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

A 55-year-old female enrollee has requested mammoplasty to replace mammary implants for the treatment of her condition. Findings:  The physician reviewer found that the patients implants were originally placed for cosmetic reasons.  Her implants were removed to allow an adequate evaluation of microcalcifications. She does not have breast cancer, and the implants were not replaced for a functional reason or to correct a congenital anomaly or to reconstruct a breast following cancer treatment. For this patient, her original and replacement implants were placed for the sole indication of enlarging otherwise normal breasts. This is the definition of a cosmetic breast augmentation. The insurer does not provide coverage for cosmetic surgery.
Appeal type: Medical Necessity
Decision: Upheld

A 46-year-old female enrollee has requested for a right knee replacement for treatment of her knee pain. Findings:  The physician reviewer found that total knee replacement or arthroplasty is an extremely successful procedure for end stage arthritis of the knee. The success rate is very high with 15-20 year follow-ups in the literature at 90+% successful.  Pain relief and improved function make total knee arthroplasty (TKA) a successful procedure. TKA in young patients has a more variable result. Patients younger than 40 years of age may have a failure rate of 12% at 8 years, which is higher than observed in most older age groups (see Archibeck, et al.). Total knee replacement in obese patients was associated with lower functional scores, increased patella pain and increased incidence of non-progressive radiolucent lines. Although postoperative knee scores were lower, improvement in knee scores was higher and revision rates were similar in these patients when compared with non-obese patients.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a 13-year-old male has requested Genotropin for the treatment of the enrollees short stature. Findings:  The physician reviewer found that there has been a question of hypotonia, but no diagnosis of Prader-Willi Syndrome has been suggested. The patients mid-parental height is 57.5 while his predicted adult height is 52.3. Thus, he has idiopathic short stature, and is under the care of a pediatric endocrinologist. Based upon FDA guidelines of July 2003, growth hormone therapy is medically appropriate for this patient.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary:  An enrollee has requested authorization and coverage for acupuncture services (twice a week for 5 months and once a week thereafter) and chiropractic services (twice a week for 5 months and once a week thereafter).According to medical literature, a full course of acupuncture is considered six treatments. Additionally, a study by researchers found that a positive, clinically significant number of chiropractic visits is nine to twelve visits. In this case, the patient has had both acupuncture and chiropractic sessions approved (at least 12 sessions of each type). The submitted documentation shows that the patient has had prior chiropractic treatment, with no change in symptoms. Additionally, there were no quantifiable improvements noted after past acupuncture treatments. Therefore, acupuncture services (twice a week for 5 months and once a week thereafter) and chiropractic services (twice a week for 5 months and once a week thereafter) are not medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested services 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 oriental medicine and chiropractic 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: Urgent Care
Decision: Upheld

Nature of Statutory Criteria/Case Summary:   An enrollee has requested left radical nephrectomy and related services on an emergent or urgent basis. Findings:  The physician reviewer found that the submitted documentation does not demonstrate the patient was experiencing an emergency medical condition. In this case, the patient presented for a left radical nephrectomy due to a renal mass found on imaging. Emergency surgery was not recommended at the time the mass was found or on follow-up shortly thereafter. The patient was given various treatment options and decided to undergo left radical nephrectomy. At that time, the patient was not experiencing acute symptomatology that was likely to place his health in serious jeopardy, cause serious impairment to body functions or cause serious dysfunction to a body organ or part without surgical intervention. All told, based on the documentation provided for review the patients symptoms did not meet prudent layperson criteria for emergency services on the dates in question.  Further, it has not been established that criteria for urgently needed services were met. The documentation submitted for review fails to demonstrate signs or symptoms of infection or injury that would require immediate treatment. Moreover, the patient was given the option of returning home for treatment by his provider. In this case, treatment could have been delayed until he returned home where he could have been safely treated. There was no indication that a prudent layperson in a similar situation would have believed immediate medical attention was necessary to prevent serious deterioration of ones health. Further, there was no evidence that his condition was deteriorating or that he was in acute distress. In sum, based on the patients clinical presentation he did not meet prudent layperson criteria for urgently needed services. As such, the Health Plans denial should be upheld.  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 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.
Appeal type: Medical Necessity
Decision: Upheld

