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

The patient is a 34-year-old male with multiple neurofibromatosis with associated chronic pain. The patient is status post multiple surgeries and is recalcitrant to several medications and injection therapies. The patients provider indicates the patient has been tried on Actiq and has obtained significant relief. The Health Plan has denied coverage for Actiq on the basis it is not medically indicated for treatment of the patients condition. Although Actiq is used primarily in the treatment of cancer pain, it is also used for patients with severe pain due to other organic etiologies that are recalcitrant to multiple attempts with standard therapies and medications. This patient has demonstrated ineffectiveness of multiple treatment options including injections and several narcotic medications. Actiq appears to have been significantly better than other available therapies for treatment of this patients pain and therefore, should be authorized. Accordingly, I have determined that the requested medication is medically necessary for treatment of the patients medical condition. The Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Overturned

The patient is a 55-year-old male with bilateral knee pain from osteoarthritis. He was treated with a series of Synvisc injections in 2003 and a second in April 2005 with good results.  He is now requesting authorization for a third series of Synvisc injections to treat his knee pain. The Health Plan denied the request based upon a determination that the requested therapy is not medically necessary.The use of Synvisc for osteoarthritis is an established course of treatment. In some cases relief is provided for an extended period of time. In this case two years elapsed between the first and second series and six months between the second series and the request for the third series. A repeat series is reasonable for patients who get relief from the previous treatment.  In this case, the second series of Synvisc injections was helpful, and therefore a third and final series is appropriate to attempt to alleviate the patients pain. Accordingly, I have determined the requested therapy is medically necessary for treatment of the patients medical condition. The Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Overturned

The patient has requested reimbursement and prospective authorization and coverage for acupuncture services. The records provided for review indicates that this patient is status post shoulder surgery with subsequent frozen shoulder. The patient reports severe pain and a limited range of motion, which has delayed his ability to progress in physical therapy. The patient underwent treatment with acupuncture before and after surgery with gains described as significant pain relief and improved range of motion. Current medical literature supports a role for acupuncture in this clinical setting. Medical literature notes that acupuncture is an effective long-term treatment for patients with shoulder pain (from soft tissues lesions). Based on the peer-reviewed medical literature and this patients prior response to care, the acupuncture treatment and five additional acupuncture treatment sessions were and are medically necessary for treatment of this patient. Final Result: The reviewer determined that a portion of the services at issue were and are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be partially overturned. Credentials/Qualifications: The reviewer is board certified in oriental 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

Nature of Statutory Criteria/Case Summary: An enrollee has requested air ambulance and associated ground ambulance transportation services for treatment of the enrollees medical condition.  Findings: The physician reviewer found that the air ambulance and associated ground ambulance transportation services was medically necessary for treatment of the patients medical condition. There is sufficient support in the peer-reviewed literature to support the services at issue in this clinical setting. Herzer and colleagues found an association between time to rehabilitation after a spinal cord injury (SCI) and lower functional level, concluding that Earlier rehabilitation following traumatic SCI may improve patients functional status at discharge. In this case, the patient sustained a cervical spinal cord injury some distance from home. Timely rehabilitation can minimize health risks and improve functional outcomes. Transport home by air ambulance was medically necessary for the patient to receive early specialized rehabilitation in close proximity to his support network. As such, the air ambulance and associated ground ambulance transportation services have been established as 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 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.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for a Synvisc-One injection in the right ankle. Per the medical literature, although viscosupplementation may relieve ankle pain in some individuals with osteoarthritis, it is not known as to which individuals will benefit. The current evidence is limited, and guidelines from organizations such as the American Academy of Orthopedic Surgeons indicate that the evidence is not conclusive. In light of the foregoing, viscosupplementation can only be recommended in individuals with a history of lasting benefit from prior injections, and in carefully selected cases where everything else has been tried, and the options are limited. In this case, the patient has a history of relief from a prior injection and has tried and failed conservative treatments. Given the patients limited options and based on the current medical literature, the requested services are medically indicated. Therefore, a Synvisc-One injection in the right ankle is medically necessary for the treatment 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 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: Upheld

