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

Nature of Statutory Criteria/Case Summary: An female enrollee has requested authorization and coverage for magnetic resonance imaging (MRI) of the neck for evaluation of the enrollees neck pain. Findings:  The physician reviewer found that the documentation submitted for review does not support a medical indication for MRI. MRI of the cervical spine is not indicated unless the patient has undergone a documented six-week trial of physical therapy and anti-inflammatory medicine. There is no documentation showing that the patient has undergone physical therapy. In addition, AIM Specialty Health guidelines recommend a plain x-ray of the cervical spine prior to having a MRI. The medical records do not indicate that this has been performed. Thus, the patient does not meet criteria for a cervical spine MRI. Final Result: The reviewers determined that the requested diagnostic procedure is 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: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for acupuncture. The submitted documentation and medical literature support the present request for acupuncture. In a 2007 study of the efficacy of acupuncture in myofascial pain syndrome, Ga and colleagues concluded that there was no significant difference between acupuncture needling and 0.5% lidocaine injection of trigger points for treating myofascial pain syndrome. In a 2009 study, researchers investigated the remote effect of acupuncture on the pain intensity recorded from a myofascial trigger point of the upper trapezius muscle, and their results were that the pain intensity in the myofascial trigger point was significantly reduced after remote acupuncture, but not after sham acupuncture. In a subsequent 2011 study involving the remote effect of acupuncture in the upper trapezius muscle, Chou and colleagues found that immediately after acupuncture, all measured parameters improved significantly, but not in the placebo control group. In this case, there is no indication that the patient has yet undergone an acupuncture trial. Given that the patient continues to be significantly symptomatic despite previous care (oral medication), acupuncture for pain management and function improvement would be reasonable and is supported by the peer reviewed literature. Under these circumstances, acupuncture services are medically necessary for treatment of the patients medical condition.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 a licensed acupuncturist and a doctor of oriental medicine. 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 70-year-old male enrollee has requested for a robotic-assisted radical prostatectomy for treatment of his prostate cancer.      Findings:  The physician reviewer found that laparoscopic radical prostatectomy has advantages over conventional radical prostatectomy and has become the preferred surgical option. Laparoscopic radical prostatectomy can be performed with or without robotic assistance. There are no documented advantages to robotic-assisted laparoscopic prostatectomy versus conventional laparoscopic prostatectomy with appropriate experience and training.
Appeal type: Medical Necessity
Decision: Upheld

A 64-year-old female enrollee requested authorization and coverage of blepharoplasty of the left eye. The Health Plan  denied the request indicating that the requested procedure is not medically necessary for treatment of the enrollees impaired vision.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

A 51-year-old female enrollee has requested brachytherapy with Mammosite RTS for the treatment of her left breast ductal carcinoma in situ. Findings:  Two physician reviewers found that accelerated partial irradiation (APBI) has been used as part of breast conserving treatment for early stage breast cancer for approximately twenty years using brachytherapy catheters. The Mammosite balloon has been used for only eight years, although the radiation physics are very similar to that of brachytherapy. There are several reports of the efficacy of APBI using the Mammosite balloon with five-year outcomes demonstrating efficacy and comparable outcomes to traditional whole-breast irradiation.
Appeal type: Medical Necessity
Decision: Overturned

The representative of a 51-year-old male enrollee has requested inpatient mental health services received for treatment of his frontal temporal dementia.   Findings:  The physician reviewer found that at the time of admission the patient was actively psychotic. Additionally, the patient demonstrated agitated and aggressive behavior and exhibited poor insight and judgment. He also suffered from multiple medical conditions including: dementia, seizure disorder, hypertension, obesity, hypercholesterolemia and hyponatremia, with a serum sodium of 129. The goals of hospitalization were clearly to protect the patient from danger to himself and others due to his psychotic, agitated and aggressive state. His chronic dementia was an exacerbating factor, as it would be expected to further decrease his already limited self control. The treatment plan included the use of antipsychotic medication, Seroquel, as well as the anticonvulsant medication, Depakote, commonly used to decrease agitation in demented patients as well as for the treatment of seizure disorders. It was also a goal of treatment to normalize the patients serum electrolytes, as the hyponatremia noted on admission could well have been another factor adding to his confusion. Medication dosages were adjusted during the hospitalization. The patients mental health was reported to have recently deteriorated from its previous baseline. His inpatient stay included active treatment and the treatment provided could reasonably be expected to result in improvement in his condition. Based upon review of the medical records, the patients inpatient hospitalization for the period in question was medically necessary and consistent with the standard of care for his clinical history and acute presentation.
Appeal type: Medical Necessity
Decision: Overturned