The parent of a 24-year-old female enrollee has requested a neuro-rehabilitation program and a cerebral angiography for treatment of the enrollees traumatic brain injury. Findings:  The physician reviewer found that review of the submitted documentation demonstrates that the patient has had a severe traumatic brain injury with persistent neurologic impairments, diagnosed as vegetative state. As noted in the relevant literature, accepted treatment for vegetative state is supportive care. Rehabilitation efforts and stimulation may be utilized to attempt to improve recovery. However, there is no evidence that any particular rehabilitation strategies change outcomes. A prospective study by Lippert-Gruner, et al. conducted to assess the one-year outcome of comatose patients after severe traumatic brain injury showed Despite intensive rehabilitation treatment, severe traumatic brain injury is still burdened with significant mortality and morbidity. Thus, while continued efforts at support and stimulation are potentially helpful, there is no evidence that a neuro-cognitive rehabilitation program will result in an improved outcome for this patient. As such, the proposed rehabilitation program is not medically necessary for treatment of the patients condition.Regarding the request for cerebral angiography, there is no data included in the submitted records to suggest an undiagnosed cerebral vascular abnormality. Angiograms are invasive, and there is no evidence of the potential benefit of angiogram in this setting which would offset the risks associated with this procedure. Thus, there is no medically necessary indication for a cerebral angiography for this patient.
Appeal type: Medical Necessity
Decision: Overturned

This patient is a 45-year-old male who has long-standing widespread psoriasis and now psoriatic arthritis. The patient has tried many medications over the years as well as UVB therapy to treat his condition. He was enrolled in a study with Enbrel and had a great response. The patients medical history is significant for hypertension and hypercholesterolemia, for which he takes medication. The patients dermatologist feels Enbrel is the best treatment at this time for the patients psoriasis. The Health Plan has determined Enbrel is not medically necessary for the patients condition.  Upon review of the submitted clinical evidence and relevant medical literature, Enbrel is medically appropriate for this patient. The Health Plan has proposed the patient be tried on cyclosporine. Cyclosporine can further increase blood pressure in this patient who already is on blood pressure medications. Additionally, cyclosporine will not help the patients arthritis, and can cause elevation of his triglycerides or cholesterol. The other medicine the Health Plan has recommended is Soriatane; however, Soriatane can be difficult to use in patients such as this patient who already have elevated lipid profiles. Furthermore, it can cause liver disease and this patient has had liver enzyme elevations with his methotrexate. Moreover, Soriatane will not help the patients arthritis.The submitted clinical information documents that the patient has been tried on systemic medications in the past including methotrexate and Amevive. Thus, he has already failed two systemic medications and UVB. Enbrel is the most medically appropriate medication for this patient at this time. For this patient it carries less risk of complication, and helps two disease processes at the same time. Therefore, I have determined that the requested medication is medically necessary for treatment of the patients medical condition. The Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Upheld

A 30-year-old female enrollee has requested for intensive inpatient physical rehabilitation for treatment of her spinal injury with resultant paraplegia. Findings:  The physician reviewer found that the patient has already had an inpatient rehabilitation stay, and there are no medically unstable issues that require inpatient care at this time.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary:   An enrollee has requested breast tomosynthesis for evaluation of her medical condition.  Findings:  Three physician reviewers found that breast tomosynthesis was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Those patients who have dense breasts that can benefit most from tomosynthesis. The ability to separate out the overlapping structures enables the possibility of demonstrating an otherwise occult tumor. Therefore, the services at issue were likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Final Result: Three reviewers determined that the services at issue were 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: 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: Overturned

