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

A 35-year-old male enrollee has requested Levitra and Cialis for the treatment of his erectile dysfunction. Findings:  The physician reviewer found that while treatment of the underlying cause should not be overlooked, the fact remains that even if that were corrected, erectile dysfunction might well persist once it has developed in the first place. In any event, the first line treatment of the erectile dysfunction in this patient would be with oral PDE-5 inhibiting medications, such as Viagra, Levitra, and Cialis, as prescribed by his urologist.
Appeal type: Medical Necessity
Decision: Upheld

A 43-year-old male has requested magnetic resonance imaging (MRI) of the abdomen for evaluation of his abdominal pain and small intestinal bacterial overgrowth (SIBO).  Findings:  The physician reviewer found that based on review of the available records, this patient complains of abdominal cramping, pain, and bloating. His hydrogen breath test is consistent with SIBO. His appetite is good and he denies any weight loss. His laboratory studies have been normal without evidence of any anemia, or abnormalities in liver or renal function. His EGD, colonoscopy, and ultrasound abdomen have been unremarkable. His abdominal examination did not reveal any masses and there was no mass seen or suspected on the ultrasound of the abdomen. For these reasons, the requested MRI of the abdomen in this case is not medical necessary.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for physical therapy twice daily. Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity for the requested physical therapy services. The patient has had physical therapy treatments and is now at eight months status post injury. The patient has already reached a plateau with skilled treatments due to the orthopedic injury that he sustained. Further skilled therapy is not expected to significantly improve his condition. As of 3/18/16 he had range of motion from -15 to 120 degrees. He was making progress with therapy. He remained pain free. On 5/27/16, his provider had recommended a night splint. On 6/2/16, his motion had significantly improved. He had range of motion from about -15/20 to 130 degrees.  Although the patient describes being unable to perform self-stretching, there is no impairment of the right upper extremity. Per the records, he is right hand dominant and his stretching technique can be modified. A splint had been recommended and could be considered as an alternative treatment. 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 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: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for a sleep study performed for evaluation of the enrollees excessive daytime sleepiness. Findings:  The physician reviewer found that while polysomnography has traditionally been used to evaluate obstructive sleep apnea (OSA), the medical literature and current studies support testing for OSA in the home environment. As a result, the standard practice at this time is to test patients with suspected OSA with unattended sleep testing.  Such testing has been shown to be equally beneficial in terms of the establishment of OSA in the lab testing. Moreover, unattended or in home sleep testing is a less resource intense environment. In this patients case, there was no documentation of any contraindications to unattended testing or home sleep testing. The patient had no complaints of limb movements. Given that there is clinical support in this diagnostic paradigm towards ambulatory testing and this patient had a previous established diagnosis of OSA, the sleep study performed was not medically necessary for the evaluation of this patient. Final Result: The reviewer determined that the services at issue were 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 neurology with sub-specialty certification in sleep medicine and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

A 42-year-old female enrollee requested authorization and coverage of continued physical therapy for the treatment of an ankle fracture.  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 overturned the health plans denial on the basis that the requested therapy is  medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld

The patient is a 52-year-old woman with multiple problems who requests growth hormone (GH) therapy based on nonspecific symptoms, low GH concentrations, and a sub-optimal response to a GH releasing hormone stimulation test. She has also been given the diagnoses of chronic fatigue syndrome, sleep apnea, chronic pain syndrome, and leaky gut syndrome. She takes a multiplicity of medications and amino acid supplements, many of which could affect GH and GH stimulation. The patients provider has recommended the patient receive GH injections. The Health Plan has denied authorization and coverage for growth hormone therapy on the basis it is not medically necessary for treatment of the patients medical condition.The diagnosis of adult growth hormone deficiency (AGHD) is based on the clinical context, which is suggestive of some disorder of the hypothalamic pituitary axis. Other causes for the patients symptoms could be her depression, chronic fatigue syndrome, perimenopause, obesity, chronic pain, and sleep apnea. These must be considered before undertaking a course of testing for isolated AGHD. With the exception of a low ACTH level associated with a normal cortisol level the rest of the tested pituitary hormones appear normal. The patients head MRI, IGF-1s (which are decreased in 70% of patients with AGHD), ILGF-1, and IGFBP3 concentrations were all normal. Her low GH levels and inadequate response to the GH releasing stimulation test in this context could also be caused by any of her other conditions. As such, it has not been established that GH therapy is medically indicated in this patient.Based upon the information set forth above, I have determined that the requested therapy 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 reimbursement for air ambulance services.Findings:  The physician reviewer found that the submitted documentation supports the services at issue in this clinical setting.  Air ambulance is considered medically necessary under certain circumstances. These circumstances can include when the point of pickup is inaccessible by land or when there is a great distance or obstacle involved in land transport.  Another circumstance would be when the time needed to transport the patient by land poses a threat to a patients survival or the proper equipment needed for the patient is not available on a land ambulance.  A patient might also require air ambulance services in order to be transferred from one institution to another in order to receive specialized services such as trauma care or a burn unit.  The medical conditions to be considered include unstable vital signs, spinal cord injury, severe chest or abdominal injury, severe burns, or amputations.  Generally, ground transport times greater than 30 minutes would justify the initiation of air transportation.  The total estimated time from the initial call for transportation to arrival of the patient at the receiving facility should be projected to be significantly shorter by one hour.  This takes into account the availability of appropriate ambulance crews and the time required to mobilize the aircraft as well as including distance travelled.  This patient was transferred from a rural hospital after orthopedic consultation determined he required a higher level of care.  Ground transportation was estimated at 2 hours and 50 minutes.  However, on the day in question, there was road work along that route so the estimated travel times by ground would have been longer.  Transfer needed to be timely, as there was concern from the accepting provider that the patient might require emergent surgical intervention.  Additionally, the patient had an elevated white blood cell count and was persistently tachycardic.  This raises concern for systemic inflammatory response syndrome, if not sepsis.  Final Result: The reviewer determined that the services at issue were 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 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: Experimental/Investigational
Decision: Overturned