A female enrollee requested custom made foot orthotics for medical treatment of her plantar fasciitis. Findings:  The physician reviewer found that this patients prior treatment has included shoe modifications, oral anti-inflammatory medications, and oral pain medications.  Per the medical records, she continues experience pain.  The current literature demonstrates the effectiveness of custom functional orthotics in the treatment of arch pain, heel pain, and painful plantar fasciitis.  Custom functional orthotics for treatment of painful plantar fasciitis are standard of care in this clinical setting.  All told, the requested custom made foot orthotics are medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: A enrollee has requested authorization and coverage for a computed tomography (CT) scan of the abdomen and pelvis. Findings:  The physician reviewer found that in the medical literature reported that non-contrasted CT is a sensitive imaging modality for the detection of urinary tract calculi and obstruction. Studies concluded that the majority of the patients evaluated required no further imaging to determine the need for urological intervention. Thus, the literature supports the use of ultrasound for the detection of hydronephrosis, and CT has been documented to be effective for the detection of ureteral stone. Thus, further evaluation with non-contrast CT of this patients left renal collecting system dilatation seen on ultrasound is appropriate. Given this support, the requested CT scan of the abdomen and pelvis is medically necessary for evaluation of this patients medical condition. Final Result: The reviewer determined that the requested diagnostic procedure 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 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: Upheld

A 50-year-old female enrollee has requested right knee replacement surgery for the treatment of her right knee osteoarthritis. Findings:  The physician reviewer found that there is no question that this patient has fairly severe arthritis of her right knee and she has had multiple prior knee surgeries. However, the records demonstrate that three individual orthopedists have recommended that the patient not proceed with knee replacement because of an unfavorable risk/benefit ratio. Knee replacement surgery requires a reliable patient who can clearly show that he or she would carry out the rehabilitation program appropriately. The submitted records demonstrate that the patient has had compliance issues with her treatment regimens to date. Therefore, it is highly unlikely that she would be able to meet the demands of a post-operative rehabilitation program at this time. Thus, I agree with the patients orthopedists that the risk/benefit ratio for the requested surgery is extremely unfavorable, and as such, knee replacement surgery is not clinically indicated or necessary for this patient.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for 75 mg of Lyrica two times daily and lidocaine topical ointment 5%. In studying the use of pregabalin for neuropathic pain in adults, Researchers concluded there was limited evidence of benefit in neuropathic back pain or sciatica, neuropathic cancer pain, or polyneuropathy. The North American Spine Societys clinical guidelines concluded, There is insufficient evidence to make a recommendation for or against the use of gabapentin in the treatment of lumbar disc herniation with radiculopathy. The U.S. Food and Drug Administration has not approved the use of Lyrica or lidocaine ointment for the treatment of lumbar radiculopathy. There is a lack of studies evaluating the use of lidocaine ointment for lumbar radiculopathy or related neuropathic pain. In this case, the patient has lumbar radiculopathy with neuropathic pain. As she has tried and failed Elavil, gabapentin, and other conservative nonpharmacologic treatments, the patients provider started her on a trial of Lyrica and lidocaine ointment. However, clinical guidelines do not support the use of Lyrica for lumbar radiculopathy, and there are a lack of studies evaluating the use of lidocaine ointment for lower back pain. Therefore, 75 mg of Lyrica two times daily and lidocaine topical ointment 5% are not medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested medications 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 anesthesiology with sub-specialty certification in pain 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

1The enrollee is requesting authorization and coverage for for Synvisc One injections to both knees. The enrollee has bilateral osteoarthritis of the knees causing pain and swelling. An orthopedic evaluation indicated there was bilateral knee swelling and tenderness, with a positive McMurray and Appley compression sign. The enrollee received Synvisc One injections and reported that, within one to two weeks afterwards, her pain was greatly reduced and she remained pain free for six to eight months. The requested Synvisc One injection is approved by a governmental body for the treatment of knee pain in enrollees who have failed to respond adequately to conservative non-pharmacologic therapy and simple analgesics. Overall, viscosupplementation injections (Synvisc One) are supported as a standard of care for enrollees with knee pain who have failed conservative care. In this case, the enrollee has osteoarthritis in both knees and she has remained symptomatic, despite prior treatment; including medication management, exercise, and corticosteroid injections. Therefore, repeat injections would be medically necessary for symptom relief, and to delay possible surgical interventions.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 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 similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

