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

Nature of Statutory Criteria/Case Summary:  An enrollee has requested magnetic resonance imaging (MRI) of the hands for evaluation of his hand pain.  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested services.  In the clinical setting of trauma, where an obvious cause is not apparent, MRI may be beneficial in detecting occult fractures or contusions.   Similarly, where there is a specific tendon injury or localized symptoms, MRI will provide the best imaging available.  Other etiologies, including tumors, cysts, and infection also may be appropriately evaluated with MRI.  Per the medical evidence, MRI has also been helpful in the early diagnosis of rheumatoid arthritis.  However, in this patients case, the records do not support the requested services.  His pain is not reportedly localized.  The records indicate that his pain is bilateral.  There are no reported objective signs, and there is no indication of a systemic arthritis.  An MRI is not appropriate in this clinical setting of generalized pain and is not likely to alter the patients treatment.  All told, the requested MRI of the hands is not medically indicated for the evaluation of this patient. Final Result: The reviewer determined that the requested services are 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 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

A male enrollee requested urgent care services on an emergent basis. Findings:  The physician reviewer found that this patient presented to the urgent care in no acute stress, with symptoms of watery stool present for five days and with no vomiting. In this clinical setting he could have made an appointment with his primary care physician for evaluation. The patient did not have fever, vomiting, weight loss, and his vital signs were normal. Moreover, the patient was not 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. In sum, the services did not meet prudent layperson criteria for emergency care.
Appeal type: Medical Necessity
Decision: Upheld

A 57-year-old female enrollee has requested a power-operated vehicle (POV) for mobility.  Findings:  The physician reviewer found that she does not meet Medicare guidelines for a POV. She is not totally non-ambulatory and does not have weakness of the upper extremities. Though the patient does have a mobility deficit, which can cause increased risk of morbidity during her activities of daily living, this can be corrected with the use of a manual wheelchair. Given the absence of any documented upper extremity complaints, the patient should be able to operate a manual wheelchair.
Appeal type: Medical Necessity
Decision: Upheld

The representative of a 27-year-old male enrollee has requested a neuropsychological panel assessment for evaluation of his behavioral health issues.   Findings:  The physician reviewer found that this patient has a long history of developmental disabilities. The patient has mood dysregulation and is appropriately managed on valproate and an antipsychotic medication. The patient is now transitioning into his young adult years and is presenting with ongoing behavioral problems. His parent has requested additional services to assist her with the management of this patient. In the medical literature, there has been a substantial increase in recognition of autism over the past few decades. However, this patients records do not support a diagnosis of autism at this time. Specifically, there appears to be no objective evidence that the patient meets diagnostic criteria for autism. Therefore, the requested neuropsychological panel assessment is not medically necessary for further evaluation of this patients medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for intensity modulated radiation therapy (IMRT) with image guided radiation therapy (IGRT). Findings:  The physician reviewer found that there is sufficient support in the medical literature for the efficacy of requested services in this clinical setting. In general, IMRT is not an experimental technique, but rather a radiation planning and delivery tool available to the radiation oncologist to better shape the radiation dose distribution, and therefore minimize the dose to normal structures. IMRT is a tool that clinicians can use when there is concern about sparing normal tissues from high dose exposure. IGRT is a means of using daily image guidance to help localize the target so as to minimize normal tissue dosing. IGRT allows accuracy of treatment delivery, so when generating a planning target margin, the margins can be reduced, and thus allow reduction in the volume of normal tissues exposed to radiation. IGRT images can be obtained prior to treatment on a daily basis (interfraction IGRT), and/or before and during radiation (intrafraction IGRT). The data that supports pelvic/prostate therapy is not for routine use in patients with metastatic disease, but something that could be considered in select patients. For this patient who has a single oligometastasis to be treated with SBRT, IMRT may maintain acceptable radiation exposure to the bowel, bladder and rectum. It is plausible that without IMRT, the patient would be at a significant risk of toxicity from radiation, and that IMRT would appreciably reduce the toxicity risks. The clinical records support that this patient is well selected for radiation. This patient would benefit and would better tolerate IMRT therapy to the prostate and pelvic nodes. Therefore, IMRT with IGRT is likely to be more efficacious than the available modalities for the treatment of this patients medical condition.Final Result: The reviewers  two of the three  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: Physician reviewers are board certified in radiation 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: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for bowel retraining therapy without biofeedback for treatment of his severe outlet constipation. Findings:  The physician reviewer found that there are a number of causes for obstructed defecation syndrome and pelvic floor dysfunction such as rectocele, rectal intussusception, paradoxical muscular contraction, descending perineum syndrome, sigmoidocele, or enterocele. Some of these are structural anatomical issues, but others are functional issues with normal anatomy. Bowel retraining therapy can be effective, and should be attempted before any more invasive intervention is considered. Unlike biofeedback therapy, bowel and pelvic floor retraining are easily translated into activities of daily living because the sensory cues of biofeedback therapy are not applied in training. In this case, the test confirmed a functional component to the patients outlet constipation. 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 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: Upheld