A 64-year-old female enrollee has requested for Provigil for treatment of her major depression with hypersomnia. Findings:  The physician reviewer found that Modafinil is being used as an adjunctive agent to augment the antidepressant. Augmentation of antidepressants is a frequent and highly useful practice in the treatment of many patients with depression. Moreover, there are publications suggesting therapeutic benefit of modafinil in this particular clinical situation, as noted by DeBattista and colleagues and Schwartz and colleagues. It is clinically sound and medically necessary to treat this particular patient with modafinil (Provigil) in conjunction with antidepressants.
Appeal type: Experimental/Investigational
Decision: Upheld

A 55-year-old male enrollee has requested external cardiac ambulatory telemetry (ECAT) for an evaluation of his atrial fibrillation. Findings:  Three physician reviewers found that continuous cardiac ambulatory telemetry has not been shown to improve health outcomes or patient management when compared to established portable cardiac monitoring devices and is not recommended as initial evaluation for the identification of supraventricular dysrhythmias. Based on the records provided, the patient had at least one episode of atrial fibrillation followed by a Holter monitor showing normal sinus rhythm. The patient also reported infrequent palpitations. In this circumstance, the standard accepted medical practice for assessment of recurrent atrial fibrillation includes daily pulse checks if able and serial Holter monitoring. The latter would be particularly appropriate for this patient with intermittent symptoms lasting about five minutes. The scientific literature does not demonstrate that ECAT will provide added clinical value in this setting.
Appeal type: Experimental/Investigational
Decision: Upheld

A 51-year-old female enrollee has requested Atlas Orthogonal Chiropractic Technique for the treatment of her cervical and thoracic spine deviation and spondylitic changes. Findings:  Three physician reviewers found that the chiropractic treatment at issue is not likely to be of any greater value for treatment of the patients condition than any available standard therapy. The records provided reflect the chiropractic services the patient received but the results are not impressive. The technique at issue, the Atlas Orthogonal Chiropractic Technique is only practiced by a handful of chiropractors and is not supported in the clinical literature as safe and/or effective. This patients examination and diagnostic findings are consistent with an arthritic spine. There is no indication why this patient could not be treated with the proven chiropractic techniques available for treatment of her condition. The requested technique offers no proven likelihood of additional relief greater than traditional chiropractic manipulation. The Cochrane Library Database and the Agency for Healthcare Policy and Research do not document that the Atlas Orthogonal Chiropractic Technique is any more effective than any other traditional chiropractic manipulative technique.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a 4-year-old male enrollee has requested a 3-6 month trial of intravenous immune globulin (IVIG) treatment for treatment of the enrollees inflammatory disorder with fevers.   Findings:  The physician reviewer found that the submitted documentation establishes the medical necessity of the requested IVIG therapy. Intravenous immunoglobulin is a pooled blood product containing a broad range of antibodies against pathogens and foreign antigens that can be used to modulate immunodeficiency and autoimmune disorders. The U.S. Food and Drug Administration (FDA) has approved its use for treatment of the following disorders: primary immunodeficiency disease, idiopathic thrombocytopenic purpura, Kawasaki disease, chronic lymphocytic leukemia with frequent infections, bone marrow transplantation, pediatric human immunodeficiency virus to prevent other infections and chronic inflammatory demyelinating polyneuropathy. Detailed guidelines have been developed to ensure safe administration of both intravenous and subcutaneous use. IVIG has been used off-label for treatment of PANDAS (pediatric autoimmune neuropsychiatric disorders associated with streptococcal infections), Guillain-Barre syndrome, multifocal motor neuropathy, autoimmune mucocutaneous blistering diseases such as Stevens-Johnson syndrome and toxic epidermal necrolysis, multiple sclerosis, systemic lupus erythematosus and other autoimmune vasculitis, and myasthenia gravis, to name but a few. The scope of IVIG use has expanded beyond treatment of patients with primary immunodeficiencies and its administration has had life-saving and life-altering effects in a number of patients. For many patients with well-defined clinical conditions, guidelines either exist or are being developed for administration of IVIG. For patients with conditions that remain undiagnosed, but yet who possess many signs and symptoms consistent with inflammatory and autoimmune dysfunction, a trial of IVIG is medically appropriate. Such is the case with this patient. Thus, a 6 month trial of IVIG is medically necessary and appropriate for this patient.
Appeal type: Medical Necessity
Decision: Upheld

