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

A 53-year-old female enrollee has requested coverage for past facet joint injections for treatment of her osteopenia and diffuse connective tissue disease.  Findings:  The physician reviewer found that although more specific diagnostic codes involving lumbar facet dysfunction, such as spondylosis and enthesiopathy would be helpful, the provider clearly delineates suspected facetogenic pain in the lumbar spine from the L4-5 level. The patient has a complicated polyarthralgia with gluten enteropathy and immune system dysfunction causing connective tissue disease, which can affect the facet joints. According to the patients provider, magnetic resonance imaging (MRI) showed arthropathy, examination showed tenderness over this level, and the patient has been refractory to topical and systemic medications, lifestyle modifications and dietary changes. Therefore, an image guided injection is both diagnostic and therapeutic and was clinically indicated when performed. Although more conventionally done with x-ray and computed tomography (CT) scanning technology, ultrasound is a safe emerging alternative that allows direct joint visualization and proper observation of medication placement intra-articularly without exposing the patient to radiation. Consistent with these findings, the bilateral facet joint injections at L4-5 provided this patient were medically necessary and should therefore be a covered therapy.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for a positron emission tomography (PET) scan. Richters transformation, or Richters syndrome, refers to the development of an aggressive lymphoma in patients with CLL. The diagnosis of Richters syndrome requires analysis of tissue, typically from a lymph node or bone marrow biopsy. Richters syndrome appears as an aggregation of cells that are larger than typical CLL cells. Areas of Richters syndrome and CLL can be present in the same biopsy. It is also possible to have Richters syndrome only in some lymph nodes, while others may still show typical CLL. Signs indicating the possibility of Richters syndrome include rapid growth of lymph nodes and high or rapidly rising levels of LDH. According to the National Comprehensive Cancer Network (NCCN), PET imaging is indicated to help identify lymph nodes suspicious for Richters syndrome. This patients records document a rapidly rising white blood cell count and elevated LDH. Thus, the consideration of a Richter transformation was reasonable. In conclusion, the use of PET/CT scanning has become relatively common in the evaluation of worsening CLL. Thus, the PET scan was likely to have been more beneficial for evaluation of this patients medical condition than any available standard therapy. Findings:  Three physician reviewers found the PET scan was likely to have been more beneficial for evaluation of this patients medical condition than any available standard alternative.Final Result: The reviewers determined that the PET scan was likely to have been more beneficial for evaluation of this patients medical condition than any available standard alternative.Credentials/Qualifications: Physician reviewers 1, 2 and 3 are board certified in diagnostic radiology 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: Upheld

This patient is a 14-year-old female with a monosome chromosome 10-P translocation with a history of speech delay (receptive greater than expressive), cognitive delays, and seizures. The patient has been receiving speech therapy since 1996. At issue is whether continued speech therapy is medically necessary.Review of the submitted clinical records indicates there is a lack of objective documentation demonstrating the patient has made significant gains with speech therapy. The patients deficient language skills are life-long deficits and are educational rather than medical in nature. As such, continued speech therapy in a medical setting is not warranted. Therefore, I have determined that the requested therapy is not medically necessary for the treatment of the patients medical condition. The Health Plans denial should be uphe
Appeal type: Urgent Care
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested emergency services on an emergent basis or urgent basis for treatment of her medical condition.  Findings: The physician reviewer found that the review of the submitted documentation demonstrates that a prudent layperson would have sought immediate medical attention. Upon review of the submitted medical records, the patient presented with blunt head and chest trauma with multiple orthopedic fractures. She underwent several emergency orthopedic surgeries.  She was stabilized relative to her abdominal, chest, and head injuries in the ICU, and treated for a deep vein thrombosis. She subsequently underwent additional orthopedic surgeries.  The staged treatment of the patients leg, hip, and arm fractures is an extension of her emergency treatment to avoid serious impairment and dysfunction. The continuation of care with the initial orthopedic surgeons was indicated for optimal continuity of care in the setting of staged orthopedic trauma surgery without delay. Based on the patients presenting complaints and symptoms, a prudent layperson in this circumstance would reasonably believe she was suffering from a serious medical condition. In sum, the patient was suffering from a serious medical condition that was likely to place the patients health in serious jeopardy, cause serious impairment to body functions or cause serious dysfunction to a body organ or part. Thus, the services met prudent layperson criteria for emergency care.Final Result: The reviewer determined that the patients symptoms met prudent layperson criteria for emergency services. 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: 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 tomosynthesis is a technique that was developed several years ago as a problem solving adjunct to routine mammography. Applying the same basic concept as computed tomography (CT) scanning, the logic is that by separating the various layers of breast tissue, one can better detect abnormalities.  This has been shown to be most useful in the evaluation of the dense breast.  Tomosynthesis has not been shown to provide significant increased value in patients who do not have dense tissue that could obscure an abnormality, especially when there have been no changes when compared to prior studies.  It is specifically 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. For these reasons, 3D tomosynthesis was likely to be more beneficial than any available standard modes for breast screening.  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.  Credentials/Qualifications: All three physician 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 23-year-old male enrollee has requested inpatient psychiatric hospitalization for treatment of his medical condition.  Findings:  The physician reviewer found that this patient clearly exhibited suicidal ideation throughout his stay and lacked a strong support system outside the hospital setting.  The inpatient hospitalization was consistent with standards of medical practice in the community and his care could not be provided safely on an outpatient basis. Inpatient hospitalization was therefore medically necessary for this patient.
Appeal type: Experimental/Investigational
Decision: Upheld

