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

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for magnetic resonance imaging (MRI) of the right knee (CPT 73721). As noted by Hayashi and colleagues, the best initial imaging examination for the evaluation of chronic knee pain in an adult patient is radiographs. In the setting of osteoarthritis diagnosed by initial radiographs, MRI may be indicated in follow-up if the patients symptoms are not explained by the radiographic findings. According to the American College of Radiology (ACR) recommendations for the evaluation of chronic knee pain in a patient with initial radiographs demonstrating degenerative changes, MRI may be appropriate as the next imaging examination. In this case, despite conservative measures including cortisone injections, the patients chronic knee pain is not explained by the radiographs. Applying the ACR criteria and recommendations from the peer-reviewed medical literature, the next logical step in this patients work-up is MRI (Javaid, et al.). Accordingly, the requested MRI of the right knee (CPT 73721) is medically necessary for evaluation of this patient. Final Result: The reviewer determined that the requested services are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in radiology with subspecialty certification 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: Experimental/Investigational
Decision: Overturned

A 55-year-old male enrollee has requested a percutaneous intracranial balloon angioplasty with possible stenting for the treatment of basilar artery stenosis.  Findings:  Two physician reviewers found that multiple medical organizations have statements supporting intracranial angioplasty/stenting, and the Food and Drug Administration has approved two intracranial stenting devices. The procedure is being routinely performed in many academic stroke centers in the United States.
Appeal type: Medical Necessity
Decision: Overturned

A 56-year-old male enrollee has requested bilateral hernia repair for treatment of his hernia.  Findings:  The physician reviewer found that the records indicate that the providers have not been able to identify hernia on physical examination. However, the patient is symptomatic in the region consistent with findings on CT and ultrasound. Further, the medical literature supports repair for this patient population over watchful waiting as noted by Fitzgibbons and colleagues. Given the records provided for review, the requested bilateral hernia repair surgery is indicated because of the left lower quadrant pain and the documentation of a hernia on two imaging modalities. Since there is evidence of a right sided hernia as well, it is clinically reasonable to repair both hernias at the same time. Thus, the requested surgery is supported as medically necessary for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the psychiatric residential treatment center (RTC) for treatment of the enrollees behavioral health issues. Findings:  The physician reviewer found that to objectively determine the appropriate level of care for the patient, the case was examined using the Child and Adolescent Level of Care Utilization System (CALOCUS). The patient was at significant risk of harm (score 3) with a history of suicide attempts and self-injurious behavior. The patient did not have any active suicidal or homicidal ideation. The patient demonstrated moderate functional impairment (score 3) since her substance use has impaired her ability to perform adequately in school. The patient has a co-morbidity of polysubstance use and depression (score 3). The patient has a moderately stressful recovery environment (score 3) that is supportive (score 2). The patients response to treatment has been equivocal (score 3) with prior outpatient treatment and inpatient treatment. She is at times obstructive with care and at other times will passively accept care. She has demonstrated an inconsistent capacity to deal with stressors and has demonstrated a limited ability to follow-up with treatment recommendations. Overall, the patient has been obstructive to treatment (score 3) and demonstrated distrustful relationships with providers. The patient acknowledged the existence of a problem but resisted accepting responsibility for perpetuation of the problem. She will frequently rationalize behaviors and consequences. She has a history of being noncompliant with treatment. This gives the patient a composite score of 20, which meets the criteria for a partial hospitalization program (PHP). The records indicate that although the patient continued to need treatment for her substance use and depression, she had progressed enough to be treated at a less restrictive environment. Therefore, the RTC were not medically necessary for treatment of the patients medical condition. Final Result: The reviewer determined that the services at issue were not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in psychiatry with sub-specialty certification in child and adolescent 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.
Appeal type: Medical Necessity
Decision: Upheld

A 21-year-old female enrollee requested authorization of the medication Protopic 0.1% for the treatment of alopecia areata.  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 medication is not medically necessary for treatment of the patients medical condition at this time.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary:  An enrollee has requested monitored anesthesia care (MAC) for treatment of the enrollees medical condition. The physician reviewer found that the services at issue were medically necessary for the patients screening colonoscopy. According to Abel and Eisenkraft Myasthenia gravis is a disease of great significance to the anesthesiologist, because it affects the neuromuscular junction. Anesthetic concerns for patients with myasthenia gravis include the interactions among the disease, the disease treatment, and the medications used for anesthesia. When sedating it is preferred to use ultrashort- or short-acting sedatives, hypnotics, and anesthetic agents to minimize respiratory depression. If premedication is necessary, the smallest effective dose should be administered incrementally with continuous monitoring for signs of bulbar weakness and respiratory compromise. This is difficult for the gastroenterologist as continuous visual monitoring of the patient is required. In addition, the medical literature suggests that propofol is the preferred agent for endoscopic procedures. Given the anesthetic concerns for this patient with myasthenia gravis, the MAC services were medically necessary for treatment of the patients medical condition. 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 internal medicine with sub-specialty certification in gastroenterology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