A 53-year-old female has requested lysis of epidural adhesions (epineurolysis) for treatment of her lumbar arachnoiditis.  Findings:  Two physician reviewers found that the patient has a history of two previous lumbar spine surgeries, and still reports chronic refractory low back and lumbar radicular pain. The patient has evidence of epidural scarring and arachnoiditis on exam and magnetic resonance imaging (MRI). There is also evidence of lumbar nerve root clumping at L3 and L4 levels, especially on the right side. She is being treated with narcotic pain medication, non-steroidal anti-inflammatory drugs (NSAIDs), physical modalities and other injections with marginal results. She is not a surgical candidate and has pain with everyday activities causing disability and a negative impact on her quality of life. Her pain physician is recommending lumbar percutaneous epidural lysis of adhesions with Racz catheter. In reviewing this case, the patient has a history of failed back surgery syndrome due to epidural scarring and arachnoiditis causing refractory radicular pain. The patient has reportedly failed traditional management including medications, physical therapy, and standard interventions, though her history of interventional management is not specifically noted. At this point, she is not a candidate for re-operation as the scarring may worsen. Further, the treatment options are limited to frequent steroid injections or spinal cord stimulation. The patient is a good candidate for lysis of adhesions and if successful for six months or more may be a good candidate for long-term management via injection technique. Patients with lumbar epidural adhesions have been treated with lysis of adhesions for many years using a standard protocol with or without hypertonic saline. The literature and systematic reviews do show strong short-term and moderate long-term evidence for efficacy with a very good safety profile. It is recommended at level 1C by the American Society of Interventional Pain Physicians (ASIPP) guidelines and can be safe and efficacious in these particular cases. This procedure has adequate long-term, evidence-based literature to support its use in patients with epidural scarring and failed back surgery complications. The injection should be approved in this case as it is likely to provide this patient with an improved health outcome beyond that expected with standard therapies.
Appeal type: Experimental/Investigational
Decision: Upheld

An enrollee has requested authorization and coverage for radiofrequency ablation of the right knee. Findings:  Two of the three physician reviewers Per the medical evidence, radiofrequency ablation of the genicular nerves of the knee is not recommended until higher quality studies with longer follow-up periods are available, to demonstrate the efficacy and track any long-term adverse effects. Choi and colleagues reported that radiofrequency neurotomy of genicular nerves resulted in significant pain reduction and functional improvement in a subset of elderly chronic knee osteoarthritis pain, and thus may be an effective treatment in such cases. However, the authors concluded that further trials with larger sample size and longer follow-up are warranted.  Bhatia and colleagues concluded that radiofrequency treatments on the knee joint (major or periarticular nerve supply or intra-articular branches) have the potential to reduce pain from osteoarthritis or persistent post-arthroplasty pain. However, the authors noted randomized controlled trials of high methodological quality are required to further elaborate role of these interventions in this population. This patient presents with chronic bilateral knee pain. The records indicated that she has been diagnosed with osteoarthritis of the knees, severe in the medial compartment. She reported significant functional limitations in activities of daily living. The treating provider has recommended genicular nerve radiofrequency ablation for the right knee to reduce knee pain, following positive genicular nerve blocks. She has been advised to lose weight prior to total knee replacement and delay surgery due to her young age. However, the requested services are not currently supported as safe and effective by evidence-based guidelines and peer-reviewed literature. There is a lack of large volume, long-term peer-reviewed outcome studies to support the requested services in this clinical setting. Therefore, the requested radiofrequency ablation of the right knee is not likely to be superior over other available treatment options. Final Result: The reviewers determined that the requested services are 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: Physician reviewers 1, 2 and 3 are board certified in orthopedic surgery 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: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has digital breast tomosynthesis for evaluation of the enrollees risk of breast cancer. Findings: Two physician reviewers found that tomosynthesis is a technique that was developed as a problem solving adjunct to routine mammography. In this case, the patient has breast tissue described as being extremely dense. While one could make the argument that her mammogram has not changed since the last study, 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 the reasons provided, the digital breast tomosynthesis was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Final Result: Two reviewers determined that the service at issue was 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 physician reviewers 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: Overturned