A 48-year-old female enrollee requested authorization and coverage of a panniculectomy. The Health Plan denied the request indicating that the requested procedure is not medically necessary for treatment of the enrollees excess skin.One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer upheld the Health Plans denial on the basis that the requested procedure is not medically necessary.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: A 57-year-old male enrollee has requested authorization and coverage for Zepatier 50-100 mg for 12 weeks for treatment of the enrollees hepatitis C virus. Findings:  The physician reviewer found that According to the joint guidelines issued by the American Association for the Study of Liver Diseases (AASLD) and the Infectious Diseases Society of America (IDSA), all patients with chronic hepatitis C should be treated except those with limited life expectancy due to non-liver-related conditions. This recommendation applies to all patients, regardless of fibrosis stage. The guidelines recommend that treatment naive genotype 1a patients should be treated with regimens including or Zepatier for 12 weeks when NS5A resistance is not found. These guideline recommendations are based on clinical trial results showing a 99% cure rate when NS5A resistance is absent. AASLD/IDSA guidelines cite data showing reduced survival with delayed treatment. For these reasons, treatment with Zepatier for 12 weeks is medically necessary for the treatment of this patients hepatitis C infection. Final Result: The reviewer determined that the requested medication is 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: Upheld

The parent of a five-year-old male enrollee has requested speech therapy services, two times per week for three months for treatment of the enrollees communicative disorder and developmental dysarthria. Findings:  The physician reviewer found that the reports written were performed by two different therapists. In the second report, the therapist changed the goal for word production from 80% to 90% accuracy. However, she did not document whether he achieved the 80% accuracy goal documented in the first report.  In addition, the Expressive One-Word Picture Vocabulary Test in the initial report gives an age equivalent of one year seven months, but states that this was estimated based on the parents report.  Thus, this was not an objective finding.  This test was not performed in the second report.  The second Receptive One-Word Picture Vocabulary Test performed showed an age equivalent score of four years six months, but they were unable to perform the test in the previous year.  The therapist did not specifically document whether he achieved the goals outlined in the first report.  Based upon the submitted documentation, it cannot be determined whether the patient has made functional gains from speech therapy.  All told, the medical necessity of speech therapy, two times per week for three months, has not been established by the submitted documentation.
Appeal type: Medical Necessity
Decision: Upheld

A 40-year-old male enrollee has requested the prescription medication Lyrica for treatment of his neck and back pain. Findings:  The physician reviewer found that the patient has been diagnosed with cervical dystonia and is being treated appropriately. Lyrica is not indicated for the pain associated with cervical dystonia. This residual pain is likely to respond to any of a number of interventions including more aggressive Botox therapy, muscle relaxants, Gabapentin or Amitriptyline. The use of Lyrica for this patient would not be considered the standard of care.
Appeal type: Medical Necessity
Decision: Upheld

The patient is a 39-year-old female who has a body mass index (BMI) of 38.1. She has joint pain, hiatal hernia, and GERD. She has requested authorization for gastric bypass surgery. The Health Plan has denied authorization for the requested procedure on the basis that it is not medically necessary.With a BMI of 38 and no significant comorbid condition, the patient does not meet nationally accepted medical necessity criteria for consideration of weight loss surgery. There is potential that further attempts at conservative weight loss will be successful. Furthermore, as the patient has the potential for further weight loss through conservative means, the risks of weight loss surgery outweigh the potential benefits of the procedure. Therefore, I have determined that the requested procedure is not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld

A 32-year-old female enrollee has requested for brain MRI for evaluation of her severe migraines.    Findings:  The physician reviewer found that the incidence of intracranial pathology in patients with migraine is no different than the general population. The neuro-imaging guidelines from the US Headache Consortium and the American Academy of Neurology specifically state that neuro-imaging (CT or MRI) is not medically necessary unless the patient has atypical features.
Appeal type: Experimental/Investigational
Decision: Upheld