A 46-year-old female enrollee has requested MR guided high intensity focused ultrasound (MRgFUS) ablation surgery for the treatment of her uterine fibroids. Findings:  Three physician reviewers found that this patient has symptomatic uterine fibroids. Hysterectomy, myomectomy and now uterine artery embolization (UAE) are approved and supported in the medical literature as non-investigational treatments for uterine fibroids. While MRgFUS ablation of uterine fibroids is a promising therapy for the treatment of symptomatic fibroids, only short-term results are available regarding its effectiveness and safety. Long-term studies continue to examine the safety and long-term benefits of MRgFUS. At this time, there is not adequate data from which to conclude that MRgFUS of fibroids is likely to be more efficacious in the long-term than the alternatives.
Appeal type: Experimental/Investigational
Decision: Upheld

A 64-year-old female enrollee has requested breast magnetic resonance imaging (MRI) with computer-aided detection (CAD) for an evaluation of her medical condition status post lumpectomy. Findings:  Three physician reviewers found that the appropriate imaging studies for patients with breast pain are mammography and/or breast ultrasound. If there is an indeterminate finding on conventional imaging or physical exam, then breast MRI can be useful, as noted by the American Society of Breast Surgeons. The breast MRI study performed was done for diagnostic purposes for evaluation of left breast pain and not for screening purposes. There is no documentation of a recent mammogram or breast ultrasound prior to the MRI.
Appeal type: Medical Necessity
Decision: Overturned

The patient has requested authorization and coverage for vibration amplification of sound energy at resonance (VASER) liposuction. There is sufficient support for the requested services in this clinical setting. This patient presents with complaints of progressive difficulty in her ability to function due to pain related to lipedema. She underwent two VASER liposuction procedures, and second procedure was complicated by skin necrosis and skin bullae, indicating both partial and full thickness injury of the bilateral mid-distal inner thighs. The records support that the requested services will be performed to improve function and more closely approximate a normal appearance. Additionally, the requested services are likely to provide more than a minimal improvement in the patients appearance. The timing of the third VASER liposuction depends on the findings of an additional evaluation following the patients recovery from the two liposuction procedures and related complications. Accordingly, the requested VASER liposuction is reconstructive in nature for the treatment of this patient. Final Result: The reviewer determined that the requested services are medically necessary and reconstructive in nature for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in plastic 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 authorization and coverage for morphine 30 mg, two tablets, two times per day. The Center for Disease Control 2016 Guidelines, adopted and restated by the American Society of Interventional Pain Physicians, clearly state that clinicians should continue opioid therapy only if there is clinically meaningful improvement in pain and function that outweighs risks to patient safety and clinicians should offer or arrange evidence-based treatment (usually medication-assisted treatment with buprenorphine or methadone in combination with behavioral therapies) for patients with opioid use disorder.Here, the patient has been a chronic opioid user. Since beginning an opioid regimen, there is no documentation of meaningful improvement in function or pain. There is also evidence suggesting that continued opioid use could be dangerous for this patient with opioid user disorder. The patient signed and understood the implications of a pain contract. The patient violated this contract, knowing that by doing so, the clinical provider would cease prescribing opioids. The records indicate that the patient was referred back to the chemical dependence program. The records further indicate that the patient did not avail himself of this program, and instead sought approval from an out-of-network pain physician to continue his opioid medications. Of note, the enrollee was also instructed to seek care at the emergency department if significant withdrawal symptoms occurred. The recommended chemical dependence program would also assist in medical management of withdrawal symptoms. The patient is a long-time opioid user for whom there is no documented improvement in function or pain. Evidence suggests that continued opioid use could be dangerous for this patient with opioid use disorder. Therefore, the requested prescription for morphine 30mg, two tablets, twice daily is not medically necessary for treatment of this patients chronic pain.Final Result: The reviewer determined that the requested medication is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is board certified in anesthesiology and pain management, and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