A 32-year-old female enrollee requested authorization and coverage of jaw surgery. The Health Plan denied the request indicating that the requested procedure is not medically necessary for treatment of the enrollees jaw pain.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 at this time.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for breast augmentation. This patients records document male-to-female transition with orchiectomy and treatment for at least three years with hormones. The patients providers have documented persistent gender dysphoria with regard to the patients chest. Her providers have recommended feminizing mammoplasty. The World Professional Association for Transgender Health (WPATH) Standards of Care acknowledges that, For certain patients, an intervention like a reduction rhinoplasty can have a radical and permanent effect on their quality of life, and therefore is much more medically necessary than for somebody without gender dysphoria. The WPATH noted that feminizing mammoplasty for the male-to-female patient is often of greater practical significance in the patients daily life than reconstruction of the genitals. Moreover, the requested breast augmentation surgery is in accordance with the generally accepted standards of mental health and substance use disorder care, clinically appropriate in terms of type, frequency, extent, site, and duration, and not primarily for the convenience of the patient or provider. Given these findings, the requested breast augmentation is medically necessary for treatment 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 psychiatry with expertise in transgender health 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 the magnetic resonance imaging (MRI). Findings:  The physician reviewer found that the documentation submitted for review does not support a medical indication for MRI. Thyroid cancer is the most common of the endocrine neoplasms. There are multiple different cell types, and the survival rates and rates of recurrence are highly related to specific cell type. Treatment of thyroid cancer is most commonly a total thyroidectomy followed by radioactive iodine as was performed in this case. The modalities most commonly used in suspected cases of metastasis are direct physical exam, ultrasound, thyroglobulin monitoring, chest x-rays, computed tomography (CT) scanning, and positron emission tomography/computed tomography (PET/CT) scanning. A study discussed current surveillance strategies of differentiated thyroid cancer. The authors stated that Current surveillance strategies rely primarily on serial serum thyroglobulin (Tg) measurements in combination with cervical sonography to identify local-regional nodal recurrence and image-guided fine needle aspiration (FNA) of suspicious lesions. The authors further discuss the use of PET/CT scanning in patients with metastases. There is a lack of published studies that recommend MRI as a first-line diagnostic procedure in the evaluation of recurrence.  Moreover, the National Comprehensive Cancer Network (NCCN) recommends physical examination and sonography as surveillance. In this case, there is a lack of clinical rationale to suspect that the patients three to four days of neck pain and chest pain were related to her thyroid cancer diagnosis. Further, there were no physical findings to warrant MRI. All told, the MRI was not medically necessary for evaluation of the patients medical condition. Final Result: The reviewer determined that the diagnostic procedure at issue was not medically necessary for evaluation of the patients medical condition. Therefore, the Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned

The enrollee is requesting authorization and coverage for residential treatment center (RTC) level of care services. The enrollee has opioid use disorder, severe; suicidal ideations; major depressive disorder, and generalized anxiety disorder. The Level of Care Utilization System (LOCUS), developed by the American Association of Community Psychiatrists, is a level of care assessment tool widely used by clinicians throughout the country to support accurate level of care recommendations. The six dimensions of LOCUS include risk of harm, functional status, comorbidity, recovery environment, level of support, and treatment and recovery history. For risk of harm there is no active suicidal/homicidal ideation exists, but extreme distress and/or a history of suicidal/homicidal behavior exists. The enrollee engages in excessive use of substances, resulting in potentially harmful behaviors, without current involvement in such behavior. For functional status, there is significant disturbances in vegetative activities, such as sleep, eating habits, activity level, or sexual appetite, which do not pose a serious threat to health. Recent gains and or stabilization in function have been achieved while participating in treatment in a structured and /or protected setting. For comorbidity, the enrollee has significant psychiatric symptoms and signs are present which are themselves somewhat debilitating, and which interact with and have an adverse affect on the course and severity of any co-existing substance use disorder. For recovery environment level of stress, the enrollee has difficulty avoiding exposure to active users and other pressures to partake in alcohol or drug use. For recovery environment level of support, the enrollee has a few supportive resources that exist in the current environment and may be capable of providing some help if needed. For treatment and recovery history, the enrollee attempts to maintain whatever gains that can be attained in intensive treatment have limited success, even for limited time periods or in structured settings. The enrollee does not use available resources independently, or only uses them in cases of extreme need. The enrollees composite LOCUS score is 23, which correlates with Level 5, medically monitored residential services.Final Result: The reviewer determined that the requested service is not medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The physician reviewer is board certified 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 similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has been diagnosed with articular disc disorder of the temporomandibular joint (TMJ). The patient reported jaw clicking, neck pain, and ringing in the ears. Physical examination findings included no mandible deflection. Clicking was noted with opening and closing of the mouth. Muscle spasm and pain were noted in the craniofacial muscles. The patient has requested authorization and coverage for a mouth guard for the TMJ.  The Health Plan denied the request and reported the requested device is not medically necessary for the treatment of this patient. At issue in this case is whether a mouth guard for the TMJ is medically necessary for the treatment of the patients medical condition. Zhang and colleagues reported, The results indicated that splint therapy increased maximal mouth opening (MMO) for patients with a MMO less than 45mm and reduced pain intensity measured using the visual analogue scale (VAS) for patients with temporomandibular disorders (TMD) without specific description (TMDSD). Splint therapy also reduced the frequency of painful episodes for patients with TMJ clicking. Ebrahim and colleagues reported, Although overall results are promising for the reduction of pain, establishing the role of splints for patients with TMDs will require large trials with stronger safeguards against bias. In this case, there is no medical etiology identified in the medical records for the patients symptoms. There was also no note of discomfort in the muscles of mastication or splint therapy attempts to alleviate the muscular aspect of the symptoms. The medical evidence does not support the requested device in this clinical setting. Therefore, a mouth guard for the temporomandibular joint is not medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested device is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is a licensed Doctor of Dental 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