Physician 1: The patient is a 54-year-old female who has been diagnosed with degenerative disc disease at three levels. Her physician has indicated she has tried and failed several attempts at conservative treatment including physical therapy and chiropractic care. Her physician has recommended the patient undergo artificial disc replacement at multiple levels. The Health Plan has denied this request indicating the requested procedure is experimental in nature.The patient has documented degenerative disc disease at three levels in the lumbar spine. There is no data to support artificial disc surgery at multiple levels. Additionally, there are no long-term outcomes studies. The proposed procedure is purely experimental. Given the lack of long-term data, I have determined that the requested procedure is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Plans denial should be upheld.Physician 2: The patient is a 54-year-old female with degenerative disc disease who has failed medications for pain and physical therapy and chiropractic manipulation. Her physician has recommended the patient undergo artificial disc replacement at multiple levels. The Health Plan has denied this procedure indicating the requested procedure is experimental and not a covered benefit.The use of multi-level artificial disc replacement in patients with degenerative disc disease is clearly investigational and without scientific merit. The existing studies do not show a major short-term advantage over fusion for one level disease. The use in this patient of multiple level disc replacement is not consistent with existing literature and cannot be recommended. Therefore, I have determined that the requested procedure is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Plans denial should be upheld.Physician 3: The patient is a 54-year-old female with degenerative disc disease. She is requesting multi-level artificial disc replacement. The Health Plan has denied authorization and coverage for the requested procedure on the basis it is experimental. Artificial disc replacement remains an experimental procedure without established clinical efficacy. There is no appreciable benefit conferred with the use of the artificial disc replacement. It remains an unproven procedure without established benefit. Therefore, I have determined that the requested procedure is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld

A 51-year-old male enrollee has requested proton beam therapy for treatment of his esophageal cancer. Findings:  The physician reviewer found that proton beam therapy is an FDA-approved tool available to clinicians to treat patients with radiotherapy. For distal esophageal/gastroesophageal junction cancer, proton beam therapy is one of several options. At this time, proton beam therapy is not considered medically necessary in this setting as there is limited data to support its use; and while there are some dosimetric advantages, there are also dosimetric disadvantages. For this particular patient, the dosimetric advantage was not in the maximal doses to critical organs such as heart, liver and esophagus, but rather the mean and lower integral dose delivery, which may not be clinically meaningful. There is inadequate evidence that proton beam therapy was a superior option compared to IMRT or conventional 3-D radiation, which are considered the standard therapies for the treatment of this patients disease. As such, proton beam therapy was not medically necessary in this case.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for a hysteroscopy myomectomy procedure under a tertiary level of care. Vilos and colleagues note that for symptomatic fibroids causing menstrual abnormalities such as heavy, irregular, and prolonged uterine bleeding, hysterectomy is a definitive solution. The authors further stated that hysteroscopic myomectomy should be considered first-line conservative surgical therapy for the management of symptomatic intracavitary fibroids.  In this case, the patients fibroids have resulted in a significant bleeding pattern requiring iron infusion therapy, emergent evaluations for heavy bleeding episodes. She has not responded to hormonal medication therapy. Evidence-based practice supports surgical intervention as medically indicated and clinically appropriate to treat this patients condition. Therefore, a hysteroscopy myomectomy procedure under a tertiary level of care is medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested treatment is 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 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.
Appeal type: Experimental/Investigational
Decision: Upheld

A 48-year-old male enrollee requested authorization and coverage of metal-on-metal hip resurfacing for the treatment of osteoarthritis.  The health plan denied the enrollees request indicating that the requested procedure is considered experimental.Three physician reviewers performed an experimental/investigational Independent Medical Review. All three physician reviewers concluded that the metal-on-metal hip resurfacing is not likely to be more beneficial for treatment of the enrollees osteoarthritis than any available standard therapy.  Because all three-physician reviewers concluded that the requested procedure is not likely to be more beneficial for treatment of the enrollees medical condition than any available standard therapy, the review organization upheld the health plans denial.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Jublia 10% solution. A study notes there are several treatment options for onychomycosis, or fungal infection of the nail, including oral antifungals, topicals and devices. Oral antifungals, such as terbinafine, have higher cure rates and shorter treatment periods than topical treatments, while topical treatments, such as efinaconazole, have less serious side effects than oral antifungals, but also have generally lower cure rates and much longer treatment regimens. The U.S. Food and Drug Administration (FDA) approves the use of Jublia (efinaconazole) 10% solution for the topical treatment of onychomycosis of the toenails, administered once daily for 48 weeks. In this case, the patient has a long documented history of onychomycosis. The records document a clinical history of improvement on topical Jublia 10% solution.  There is sufficient support for the requested medication in this clinical setting. Therefore, Jublia 10% solution is medically necessary for the treatment of this patient.   Final Result: The reviewer determined that the requested medication is 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 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.