A female enrollee requested a power wheelchair for medical treatment of her right knee osteoarthritis and shoulder pain. Findings:  The physician reviewer found that in the current case, physical therapy noted good strength and functional range of motion in the left-sided limbs. There are no musculoskeletal or cardiovascular impairments that would preclude the use of an optimally fitted manual wheelchair in an appropriate environment. Moreover, physical activity is appropriate for general health and especially for musculoskeletal conditions such as osteoarthrosis (Hagen, et al). All told, the requested power mobility device is not medically necessary for treatment of this patients medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary:   An enrollee has requested joint manipulation under anesthesia during surgery to remove a plate and screws from the arm for treatment of her medical condition. Findings:  Two physician reviewers found that peer reviewed literature supports the use of manipulation under anesthesia (MUA) for conservative treatment of isolated dislocation of the pisiform bone, scapholunate dislocation, and adhesive capsulitis of the wrist in small case studies. However, there is a lack of long-term peer-reviewed outcome studies to support the use of MUA in the wrist, beyond closed reduction of acute displaced fractures. There is a lack of current evidence based medical peer-reviewed support for the use of MUA in the wrist to improve range of motion status post hardware removal. The use of this procedure for improving range of motion of a joint is generally supported for the shoulder following failure of conservative treatment where range of motion remains significantly limited. In this case, the patient reported limited wrist range of motion, especially pronation and supination. Moreover, there is a lack of compelling rationale presented to support MUA in the absence of a conservative treatment trial. Therefore, the joint manipulation under anesthesia during hardware removal surgery was not likely to be more beneficial for the treatment of the patients medical condition than any available standard treatment. Final Result: Two reviewers determined that the services at issue were not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld.  Credentials/Qualifications:  All three reviewers are board certified in orthopedic surgery and are actively practicing.  All three reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Synvisc/Synvisc One for treatment of the enrollees bilateral knee osteoarthritis.  Findings:  The physician reviewer found that the use of hyaluronan is not consistently supported by evidence based literature. There have been carefully conducted double-blinded studies, which do not report any clinical effect from hyaluronan injection. There is also a low but present risk of iatrogenic infection being introduced into the joint during the process of injection. A recent meta-analysis of the efficacy of viscosupplementation reviewed a total of 89 trials involving 12,667 adults. The authors of this research reported that in patients with knee osteoarthritis, viscosupplementation is associated with a small and clinically irrelevant benefit with an increased risk of serious adverse effects. Several studies evaluating repeated treatment protocols document adverse events including inflammatory changes within the knee joint in some cases requiring arthrocentesis after multiple injections. The risk of sensitization is expected to increase after repeated exposure to an antigenic substance. By reason of the limited or no benefit demonstrated in well-designed, double-blinded studies and the documented incidence of acute local reactions, the requested Synvisc/Synvisc One is not supported as medically necessary for treatment of this 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. 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 22-month-old male enrollee has requested  for speech therapy for treatment of the enrollees language delay. Findings:  The physician reviewer found that extensive review of the literature including a meta-analysis by Law et al. noted the positive effect of speech and language therapy interventions for children with expressive phonological and expressive vocabulary difficulty. Feldman and Messick note that treatment for language disorders is predicated primarily on the childs language profile and level of communication skills. Those children with mild to moderate disorders are more likely to resolve their delay compared to those with severe disorders. Children who participate in speech-language treatment show better improvement than those children who have no treatment. Gallagher et al. evaluated speech and language interventions for 24 preschool children with specific language impairment. They found statistically greater improvement with intensive direct speech and language therapy delivered by speech and language therapists over an eight-month period when compared to no intervention or nursery-based intervention. Given the above cited peer reviewed medical literature and the records provided, the requested speech therapy is medically necessary in this case.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Hetlioz for treatment of the enrollee's non-24 sleep wake disorder.  Findings:  The physician reviewer found that the request for Hetlioz is not medically necessary for treatment of the patients medical condition. According to the American Academy of Sleep Medicine criteria for non-24 sleep wake disorder, The sleep disturbance is not better explained by another current sleep disorder, medical or neurological disorder, mental disorder, medication use, or substance use disorder. (Sateia). The progress notes do not indicate the patient has been screened for substance use disorders or has had a neurological evaluation. In addition, the guidelines for insomnia recommend cognitive behavioral therapy (CBT) as the initial therapy rather than medication (Smith and Neubauer). According to Trauer and colleagues CBT is an effective treatment for adults with chronic insomnia with clinically meaningful effect. In this case, the records submitted for review indicate that the patient has tried various sleep hygiene methods but there is no evidence the patient has had a trial of CBT for insomnia. For the reasons provided, the requested medication is not medically necessary for treatment of the patients medical condition.  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 psychiatry and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.