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

Nature of Statutory Criteria/Case Summary: A 59-year-old male enrollee has requested authorization and coverage for computed tomography (CT) and magnetic resonance imaging (MRI) services to be provided every four (4) months for the next five (5) years. The patients tumor size of 17 cm places it in a high risk category. Even though resection was complete and the first post-operative scans revealed no evidence of local or distant metastasis, careful surveillance is indicated. The National Comprehensive Cancer Network (NCCN) guidelines for this stage of renal cell cancer advocate CT of the chest every six months for three years, then annually for five years. MRI of the chest is not indicated as such technique does not evaluate the lungs for metastatic deposits. The NCCN guidelines advocate surveillance for a similar time frame using MRI in the abdomen and pelvis. For these reasons, CT of the chest and MRI of the abdomen every six months for three years after the initial post-operative CT scan, and then annually for five years, are supported as medically necessary.Final Result: The reviewer determined that a portion of the requested services are medically necessary for evaluation of the patients medical condition. Therefore, the Health Plans denial should be partially 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: Urgent Care
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for emergency medical services.Findings: The physician reviewer found that the urgent care services provided were not necessary for treatment of an emergency medical condition. In this case, the patient presented to an urgent care facility with dizziness and palpitations. The patients symptoms were not sudden in onset. The patient had been experiencing symptoms for two months. The patient denied chest pain or shortness of breath. In addition, the patient did not report any acute neurologic deficits. There were no abnormalities identified on physical examination, EKG, or laboratory testing. Based upon the clinical documentation provided for review, the patient did not receive emergency medical services for an emergency medical condition.Final Result: The reviewer determined that the patient did not receive emergency medical services on the date of service at issue. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in emergency 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

This patient is a 48-year-old female who has degenerative arthritis in both of her knees, with the left worse than the right. She has undergone arthroscopic debridement and has also tried acupuncture treatment for pain management. The patient is unable to tolerate NSAIDs and anti-inflammatory medications. She has tried Supartz injections with success and is requesting a second series of Supartz injections. The Health Plan has denied coverage for the requested injections on the basis that they are not medically necessary.Based upon the information provided, the patient has not had a steroid injection in her knee. Steroid injection is the next appropriate step in the management of the patients pain. There is no data to support the contention that a second series of Supartz injections is likely to have greater value than steroid injection or other conservative measures. A second series of Supartz injections is not standard of care for patients such as this patient. Therefore, I have determined the requested injections are not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a 1-year, 11-month-old female has requested speech therapy twice per week for 60 minute sessions for treatment of her speech delay.  Findings:  The physician reviewer found that based on review of the available records, this patient is globally delayed, both in motor and intellectual development. In addition, she clinically demonstrates hypotonia, which suggests that she has an organic cerebral basis to her developmental deficits. It is within the standard of care to prescribe speech therapy for a toddler with speech delay. The value of speech therapy, in a developmentally delayed child, is well documented in the peer-reviewed medical literature. The effectiveness of speech therapy in a young child is emphasized by Law and colleagues, who reported that children with speech delay can be readily treated. Further, Goorhuis-Brouwer and Kniff evaluated speech-delayed children, such as this cognitively delayed patient, and concluded that such children are candidates for successful speech therapy. Similarly, Prelock and colleagues discussed the evaluation and the value of treatment for speech delayed children. Consistent with these findings, it is medically necessary that this patient receive the recommended two hours weekly of individual speech therapy for six months. Following six months of therapy, the patient needs to be reassessed to determine the need to continue either one or two hours of speech therapy for the next six months.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for foot orthotics (CPT L3020). Findings:  The physician reviewer found that  foot orthotics are effective in reducing pain for patients with plantar fasciitis. In this case, the records document that the patient has pronation, plantar fasciitis, pain in the feet, and gait instability. Given that foot orthotics support abnormal foot biomechanics, foot medial column and arch abnormalities, and assist in improving gait stability, the requested equipment is medically indicated. Therefore, foot orthotics (CPT L3020) 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 a licensed D.P.M., board certified in podiatry, and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