A 64-year-old male enrollee requested authorization and coverage of a repeat "MRA" of the head for the treatment of arterial stenosis.  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 overturned the health plans denial on the basis that the requested services are  medically necessary for treatment of the patients medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The representative of a patient has requested reimbursement for the molecular profiling for evaluation of the enrollees recurrent multicentric glioblastoma. Findings:  Two physician reviewers found that per National Comprehensive Cancer Network (NCCN) guidelines, molecular profiling is not helpful or necessary in making treatment decisions in this clinical setting. Molecular profiling offers a comprehensive panel of molecular genetic markers on an individual patients tumor in an attempt to identify markers than can help guide therapy decision making. Per the NCCN guidelines, it has not been determined if molecular markers are useful in treatment determinations. There is currently a phase II clinical trial underway that is evaluating the efficacy of genetic molecular testing to guide individual therapy. Final Result: The reviewers determined that the testing at issue was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: Reviewers 1, 2 and 3 are board certified in internal medicine with sub-specialty certification in medical oncology 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

A 53-year-old female enrollee requested authorization and coverage of the medication Evista.  The Health Plan denied the request indicating that the requested medication is not medically necessary for the prevention of osteoporosis.One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer upheld the Health Plans denial on the basis that the requested medication is not medically necessary.
Appeal type: Medical Necessity
Decision: Upheld

The mother of a 17-year-old female enrollee, who has undergone a gradual, but alarming, escalation in self-destructive behaviors with a corresponding decline in academic performance, has requested authorization for residential treatment services.Findings:  The physician reviewer found that there are no indications of suicidal or homicidal ideations and no evidence of a thought disorder that would indicate a medical need for residential care.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested authorization and coverage for Nutropin AQ NuSpin 20 mg.Findings:  The physician reviewer found that the patients height is not less than the 3rd percentile for his age and gender. His height on 10/16/15 was 62 5/8 inches which was within the 17th percentile for his age and gender. The data point plotted on the growth chart, was within normal range. There was no evidence of growth-fall off over time. The growth hormone (GH) levels on provocative testing were not sampled over several hours. The standard serial measurement of GH in response to provocative testing should be performed over two or three hours after administration of each provocative agent.  The low levels of GH in a boy who has delayed puberty cannot be taken as definitive evidence of GH deficiency. The tests have poor sensitivity and specificity for a diagnosis of GH deficiency and are typically low in the setting of delayed puberty. The bone age, by radiology report, was normal.  Final Result: The reviewer determined that the requested medication regimen 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 pediatrics with sub-specialty certification in pediatric endocrinology 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 has a history of failure to thrive and short stature. In November 2003, the patients documented height was 90cm and growth velocity was 3.7cm over seven months. The patients provider states the patient had sustained growth velocity at less than the 10th percentile and his height standard deviation (SD) score was 2.66. A request has been made for growth hormone therapy. The Health Plan has denied the request on the basis that growth hormone therapy is not medically necessary for treatment of the patients short stature.The patients stature is less than 2.5 SD for age and gender. However, it is not possible to assess whether the patients present stature is appropriate for genetic predisposition as no parental heights were included with the information submitted. The patients growth velocity between April 2003 and May 2004 was 7cm, which is between the 10th and 25th percentile for age. Growth hormone response to non-physiological stimuli was greater than 17mg/dl and thus normal by accepted standards. Considering the above information, growth hormone therapy should be delayed until a celiac panel is repeated and celiac disease is effectively ruled out and parental height and target heights are determined. Without such information there is no evidence that growth hormone therapy is medically necessary for this patient. Based upon the information set forth above, I have determined that the requested therapy is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.