A 46-year-old female enrollee requested authorization and coverage of an adjustable bed for the treatment of reflux syndrome.  The Health Plan denied the enrollees request indicating that the requested treatment is not medically necessary.One physician reviewer performed a medical necessity Independent Medical Review.  The physician reviewer upheld the health plans denial on the basis that the requested equipment is not medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested surgical repair of the right bicep and shoulder for treatment of his medical condition. Findings: The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested services.  With regard to the treatment of ruptures of the long head of biceps tendon, the guidelines indicate that it can almost always be managed conservatively because there is no accompanying functional disability.  With regard to the evidence of impingement, the guidelines necessitate conservative treatment with an exercise rehabilitation program and corticosteroid injections and documentation of trial/failure before surgical considerations for subacromial decompression.  As such, the request for biceps tendon repair is not medically necessary.  Given the lack of documentation indicating an exercise rehabilitation program and corticosteroid injections, request for arthroscopic surgery is also not indicated.  All told, the requested surgical repair of the right bicep and shoulder is not medically indicated for the treatment of this patient.  Final Result: The reviewer determined that the requested services 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 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

Nature of Statutory Criteria/Case Summary: An enrollee has requested Euflexxa injections for treatment of her knee osteoarthritis.  Findings:  The physician reviewer found that review of the submitted documentation and relevant literature fails to demonstrate the medical necessity of the requested services. There is a lack of adequate randomized, controlled studies in the peer-reviewed literature demonstrating the clinical effect from hyaluronate injections. The medical literature assessed the efficacy of viscosupplementation for adults with symptomatic knee osteoarthritis. This study reviewed a total of 89 trials involving 12,667 adults and concluded that in patients with knee osteoarthritis, viscosupplementation is associated with a small and clinically irrelevant benefit and that there is an increased risk of serious adverse effects. Moreover, the medical guidelines for the treatment of osteoarthritis of the knee state, We cannot recommend using hyaluronic acid for patients with symptomatic osteoarthritis of the knee. Furthermore, several studies evaluating repeated treatment protocols document adverse events including inflammatory changes within the knee joint and in some cases requiring arthrocentesis after multiple injections. Based on the medical literature cited above, Euflexxa injections are not medically necessary for treatment of the patients medical condition. Final Result: The reviewer determined that the requested services 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 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: Overturned

A 52-year-old male has requested coverage for a remote real time heart monitor for evaluation of his atrial fibrillation.  Findings:  Two physician reviewers found that the patient has chronic atrial fibrillation and underwent atrial fibrillation ablation two years ago. He returned to his cardiologist complaining of frequent palpitations and dizziness and a real time monitor was ordered. The patient was started on Rhythmol, an anti-arrhythmic agent and followed up for his symptoms. In two different studies, it was noted that real time monitoring devices detected significantly more arrhythmias than standard event monitor devices (Reiffel, et al. and Rothman, et al.). Real time heart monitors have the capability of detecting asymptomatic clinically significant arrhythmias, even in patients with a previously negative work up (Olson, et al.). Additionally, real time heart monitors have been useful in detecting previously undetected atrial fibrillation, which may have been contributory to strokes in some patients (Tayal, et al.). All told, real time event monitoring has been noted to have a clinical benefit and this technology appears to improve health outcomes. In this patients case, he had a history of chronic atrial fibrillation. Despite an ablation procedure, the patient returned with recurrent symptoms. Real time monitoring was utilized in an attempt to detect the recurrence of any significant arrhythmia, its type and its duration, all of which have important implications for the therapeutic management of patients. Therefore, the use of real time heart monitoring was likely to be more beneficial for evaluation of the patients medical condition than standard monitoring devices.