The patient is a 32-year-old female with grade II oligoastrocytoma. She is also status post awake craniotomy and tumor resection in June 2000. The patient now has a recurrent tumor in an area that was previously unresectable. A request has been made for a second awake craniotomy with brain mapping. The patient has requested a referral to an out-of-plan neurosurgeon for a second awake craniotomy with brain mapping. The Health Plan indicates that the procedure is available in-plan.The Health Plans denial should be upheld. The Health Plan has offered medically appropriate and indicated services. Although the previous awake craniotomy was performed by an out-of-plan provider, it is not medically necessary for the same provider to perform the second awake craniotomy. The Health Plan has authorized the procedure and has appropriate staff available to perform the procedure. There is no evidence that the in-plan providers lack the skill or expertise to perform the procedure. Therefore, I have determined that the requested referral is not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: A 50-year-old female enrollee has requested authorization and coverage for fiducial markers for treatment of the enrollees malignant neoplasm of unspecified main bronchus.  Findings:  The physician reviewer found that The records provided for review indicate that this patient has a lesion that is in the periphery of the right lung and the provider has recommended placement of fiducial markers. The fiducial marker allows easy identification by imaging or visual inspection ensuring resection of the whole lesion. The fiducial marker is placed during electromagnetic navigation bronchoscopy (EMB). The placement of the fiducial markers is not for diagnosis, but for definitive surgical resection. As there is adequate data demonstrating that this procedure has outstanding outcomes, its use is likely to be more beneficial than standard modalities in this clinical setting. Therefore, the requested fiducial markers placement is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.One reviewer found that the requested fiducial markers placement is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: Two of the three reviewers determined that the requested services are likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications:  One reviewer is board certified in internal medicine with sub-specialty certification in medical oncology and is actively practicing. One Reviewer is board certified in internal medicine with sub-specialty certification in medical oncology and is actively practicing.  One Reviewer is board certified in internal medicine with sub-specialty certification in medical oncology and is actively practicing.  All three reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

A 57-year-old male enrollee has requested for endovenous chemical ablation for treatment of his varicose veins.  Findings:  The physician reviewer found that sclerotherapy of the greater saphenous vein or in the presence of greater saphenous vein reflux has been shown to lack durability in long-term patient outcomes. With regard to this patient, there is nothing in the documentation provided for review that supports the necessity of further sclerotherapy for this patient. The records indicate that in this clinical setting, sclerotherapy has not in fact been durable. Further, the relevant medical literature does not recommend sclerotherapy for patients who have not undergone treatment with conservative therapy since initial treatment and this patients records do not include a recent assessment of arterial perfusion or other possible etiologies for his leg pain.
Appeal type: Experimental/Investigational
Decision: Upheld

A 38-year-old female enrollee requested an ultrasound bone stimulator for medical treatment of her stress fractures of the left foot.  Findings:  Two physician reviewers found that the medical literature does not support the use of an ultrasound bone stimulator for the treatment of stress fractures in the foot. The use of ultrasound bone stimulator is indicated for fractures in sites of high risk non-unions. Fracture non-unions typically occur in bones with poor vascular supplies such as the femoral head and neck, carpal navicular bone bone and the fifth metatarsal. Further, non-unions are most common in patients with co-morbidities such as alcoholism, tobacco use, diabetes and presence of infection. In this case, the documentation submitted for review does not demonstrate a condition of fracture non-union. For the reasons provided, the device at issue was not likely to be more beneficial than standard medical therapy.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for blood test for free testosterone for evaluation of his history of decreased libido.Findings:  The physician reviewer found that there is a lack of support for the requested services in this clinical setting. While measurement of a total morning testosterone level is a rather sensitive and specific test for evaluating hypogonadism, a free testosterone level tends to be less reliable. Most guidelines recommend serum total testosterone measurement as the initial test to evaluate male hypogonadism, and reserving free testosterone assessment for men with suspected sex hormone binding globulin abnormalities or total testosterone near the lower limit of normal. Low testosterone can lead to such complications as reduced libido/erectile dysfunction, reduced muscle mass and strength, increased adiposity, osteoporosis/low bone mass, depressed mood and fatigue. For these reasons, many providers treat patients with hypogonadism when their testosterone level is less than 350 ng/dl.  While this patient is experiencing symptoms, which he attributes to hypogonadism, his symptoms are rather nonspecific and may be multifactorial in nature. The patients total testosterone level is within normal limits. As such, the measurement of free testosterone level will have limited utility and may in fact be misleading. In sum, the requested blood test for free testosterone is not medically necessary for the evaluation of this patients medical condition.Final Result: The reviewer determined that the requested medication 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 internal medicine with sub-specialty certification in endocrinology, diabetes and metabolism 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 Otezla 30 mg tablets for treatment of the enrollees psoriasis. Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested medication. The patient has tried and failed therapy with topical steroids, but there is no documentation of treatment with any systemic medication, including orals (methotrexate or cyclosporine) or injectable biologics (Enbrel, Humira, Remicade or Stelara). The records noted that the patient will be beginning therapy with Excimer laser but has not yet at this time.  Given that there is no documented medical reason as to why the patient cannot be treated with methotrexate, cyclosporine, or the injectable biologics, the medical necessity of the requested medication has not been established. There are preferred alternative therapies available for this patient. All told, the requested Otezla 30 mg tablets are not medically necessary for the 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 dermatology 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

