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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for inpatient treatment with electroconvulsive therapy (ECT).The submitted documentation supports that the requested inpatient treatment with electroconvulsive therapy (ECT) is medically necessary for the patient. Researchers have noted that the rapid relief of severe depression, mania, and psychosis by electroconvulsive therapy (ECT) is accompanied by the rapid reduction in suicide drive. In this case, the patient has multiple risk factors that are consistent with Centers for Disease Control and Prevention (CDC) Risk Factors for Suicide. The patient is single, living alone, has bipolar disorder, is unemployed, has a history of trauma (an abusive boyfriend), has suicidal ideation, would be returning to an unsupportive environment, and was hopeless and helpless. The patients chart includes the indication that she was depressed and had suicidal ideation, and the chart indicated that ECT had not kicked in. It is common for ECT to not yet have effect under such circumstances, especially as the patients first four treatments prior to admission are unavailable for review, and the patient had only received two ECT treatments at this point in her hospitalization. The submitted documentation does not support that the patient was ready for discharge, given the patients suicidal ideation and her ongoing symptoms through discharge. Given the patients risk factors for suicide and the evidence that ECT relieves the suicidal drive of bipolar depression, ongoing ECT in the safe environment of the inpatient setting was, and is, in accordance with generally accepted standards of medical practice and clinically appropriate for the patient's illness. Accordingly, the requested inpatient treatment with electroconvulsive therapy (ECT) is medically necessary for treatment of the patients medical condition.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 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 brain magnetic resonance imaging (MRI) (CPT 70551) and brain magnetic resonance angiogram (MRA) (CPT 70544) for evaluation of his medical condition. The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested services.  This patient has new onset of skin sensitivity and facial pain.  The guidelines for appropriate imaging in headache disorders suggest that MRI is preferable to computed tomography (CT), as it is better able to evaluate clinically relevant pathology, especially in the posterior fossa.  MRA is appropriate to evaluate suspected vascular lesions such as aneurysm, arteriovenous malformations or dissection.  As noted by Sudlow, imaging detected a serious abnormality in only a very small proportion (less than 0.5%) of patients without abnormal neurological signs who presented with chronic headache or migraine or tension type headache.  The authors noted that this is no greater than the proportion of completely asymptomatic individuals in whom a serious abnormality was detected on a magnetic resonance brain scan.  In this patients case, the records do not suggest a secondary cause of headache which would necessitate the requested services.  All told, the requested brain MRI and brain MRA are 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 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

Nature of Statutory Criteria/Case Summary: The patient has a history of osteoarthritis of both knees, currently more symptomatic on the left. There is a history of a fall in the past, but no recent mechanical symptoms. Previous examination revealed medial and lateral joint line tenderness. Later, a magnetic resonance imaging (MRI) scan of the left knee revealed tricompartmental osteoarthritis with several full thickness cartilage defects of the medial femoral condyle, moderate- to high-grade thinning of the articular cartilage of the lateral compartment, and moderate osteoarthritis of the patellofemoral joint. There was also a flap tear of the lateral meniscus noted. Evidence of old trauma with chronic sprains was documented. Examination later reported the patient presented with left knee pain. The provider reported the patient had Orthovisc several times in the past which helped. The patient reported a recent cortisone shot only lasted three weeks. The patient has had Orthovisc injections in multiple past years. The patient has requested authorization and coverage for Orthovisc injections in the left knee. Current medical literature reveals mixed results regarding viscosupplementation. Randomized controlled trials indicates that although viscosupplementation may relieve knee pain in some individuals with osteoarthritis, it is not known which individuals will benefit. Different studies have tried mixing hyaluronic acid with corticosteroids, platelet rich plasma, and other agents to make it more effective. Current evidence is limited, and guidelines from organizations such as the American Academy of Orthopaedic Surgeons indicate that the evidence is not conclusive. As such, the American Academy of Orthopaedic Surgeons does not currently support viscosupplementation as standard treatment for osteoarthritis of the knees. Viscosupplementation can be recommended in individuals with a history of lasting benefit from prior injections and in carefully selected cases where the options are limited. In this case, the patient has had lasting benefit from prior Orthovisc injections. Therefore, Orthovisc injections in the left knee are 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: Experimental/Investigational
Decision: Upheld