A 49-year-old female enrollee has requested for a screening colonoscopy for evaluation of her medical condition.  Findings:  The physician reviewer found that this patient appears to meet at least two of the approved indications for colonoscopy. First, she has had a pre-operative assessment of RLQ tenderness. Second, she reports a history of IBS that has not been substantiated; thus, there is suspicion of inflammatory bowel disease for which evaluation by colonoscopy is indicated.  In addition, if a colonoscopy is performed pre-operatively in this case and pathology is so determined, the colonoscopy may prove valuable, not only in re-directing the appropriate surgical approach but also for pre-operative marking for localization of a lesion.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested Cologuard stool testing for evaluation of the enrollees medical condition.  Findings: The physician reviewer found that the Cologuard stool has not been established as medically necessary for evaluation of the patients medical condition. Conventional assessment of colorectal cancer (CRC) risk largely involves detection of non-dysplastic adenomatous polyps. Cologuard demonstrates inadequate sensitivity to detect precancerous lesions. Moreover, there is a lack of peer-reviewed literature to support the medical necessity of Cologuard testing in lieu of endoscopic evaluation for suspected source of blood in stool. All told, the testing at issue was not medically necessary for treatment of the patients medical condition.Final Result: The reviewer determined that the testing at issue was 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 gastroenterology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld

A 57-year-old male enrollee has requested intensity modulated radiation therapy (IMRT), CPT codes 77338, 77301, 77385 and 77386 for treatment of his colon cancer. Findings:  Two physician reviewers found that in this case, the patient has recurrent cancer with multiple surgeries and other adjuvant treatments. The patient now has metastatic disease in mediastinum and retroperitoneal areas. This is a palliative condition which can be treated with a lower dose with conventional 3D conformal treatment. In addition, there is a lack of data demonstrating the safety and efficacy of IMRT in this patients clinical scenario. In fact, IMRT is still being evaluated in lung cancer. Moreover, there is no dose-volume histogram (DVH) comparison provided. For the reasons provided, IMRT is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a five-year-old male enrollee has requested speech therapy for treatment of the enrollees motor speech delay.  Findings:  The physician reviewer found that this patient has a phonological and articulation speech disorder. Speech therapy is helpful in managing the speech sound disorder, allowing the patient to identify and practice mature patterns of speech. An extensive review of the literature, including 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. An additional study notes that treatment for language disorders is predicated primarily on the childs language profile and level of communication skills (Feldman & Messick). Children who participate in speech-language treatment show better improvement than those children who have no treatment (Feldman & Messick). The treatment for articulation disorders is different from phonologic disorders. Articulation treatment techniques include how to produce target consonants, modeling, imitation, and using sequential steps to approximate accurate sound production. Phonologic disorders use a target rule to provide a difference in meaning (Feldman & Messick). The goal of therapy is always improvement in functional communication. Additionally, children with phonological and articulation disorders often experience embarrassment and poor self-esteem and speech therapy may reduce the negative consequences of the disorder and provide remediation. Thus, the speech therapy at issue was and is medically necessary for this patient.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a 16-year-old male enrollee has requested psychiatric residential care for treatment of the enrollees attention deficit hyperactivity disorder (ADHD) and Tourettes syndrome.  Findings:  The physician reviewer found that based on a review of the medical documents provided, this patient was a candidate for RTC level of care as he required intense services with 24-hour supervision. Given the level of safety concerns, deteriorating behavior, aggression, and the patients refusal to attend outpatient sessions, intense treatment in a 24-hour setting was medically necessary. This level of care is also consistent with the American Academy of Child and Adolescent Psychiatry (AACAP) and American Association of Community Psychiatrists (AACP) practice parameters and the Child and Adolescent Level of Care Utilization System (CALOCUS) guidelines. Therefore, the RTC services provided have been established as medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned

A 35-year-old male enrollee  requested the combination medications ribavirin, Sovaldi, and Pegasys for medical treatment of his hepatitis C genotype 4.  Findings:  The physician reviewer found that the American Association for the Study of Liver Diseases (AASLD) and the Infectious Diseases Society of America (IDSA) guidelines allow for a delay in treatment for some patients with documented early fibrosis stage, because waiting for future highly effective, pan-genotypic, DAA combinations in interferon-free regimens may be prudent. However, this patient has no contraindication to interferon-based treatment and is motivated to begin therapy to prevent further progression of disease. Per AASLD/IDSA guidelines, few data are available to help guide decision making in patients infected with HCV genotype 4. The guidelines indicate that treatment naive patients with HCV genotype 4 who are eligible to receive interferon should include daily sofosbuvir and weight-based ribavirin plus weekly Pegasys for 12 weeks. Given these findings, the requested medication combination therapy including ribavirin, Sovaldi, and Pegasys is medically necessary for treatment of this patients chronic hepatitis C.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary:  The parent of an enrollee has requested authorization and coverage for Benesch boot for treatment of the enrollee's congenital metatarsus adductus.Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested equipment. It is well noted in the medical literature that the standard of care for mild metatarsus adductus is observation, and the majority will resolve without any intervention.  In fact, even physical therapy to stretch the foot in the opposite direction could result in a curvature of the foot in the opposite direction. The literature states that typically orthotics have been shown to be of benefit only in cases of moderate to severe conditions.  Surgery is typical only in cases of severe metatarsus adductus, and generally only after failure of serial casting. The records do not document that the patients condition has been classified as either moderate or severe. All told, the requested Benesch boot is not medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested equipment is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in pediatrics 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 46-year-old male enrollee has requested Synvisc injections for treatment of his osteoarthritis. Findings:  Two physician reviewers found that the patient is relatively young and has severe osteoarthritis in his left knee.  Although he will eventually require knee replacement, a second series of injections is a reasonable alternative at this time. The first series was performed more than eight months ago and resulted in significant relief. A repeat series of Synvisc injections is medically appropriate and can reasonably be expected to alleviate his pain and postpone the need for surgical intervention.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary:  An enrollee has requested a continuous passive motion (CPM) machine for treatment of his medical condition status post total knee replacement surgery.  The physician reviewer found that review of the recent literature as reported by Harvey and colleagues suggests that there was moderate quality evidence to indicate that CPM does not have clinically important short-term effects on active knee flexion range of motion improvement. In addition, Denis and colleagues conducted a randomized controlled clinical trial to compare the effectiveness of three inpatient rehabilitation programs with and without CPM for range of motion in knee flexion and knee extension, functional ability, and length of stay after primary total knee arthroplasty. The authors found that the results of the study do not support the addition of CPM applications to conventional physical therapy after primary total knee arthroplasty as applied in this clinical trial. In light of the foregoing, the postoperative use of CPM is not supported as medically necessary for treatment of this patients medical condition. Final Result: The reviewer determined that the device at issue was 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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for ovarian vein embolization.Findings: Two out of three physician reviewers found that the requested ovarian vein embolization is likely to be more beneficial than any other available standard treatments for the patients medical condition.There is sufficient support for the requested services in this clinical setting. Gonadal vein embolization is an appropriately accepted practice in the medical community. Case reports have shown the benefit of this procedure. These studies are difficult to compare, however, due to a number of factors including different diagnostic criteria and techniques for diagnosis and treatment, as well as a failure to provide standardized evaluation of symptoms before and after treatment. Despite these limitations, the reported technical success rates of ovarian vein embolization range from 89 to 100 percent with clinical success rates of 58 to 100 percent (follow-up period of up to five years). Complication rates of 4 to 8 percent have been reported for ovarian vein embolization. Gonadal vein embolization is safe, well-tolerated, and allows for a minimally invasive approach. In this case, the patient has clinical findings and imaging studies that are suggestive of pelvic congestion syndrome. Based on the currently available data, gonadal vein thrombosis for the treatment of imaging proven pelvic congestion syndrome is a medically appropriate intervention and is considered standard therapy for this condition. Thus, the requested ovarian vein embolization is likely to be more beneficial than any other available standard treatments for the patients medical condition.Final Result: The reviewers determined that the requested services are likely to be more beneficial than any other available standard treatments for the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: Physician reviewers 1, 2 and 3 are board certified in obstetrics and gynecology and are actively practicing. All three reviewers are experts in the treatment of the enrollees medical condition and are 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: A enrollee has requested authorization and coverage for an ultralight manual wheelchair. The request for an ultralight manual wheelchair is not medically necessary for treatment of this patients medical condition. The documentation indicates that the patient has a mobility deficit. However, the documentation does not reveal that this mobility deficit cannot be helped by the use of an appropriately fitted manual wheelchair or that the patient has failed an appropriately fitted standard manual wheelchair. The physical therapy mobility evaluation reveals that the patients needs can be met with his current wheelchair and that he should have an evaluation in the future to assess his functional needs as he has not yet demonstrated the ability to be functional in general wheelchair use. The documentation does not support that an ultralight manual wheelchair is medically necessary for this patient. Final Result: The reviewer determined that the requested equipment is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in physical medicine and rehabilitation with sub-specialty certification in neuromuscular 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.