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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for biofeedback training, perineal muscle, anorectal or urethral sphincter for treatment of the enrollees pelvic floor dysfunction. Findings:  The physician reviewer found that found there are a number of causes for obstructed defecation syndrome and pelvic floor dysfunction, including rectocele, rectal intussusception, paradoxical muscular contraction, descending perineum syndrome, sigmoidoceles, or enteroceles. Some of these are structural anatomical issues, but others are functional issues with normal anatomy. If functional abnormalities are present, lifestyle modification and biofeedback therapy can be effective. The American College of Gastroenterology guidelines for the management of benign anorectal disorders recommend anorectal manometry to determine whether a functional disorder is present, and a physical functional performance test, such as a balloon expulsion test, is also warranted when evacuation or outlet disorder is suspected. These have been performed. The medical evidence supports the requested services in this patients case. 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 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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for an LED light kit (K0108) for the authorized power wheelchair.At issue in this case is whether the requested durable medical equipment (DME) accessory, an  LED light kit (K0108) for the authorized power wheelchair, is medically necessary for the patient to perform one or more mobility-related activities of daily living or instrumental activities of daily living in or out of the home, including access to the community.Optimizing lighting, whether through ambient environmental adaptations or via lighting equipment on a wheelchair is advisable as a general measure towards accident and injury prevention. This measure, however, addresses environmental concerns and falls outside of the medical necessity standard. Thus, a LED light kit is not medically necessary for the patient to perform one or more mobility-related activities of daily living or instrumental activities of daily living in or out of the home, including access to the community.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 physical medicine and rehabilitation 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: The patient has requested authorization and coverage for (1) Monovisc injections, (2) PRP injections, or (3) if (2) is determined to not be medically necessary, PRP injections for each knee. Findings: Per the medical literature, although viscosupplementation may relieve knee pain in some individuals with osteoarthritis, it is not known as to which individuals will benefit. The current evidence is limited, and guidelines indicate that the evidence is not conclusive. In light of the foregoing, viscosupplementation can only be recommended in individuals with a history of lasting benefit from prior injections, and in carefully selected cases where everything else has been tried, and the options are limited. In a systematic review and meta-analysis of the effects and safety of the combination of PRP and hyaluronic acid (HA) in the treatment of knee osteoarthritis, a study found that the combined use of intra-articular viscosupplementation and PRP can heal degenerated cartilage and delay the progression of knee osteoarthritis. Another study noted that in the treatment of  patients with symptomatic knee osteoarthritis, PRP injections resulted in 12 months of improvement in knee pain and function. In this case, the patient has mild osteoarthritis of both knees. They have tried and failed other conservative treatments, including physical therapy and nonsteroidal anti-inflammatory drugs (NSAIDs), with the alternative being a total knee arthroplasty. Given the patients limited options and based on the current medical literature, the requested services are medically indicated for the treatment of this patient. Therefore, (1) Monovisc injections, and (2) PRP 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 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: Overturned

The parent of a two-year-old male has requested speech therapy for treatment of his autism. Findings:  The physician reviewer found that autism is a complex neurological disorder with characteristic deficits in speech/language and social interaction. There are likely a multitude of etiologies, with clinical symptoms being the common denominator. There is a long history of approaches used to intervene and facilitate development of adequate communication and interpersonal skills in autistic children. Typically, children on the autistic spectrum require interventions in multiple areas, provided using a team approach. Fundamental to the diagnosis of autism spectrum disorder (ASD) are deficits in speech and language. Most children with ASD will benefit from therapies designed to improve their ability to communicate and engage in social interactions. Deficits in the use of language for social purposes are universally seen in this population. These deficits can serve as major impediments to successful social adaptation and research has shown that intervention makes a difference, and that early intervention focused on communication and social skills can significantly improve the outlook for individuals on the spectrum (Volkmar). Therefore, individual speech therapy is medically necessary and appropriate for this patient.
Appeal type: Medical Necessity
Decision: Upheld

A 48-year-old female enrollee has requested for a pneumatic compression boot for treatment of her edema. Findings:  The physician reviewer found that this patients workup is incomplete. New onset lymphedema requires a venous duplex for reflux and obstruction and a CT scan of the pelvis. The primary care physician should also review/adjust medication and eliminate any that may cause lymphedema. Once this is complete, management for lymphedema begins with leg elevation, weight loss, external compression garments and manual lymphatic drainage. Only after these are attempted should pneumatic compression garments (not boots) be utilized.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested inpatient sub-acute level two care services for treatment of his medical condition. Findings: The physician reviewer found that the documentation submitted for review fails to establish the services at issue as medically necessary in this clinical setting. The patient has made very slow progress in skilled therapies. He has multiple comorbidities and based on the documentation submitted for review, it does not appear that he will reach his baseline or show further improvement in a predictable period with continued skilled therapies. The patient requires custodial care, and continued skilled therapies are not indicated.  Therefore, continued skilled nursing facility treatment services were not and are not medically necessary for treatment of the patients medical condition.  Final Result:  The reviewer determined that the services at issue were not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.  Credentials/Qualifications:  The physician reviewer is board certified in physical medicine and rehabilitation and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