The enrollee requested authorization and coverage for prolotherapy at the right sternoclavicular joint. An x-ray showed right sternoclavicular joint subluxation. The enrollee reported pain across his trapezius and anterior chest wall. Records show the enrollee tried one session of physical therapy, and taping, without benefit. The physician recommended the continuation of exercise and taping, and the enrollee was referred to a sports medicine clinic. If the enrollees pain did not improve, the plan was for a steroid injection or prolotherapy at the sternoclavicular joint. The enrollee states he has been diligent in his attempts towards treating his condition using conventional means and prolotherapy is now his only available option. Data on the effectiveness of dextrose prolotherapy for temporomandibular dysfunction are promising, but insufficient for recommendations. A governmental agencys report on prolotherapy showed that, compared to no-injection controls, prolotherapy injections produced an inflammatory response; however, the response was similar to that seen with needle-stick and saline-injection controls.  Other researchers indicate the efficacy of dextrose prolotherapy, in acute pain, as first-line therapy, and in myofascial pain, cannot be determined from the literature. Medical records do not support attempts at appropriate conservative care, as the records show only one session of physical therapy was attempted.Final Result: Two of the three reviewers determined that the requested service is not likely to be more beneficial than any available standard therapy for treatment of the enrollees medical condition. Credentials/Qualifications: Three reviewers are board certified in orthopedic surgery and are actively practicing.  All three reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

A 47-year-old male enrollee has requested for IVIG (intravenous immune globulin) therapy for treatment of his chronic inflammatory demyelinating polyneuropathy.  Findings:  The physician reviewer found that a diagnosis of CIDP is typically made in the presence of proximal and distal weakness, with large fiber sensory loss and areflexia.  In addition, increased cerebrospinal fluid (CSF) protein and demyelinating changes on nerve biopsy are supportive of the diagnosis. Electrodiagnostic findings of multifocal conduction block or temporal dispersion of compound muscle action potential, prolonged distal latencies, and variable conduction slowing to less than 70% of normal, absent or prolonged F-wave latencies are all supportive of this diagnosis.
Appeal type: Medical Necessity
Decision: Upheld

An enrollee has requested authorization and coverage for Nutropin AQ NuSpin 20 mg/2 mL (10 mg/mL). The patient has normal stature, his bone age is not delayed more than 2 standard deviation (SD) below the mean for his age and gender.  His IGF-1 level is appropriate for pubertal stage and he has passed provocative GH testing on two occasions. The records do not indicate he has known morphological abnormalities of the pituitary gland. The most likely cause of the patients falls off in growth from the 75-25th percentile between ages 11 through 13 may be attributed to constitutional delay, likely exacerbated by the effect of stimulant medication and his underlying diagnosis of ADHD. He responded with a transient increase in growth velocity after a short course of testosterone, but growth slowed after discontinuation of testosterone as he was not far enough along in his puberty to expect a continued acceleration in growth. In addition, clinical notes indicate that he has remained on stimulant therapy for ADHD. According to  the Pediatric Endocrinology Society guidelines, a trial of GH therapy should be approved for children with otherwise unexplained short stature who pass GH stimulation tests but who meet most of the following criteria: height more than 2.25 standard deviations below the mean for age or more than 2 SD below the mid-parental height percentile; (2) growth velocity < 25th percentile for bone age; (3) bone age more than 2 SD below the mean for age; (4) low serum IGF-1 and/or IGFBP-3; and/or (5) other clinical features suggestive of GH deficiency. Based on the records provided, this patient does not meet most of the above criteria, and his height is not short enough to consider GH treatment for a diagnosis of idiopathic short stature. Therefore, the requested Nutropin AQ NuSpin 20 mg 2 mL (10 mg/mL) has not been demonstrated as medically necessary for the treatment of this patients medical condition.Final Result: The reviewer determined that requested medication is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is board certified in 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: Overturned