The patient is a 50-year-old female seeking authorization for lower body contouring to improve the results of liposuction of the thighs. She has seen a number of providers regarding body contouring. The Health Plan has denied authorization for the requested procedure.The photographs and other information submitted provides no evidence that the requested procedure is medically necessary. There is no evidence the patient has functional deficits which could be corrected by the requested procedure. In addition, there is potential the requested procedure would not fully improve the results of the previous liposuction. There is no medical justification for the requested procedure. Therefore, I have determined the requested procedure is not medically necessary for treatment of the patients condition. The Health Plans denial should be upheld.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the advanced lipoprotein testing. Based on the records provided, the patient presented with some cardiovascular risk, given her diagnoses of hypertension, hyperlipidemia, and abnormal liver panel, and obesity. In this circumstance, guidelines for the management of cardiac risk and dyslipidemia have been established, are periodically updated by expert committees and are endorsed by several national organizations. These guidelines do not recommend routine performance of specialized tests in the context of assessing coronary risk, including lipoprotein associated phospholipase A2, sub-classifications of low density lipoprotein (LDL) cholesterol, high density lipoprotein (HDL) cholesterol subclasses, lipoprotein (a), C-reactive protein (CRP), high sensitivity CRP, and homocysteine. Treatment changes or additions based on the results of screening with these specialized tests has not been shown to improve cardiac outcome incremental to that achievable by treatment based on standard risk factor profiling and basic lipid analysis. Accordingly, the advanced lipoprotein testing was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.  Findings:  Three physician reviewers found the advanced lipoprotein testing was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. For these reasons, the Health Plans denial should be overturned. Final Result: The reviewers determined that the services at issue were not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. For these reasons, the Health Plans denial should be upheld.Credentials/Qualifications: Physician reviewers 1, 2 and 3 are board certified in internal medicine with subspecialty certification in cardiovascular disease 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

Nature of Statutory Criteria/Case Summary: A parent of an enrollee has requested authorization and coverage for continuation of speech and language therapy. Findings:  The physician reviewer found that according to a study  Empirical evidence exists for many of the different interventions in speech-language pathology. However, relatively little is known about the optimal intensity of those interventions. In this case, the patient been receiving speech therapy since October 2015. At the onset of speech therapy, testing indicated comprehensive language at five years and three months and expressive language of three year three month of age equivalency.  After one year of speech therapy repeat testing indicated similar scores. The records submitted for review demonstrate, that this patient has not had significant improvement in either expressive or speech comprehension after a year of speech therapy. Final Result: The reviewer determined that the requested therapy 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 qualification in child neurology 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 patient is a 41-year-old female with multiple myeloma serologically relapsed following induction chemotherapy and allogeneic transplantation. She is somewhat intolerant of thalidomide and has an increasing M-spike. She is in good clinical condition. The patient has requested authorization for a cancer treatment protocol offered by an out-of-network provider involving melphalan and Velcade.The proposed treatment protocol is medically appropriate for this patient and should be authorized. Myeloma patients who have progressed following or during melphalan chemotherapy may respond again to remarkably lower doses when given in combination with arsenic trioxide or Velcade. As such, the proposed treatment protocol is medically reasonable and indicated for patients such as this patient. Therefore, I have determined that the requested protocol is medically necessary for treatment of the patients medical condition. The Health Plans denial should be overturned.