A 48-year-old male enrollee has requested surgical repair of non-union fracture right lower tibia for treatment of his fracture.  Findings:  The physician reviewer found that the submitted documentation demonstrates the medical necessity of the requested services in this patients case.  The current medical evidence supports the requested services for the treatment of this patient.  X-rays demonstrate sclerotic changes adjacent to a line of radiolucency which crosses the entire extent of the tibia.  The presence of repeated fractures is a clinical indication of non-union.  The anatomic location of the fracture involves a higher incidence of non-union.  In this patients case, an operative procedure is needed to treat the non-union of the distal tibia.  All told, the requested surgical repair of non-union fracture right lower tibia is medically indicated in this clinical setting.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for a biopsy on the right breast mass. Based on the documentation provided for review, this patients imaging has not revealed any suspicious masses that are concerning for malignancy. However, the patient has consistently complained of a painful mass in her breast. In addition, this mass has been documented by the provider to be palpable and the patient is obese. Therefore, the palpable mass is not likely to correspond to the 0.4 or 0.5 cm findings on the ultrasound or mammogram. With discordant findings on imaging and physical examination, if the mass cannot radiographically be identified, either serial examinations of the breast, or excision of the palpable area should be performed. Breast cancer can be radiographically occult. This patients prior imaging has not demonstrated breast cancer, yet the palpable mass has not been thoroughly evaluated. As a problem solving tool, the requested breast biopsy is indicated in a clinical setting. Thus, consistent with current guidelines, the requested biopsy on the right breast mass is supported as medically necessary for evaluation and treatment of this 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 reviewer is board certified in 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: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for bilateral upper lid blepharoplasties.At issue is whether bilateral upper lid blepharoplasties are medically necessary for treatment of the patients medical condition. Does the condition constitute an abnormal structure of the body? If so, is the abnormal structure of the body caused by any of the following: congenital effects, developmental abnormalities, trauma, infection, tumors, or disease? If so, is the requested surgery performed to do either of the following: improve function or create a normal appearance to the extent possible? If so, does the surgery provide more than a minimal improvement in the appearance of the patient?According to medical literature, Upper blepharoplasty is accompanied by a great variety of beneficial functional outcomes including an increased visual field and improvement in headache- and vision-related quality of life. Moreover, medical literature indicate that upper blepharoplasty is functionally beneficial for patients with MRD less than or equal to 3 mm measured in primary gaze.This patient has dermatochalasis as evidenced by photographs. The physical examination demonstrates MRD less than 3 mm that is supported by the photographs. The visual fields, history and photographs are also compelling evidence of functional disability. Although there are varying degrees of dermatochalasis evident in the different photographs, there is enough deformity to explain the patients complaints and the results seen with visual field testing. Therefore, the requested bilateral upper lid blepharoplasties are medically necessary for treatment of the patients medical condition In this case, surgical treatment for the patient would be for the purpose of treating disease caused by involutional deformity of the eyelids that is causing symptomatic disability. This meets the typical criteria for appropriately treating a malformed body member. The blepharoplasty surgery is appropriate to treat this disease and relieve the patients symptoms of vision loss, and not merely for cosmetic benefit. Moreover, the requested blepharoplasties are to improve function. Therefore, the requested bilateral upper lid blepharoplasties are reconstructive in nature.Final Result: The reviewer determined that the requested services are medically necessary for treatment of the patients medical condition and reconstructive in nature. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in ophthalmology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

The patient has requested authorization and coverage for custom molded orthotic shoe inserts. Conservative treatments for hallux rigidus have historically included activity modification, non-steroid anti-inflammatory medication, shoe modifications and orthotics. Custom orthotics support the medial arch and foot, reducing excessive pressure to the first metatarsophalangeal joint (MPJ). The Mortons extension is a device that further reduces first MPJ range of motion, allowing for a reduction in pain. Custom orthotics with a Mortons extension are a standard of care treatment for painful first MPJ, degenerative joint disease (DJD) of the first MPJ, and hallux rigidus. In this case, the patient was noted to have pain to the right first MPJ. A physical examination as well as an X-ray evaluation demonstrated DJD, osteophyte formation first MPJ, and hallux rigidus. Therefore, custom molded orthotic shoe inserts are medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested equipment 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 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: Urgent Care
Decision: Overturned