A 44-year-old male enrollee has requested for inpatient psychiatric care for treatment of his behavioral health condition. Findings:  The physician reviewer found that the submitted evidence demonstrates that the patient was only marginally cooperative upon admission, but clearly emotionally unstable and was not safe to be treated at a less intensive level of care. In addition to his mood disorder, the evidence is suggestive of an Axis II disorder that makes the patient a greater a risk for impulsive acting out behaviors and a safety risk. He has severe functional impairment, as he is unable to perform activities of daily living. He continues to exhibit suicidal ideation.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: At issue is whether the DaT scan was likely to have been more beneficial for the evaluation of the patients condition than any available standard therapy. A review of the records indicated that the patient presented with a history of right extremity upper tremor, rigidity, and clumsiness. The provider documented concern for Parkinsons disease. Previous trials with Sinemet and Ropinirole were unsuccessful due to side effectsFindings:  Two out of three physician reviewers found that in this case, the patients movement disorder specialist did not order the scan for three years after presentation as the patient progressed. The presentation of the patients symptoms was not typical due to the lack of the therapeutic response to dopaminergic agents. Therefore, the DaT scan was likely to have been more beneficial for the evaluation of the patients medical condition than other standard techniques. One out of three physician reviewers found that the management of this patient's symptoms could have otherwise been addressed with the introduction of pharmacotherapy, and this could occur without performance of a DaT scan. Therefore, the DaT scan that was rendered was not likely to have been more beneficial than other methods of evaluating this patient.Final Result: Two out of three of the reviewers determined that the requested DaT scan provided was likely to have been more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: Physician reviewers 1, 2 and 3 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: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for ipratropium bromide solution 0.02%.The requested ipratropium bromide solution 0.02% has been approved by the U.S. Food and Drug Administration and is supported by the medical literature as rescue therapy in COPD. In this case, the patient is a former smoker with COPD, currently managed on Anoro Ellipta, a long-acting beta agonist (LABA) and long-acting muscarinic antagonist (LAMA), and beclomethasone (QVAR), an inhaled corticosteroid (ICS). The patient is also managed with rescue therapy, including a short-acting beta agonist (albuterol), and short-acting muscarinic antagonist via nebulizer (ipratropium bromide solution 0.02%). The patient has been effectively managed with ipratropium bromide solution 0.02% based on an excellent response by clinical history. Thus, the requested ipratropium bromide solution 0.02% is medically necessary for the treatment of the patients medical condition.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 pulmonary disease and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for a total electric bed with a low air mattress. Findings:  The physician reviewer found that review of the submitted documentation and relevant literature fails to demonstrate the medical necessity of the requested equipment. The Centers for Medicare and Medicaid Services (CMS) coverage determination for hospital beds state that The physicians prescription, which must accompany the initial claim, and supplementing documentation when required, must establish that a hospital bed is medically necessary. In this case, there is a lack of documentation supporting the requested equipment. There is no documentation from a provider recommending the requested bed and air mattress. Therefore, the request for a total electric bed with a low air mattress has not been established as medically necessary for treatment of the patients medical condition. 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 physician reviewer 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 20-year-old female enrollee has requested Rituxan for the treatment of her acute cervical myelopathy. Findings:  The physician reviewer found that this patient suffered a devastating transverse myelitis that was treated very aggressively. Her evaluation did not show evidence of multiple sclerosis or neuromyelitis optica (NMO). Longitudinally extensive myelitis is a hallmark of NMO as well as systemic lupus erythematosus. However, in this case there is no mention of NMO antibody positivity, and no evidence of lupus. Nor does the patient have a history of NMO or recurrent myelitis. There are many articles concerning the use of Rituxan in patients with NMO. However, there is a paucity of literature on Rituxan in transverse myelitis. Given the patients stable status and absence of inflammation or enhancement on MRI coupled with the lack of supportive literature, retreatment with Rituxan is not medically necessary at this time. If the patient develops recurrent neurologic symptoms that suggest NMO, the request for Rituxan should be reconsidered.
Appeal type: Medical Necessity
Decision: Overturned

The parent of an 11-year-old male enrollee has requested for weekly therapy sessions for treatment of the enrollees attention deficit/hyperactivity disorder and anxiety disorder, not otherwise specified. Findings:  The physician reviewer found that there is no recent psychiatric evaluation by a child and adolescent psychiatrist, and there is no apparent treatment plan.therapy, even though prior to the psychiatric reassessment, is indicated because there is compelling evidence in the material reviewed indicating that the patient is not improving with the sporadic treatment he is currently receiving. The patients need for higher level (weekly) therapeutic services has been established.
Appeal type: Medical Necessity
Decision: Upheld

The parent of a 16-year-old female enrollee has requested  residential psychiatric treatment services for the enrollees bipolar disorder with psychotic features.  Findings:  The physician reviewer found that the medical records do not document any medication changes or medical issues that required attention. On one occasion, the patient became upset when a peer ordered her to move. She received medication and later went to sleep. This is the only intervention documented during this time period that would have required the presence of a trained staff member. Overall, the patient remained compliant with treatment and made progress. However, there are no documented treatments provided that could not have been provided safely at the PHP level of care. All told, the medical records do not support the medical necessity of the residential psychiatric treatment services provided during the said time frame.