Findings:  The physician reviewer found that An enrollee has requested authorization and coverage for bariatric surgery.According to Aminian and colleagues, the American Society for Metabolic and Bariatric Surgery (ASMBS) recommends, For patients with BMI 30 to 35 kg/m2 and obesity related comorbidities who do not achieve substantial, durable weight loss and comorbidity improvement with reasonable nonsurgical methods, bariatric surgery should be offered as an option for suitable individuals. In this population, surgical intervention should be considered after failure of nonsurgical treatments. Additionally, the medical literature reflects that metabolic and bariatric surgery is not indicated for patients with BMI less than 30 kg/m2. Additionally, for patients with BMI from 30 kg/m2 to 35 kg/m2, bariatric surgery is generally only considered when the patients have type 2 diabetes. In this case, the records do not document clinically severe or morbid obesity with a BMI that is at least 35 kg/m2 to 39.9 kg/m2 with at least one serious obesity comorbid condition such as diabetes, hypertension or sleep apnea. This patient has a normal hemoglobin A1C level, and his BMI is less than 30 kg/m2. The patient does not meet nationally accepted criteria for bariatric surgery. Therefore, the requested bariatric surgery is not medically necessary for treatment of the patients medical condition.Final Result: The reviewer determined that the requested service is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for aquatic rehabilitation physical therapy for treatment of the enrollee, who is diagnosed with juvenile osteochondrosis of tibia and fibula of both legs (Blounts disease). Findings:  The physician reviewer found that there is sufficient support in the medical literature for the requested services in this clinical setting. The patient had undergone surgery, and the recent clinical documentation did not identify that this patient would be unable to perform land based physical therapy to address any remaining deficits.  However, despite this patients ability to walk on her affected limb, with full range of motion and there was no tenderness at the osteotomy site, she had tenderness over the medial distal tibial physis. The patient was also showing signs of decreased endurance. The documentation supports that her disease is exacerbated by compressive forces. As such, the aquatic therapy would be reasonable to address her symptoms of pain during extended periods of ambulation. Peer reviewed literature has stated that it is important to identify treatment modalities to help mitigate the complications of surgery and care should be assessed for each individual patient. Therefore, after review of the clinical documentation and peer reviewed literature, aquatic rehabilitation physical therapy is medical necessary for the treatment of this patients medical condition.  Final Result: The reviewer determined that the services at issue were medically necessary for the treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in physical medicine and rehabilitation with sub-specialty certification in pediatric rehabilitation 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: Experimental/Investigational
Decision: Overturned

A 64-year-old female enrollee has requested allogeneic hematopoietic stem cell transplantation for treatment of her multiple myeloma.  Findings:  Two physician reviewers found that allogeneic stem cell transplant may be the most reasonable treatment option for patients with multiple myeloma who have not responded to autologous transplants and chemotherapy. In such a clinical situation, the medical literature supports the use of stem cell transplantation. For these reasons, the requested allogeneic hematopoietic stem cell transplantation is likely to provide this patient with greater health benefits than any available standard therapy.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Duavee for treatment of her menopausal symptoms and enlarged uterus. Findings: The physician reviewer has found that based on the submitted clinical notes and current peer reviewed literature, the requested medication is not medically necessary for treatment of this patient.  In this case, the patients chart indicates her menopause complaints were of occasional hot flashes. Menopausal management is a very complex issue. Patients have a variety of physiologic and emotional symptoms related to the change in their hormonal milieu that occurs with cessation of ovarian and or adrenal hormonal production. Management of these symptoms typically needs to be individualized and tailored to help address the specific symptoms the patient may be experiencing and kept in context with any other medical issues they may have. In this patients case, a detailed evaluation of the underlying etiology of her enlarged uterus has not been provided. Additionally, there is no mention of other management modalities that have been trialed by this patient. Specifically, there is no mention of the patient trying other medicinal (hormonal or non-hormonal) and non-medicinal form of therapies. The records do not document the patients response to other medications. While Duavee may help treat hot flashes and other menopausal symptoms, there are other equally reasonable treatment options available to this patient. Duavee may be protective of the endometrium as a SERM, but so are other more traditional progestins. These preparations all carry some risk of endometrial cancer as they are packaged with conjugated estrogens. If the risks associated with estrogens and their potential relationship to uterine or other breast/reproductive cancers is driving management, then the use of non-hormonal management such as Paxil, may be a better option. Duavee has not been found to be safer than other combination options, and has not been approved for the prevention of uterine cancer or other female reproductive tract cancers. For these reasons, the requested medication, Duavee is not medically necessary for the treatment of this patients medical condition. Final Review: 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 obstetrics and gynecology 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.