspected obstructive sleep apnea in patients with a high pre-test probability of having moderate to severe obstructive sleep apnea and no comorbid medical or sleep disorders.  In this case, the patient has pulmonary fibrosis and paralysis of the left hemidiaphragm.  He does not meet criteria for in-home testing.  All told, the requested supplemental oxygen from the date of service in question forward was not and is not medically necessary for the treatment of this patient.  Additionally, the requested in-home sleep study is not medically necessary for the evaluation of this patient. Final Result: The reviewer determined that the services at issue were not and are not medically necessary for evaluation and treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The physician reviewer is board certified in internal 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: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Cialis 5 mg, daily. Findings: The submitted documentation supports the medical necessity of the requested medication quantity. Cialis tadalafil 5 mg once daily is an option for the treatment of men with erectile dysfunction. In two recent studies, treatment with tadalafil once daily improved erectile function in men with mild-moderate impairments in erectile function following failed as needed or on demand phosphodiesterase type 5 inhibitor treatment. This patient has failed to respond to prior medications, and he reported benefit with daily Cialis. As such, use of Cialis 5 mg daily is medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested medication quantity 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 urology 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.