A 65-year-old female enrollee requested services on an emergent or urgent basis for medical treatment of her metastatic neuroendocrine tumor with carcinoid syndrome. Findings:  The physician reviewer found that the submitted clinical documentation demonstrates that the patients decision to seek care in Switzerland was consistent with the actions of a prudent layperson in this setting. Although the patient's medical condition may not have been emergent, her symptoms meet the urgently needed criteria given that the services at issue were necessary to prevent serious deterioration as no available treatment options existed for her in the United States. The record demonstrates that a CT scan revealed moderate disease progression. Given the nature of the disease, limited options for the patient in the United States, and a viable option that existed for her in Switzerland, the services at issue were urgently need to prevent serious deterioration. In sum, a prudent layperson in a similar situation would have believed immediate medical attention was necessary to prevent serious deterioration of ones health. Therefore, the services at issue meet prudent layperson criteria for urgently needed services.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for extracorporeal shock wave therapy.Findings:  Three physician reviewers found that the current medical evidence has not established the superior effectiveness of the services at issue. There is some evidence that low intensity shock wave therapy to the penis may be helpful for patients with erectile dysfunction. The theory behind this treatment is that it may increase vascular flow to the penis by stimulating vascular growth. At this time, there is a lack of randomized studies showing that this treatment option is superior to conventional therapy. Furthermore, the records do not document that this patient was evaluated for vasculogenic erectile dysfunction. Thus, extracorporeal shock wave therapy was not likely to have been of greater benefit than other available treatment modalities. Final Result: The reviewers determined that the services at issue were not likely to have been more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: Physician reviewers 1, 2 and 3 are board certified in urology 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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for sacroiliac radiofrequency ablation for treatment of the enrollees chronic low back pain.  Findings:  The physician reviewer found that this patient is being treated for low back pain. Imaging does not support the presence of inflammatory sacroiliitis and she does not have a history of extensive spinal surgery for which a SI joint fusion might be considered. In this case, the patient underwent a SI joint injection with medications including fentanyl. Use of intravenous sedation may be grounds to mitigate the results of a diagnostic block. Radiofrequency facet joint denervation of spinal nerves in the treatment of SI joint pain is not supported in this clinical setting. The safety and effectiveness of this procedure has not been established by review of the available published peer-reviewed literature. Larger, well-designed trials are needed for comparing specific procedures in defined populations for use in SI pain and to determine the potential candidates and treatment parameters for this disorder. Additionally, this patient had partial relief when receiving chiropractic treatments. Conservative care is the current recommendation for her condition. Thus, the requested SI radiofrequency ablation is not likely to be more beneficial for treatment of her medical condition than available standard therapy.Final Result: All Three reviewers determined that the requested SI radiofrequency ablation is not likely to be more beneficial for treatment of her medical condition than available standard therapy.Credentials/Qualifications: Physician reviewers 1, 2 and 3 are board certified in anesthesiology with sub-specialty certification in pain medicine 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

The parent of a 12-year-old male enrollee has requested for plasma transfusion for treatment of the enrollees atypical hemolytic uremic syndrome related to factor H deficiency. Findings:  The physician reviewer found that this patient has suffered multiple complications as a result of atypical hemolytic uremic syndrome and has been severely ill as a result.  Although the exact etiology of his disease is not known, there is some thought that the relapses have been due to infectious exposure.Given the potential risk for relapse from infectious exposure and negative impact on his quality of life, the requested services are medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: A review of the record indicates that the enrollee has been diagnosed with chronic pain syndrome, generalized joint pain and acute hematogenous osteomyelitis. He has had a nerve stimulator from 2013 to 2015 that was removed due to infection. His current medications include diclofenac, Lidocaine cream, Lyrica, and Percocet. He tried Morphine but developed a rash and sedation. He has tried OxyContin with pain reduction from 8/10 to 1/10 visual analogue scale (VAS).  The Health plan believes he needs to try other non-narcotic medications and another trial of Morphine. The physician does have an opiate maintenance agreement in place and urine toxicologies have been negative for drugs of abuse. There is a plan to taper his opiates after surgery is successful and completed.  Researchers reviewed current clinical practice guidelines and note the use of opiates as a third line medication is acceptable in treating neuropathic pain. Similarly, a study of 16 clinical practice guidelines reinforced this approach as an acceptable method of pain control. The patient has an allergy to morphine and is on multiple non-narcotic medications for pain and is participating in physical therapy. The OxyContin provides ample pain relief (from 8/10 to 1/10 VAS).  Therefore, the requested medication is medically reasonable and necessary.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 anesthesiology with a 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.