The parent of four-year-old male enrollee has requested growth hormone therapy for treatment of the enrollees idiopathic short stature.  Findings:  The physician reviewer found that the patient has idiopathic short stature of sufficient magnitude that he is on track to become a short adult without intervention because of his extreme short stature and modest growth rate. His low IGF-1 level suggests that he may respond well to growth hormone therapy. A one-year trial of growth hormone is medically indicated and appropriate since the patient falls within the 2003 Food and Drug Administration guidelines for growth hormone therapy for idiopathic short stature. He is also close to qualifying as a child with intra-uterine growth retardation who has not caught up. If there is documented improvement after the one-year trial of growth hormone, the therapy should be continued with periodic re-evaluation every six months.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested inpatient psychiatric hospitalization for treatment of his medical condition.  Findings: The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the services at issue.  The patient was not a danger to self or others, although he was mildly disruptive.  He was not violent and did not physically threaten others.  He still had thought blocking and remained psychotic, but the delusional ideation had improved to the point where he was guarded and mildly grandiose.  He did not attend to his activities of daily living.  His medications required adjustment and changes.  However, the patient appeared to be at his baseline level of functioning.  All told, inpatient psychiatric hospitalization  was not medically indicated for the treatment of this patient.  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 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 33-year-old female enrollee has requested cryopreservation of embryos for treatment of her diagnosis with breast cancer.  Findings:  Three physician reviewers found that Embryo cryopreservation has become a well-established option for women who have been diagnosed with cancer when subsequent chemotherapy or surgery will impair their future ability to have a pregnancy.  The American Society of Clinical Oncology, in conjunction with the American Society of Reproductive Medicine, issued recommendations on this topic.  They stated that embryo cryopreservation is considered standard practice and is widely available.  In their discussion of treatment of cancer patients, Georgescu and colleagues noted that in vitro fertilization with embryo cryopreservation is a well-established treatment with a good success rate.  Cytotoxic chemotherapy causes ovarian reserve depletion, whereas hormonal therapy necessitates a delay in pregnancy, resulting in infertility (Dunn and colleagues). They noted that the best established method of fertility preservation is embryo cryopreservation. Adjuvant chemotherapy regimens commonly used in the treatment of breast cancer may cause premature ovarian failure due to their cytotoxic effects on the germ cells in the ovary (Oktem and Oktay). The authors noted that embryo freezing is the most established fertility preservation strategy.  Thus, the embryo cryopreservation the patient underwent was an appropriate well-established therapy, and was her only option to preserve her fertility.  No other available standard therapy would have been helpful.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary:  An enrollee has requested substance use residential treatment services for treatment of her behavioral health conditions. Findings:  The physician reviewer found that the submitted documentation failed to support the medical necessity of the treatment intervention, as the record failed to demonstrate that less restrictive interventions targeting her substance use during the episode of illness had either been unsuccessful or would have more than likely been inappropriate.  There was no evidence of acute medical or psychiatric comorbidity.  Although her cravings were increasing, the patient was motivated to stay sober and able to identify a precipitant to her urge to drink.  She was neither engaged in specialty treatment services nor was prescribed an anti-craving medication.  In sum, there was no evidence to suggest that comprehensive specialty services provided at a lower level of care would have been unreasonable or consistent with inadequate care.  Thus, substance use residential treatment was not medically necessary for the treatment of this patient. 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 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 26-year-old female enrollee has requested for breast reduction and breast revision surgery for treatment of her left upper back pain secondary to depressed hypertrophy. Findings:  The physician reviewer found that the patient is documented to have had breast reconstruction for a significant breast deformity of tuberous breasts. This patients symptoms are consistent with symptomatic macromastia and a breast reduction is the standard treatment for this condition. Further, simply removing the implants would likely leave the patient with a breast deformity similar to that which she had prior to her reconstructive procedure. This would constitute an abnormal structure of the body caused by a congenital defect. The requested breast revision including replacement of the implants will create a normal appearance to the extent possible. Moreover, the revision procedure will provide more than a minimal improvement in the patients appearance. Therefore, the requested implant removal/reduction and revision procedure is medically necessary and considered reconstructive surgery in this patients case.
Appeal type: Medical Necessity
Decision: Upheld

The patient is a 52-year-old female with chronic back and neck pain.  In 2003 she had an MRI that demonstrated mild disc bulging at C5-6 and C6-7 with some vertebral spurring. The patient tried physical therapy and chiropractic in 2003 and 2004 respectively.  When her pain reoccurred in 2005 she apparently chose this particular PT provider because she wanted a more holistic approach to her PT.  The patient participated in two extended sessions of therapy in August and November of 2004 and found them helpful.  The Health Plan denied coverage for this therapy based upon their determination that it was not medically necessary.The information provided was reviewed and it appears the primary intervention was integration therapy.  Although there is an indication that manual therapy was provided, there is no clinical documentation confirming this.  It appears the patient was also treated with ice packs, but her condition was chronic and there was no medical necessity for that treatment.  As sensory integration is an investigational modality without proven benefit, it has not been established that the therapy provided was medically necessary.  Based upon the information set forth above, I have determined the therapy at issue was not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for surgical implant device hypoglossal nerve stimulation. Findings:  The physician reviewer found that Woodson and colleagues performed a multicenter prospective cohort study and concluded that improvements in sleepiness, quality of life, and respiratory outcomes were observed with five years of upper airway stimulation (UAS) via a unilateral hypoglossal nerve implant. Woodson and colleagues noted that serious adverse events were uncommon, and they stated that UAS is a nonanatomic surgical treatment with long-term benefit for individuals with moderate to severe OSA who have failed nasal continuous positive airway pressure treatment. Multiple additional studies indicate that hypoglossal nerve stimulation is a safe and effective treatment option for moderate to severe obstructive sleep apnea patients who have failed medical therapy. Meta-analysis has demonstrated clinically significant decreases in observed mean apnea-hypopnea index (AHI), oxygen desaturation index (ODI), and Epworth sleepiness scale (ESS), combined with improvements in quality-of-life scales. The STAR (Stimulation Treatment for Apnea Reduction) trial also showed that UAS provides significant improvement in sleep-related quality of life outcome measures with effects maintained across a five-year follow-up.In this case, the patient has already failed CPAP therapy and is not an optimal candidate for oral appliance therapy due to the severity of his obstructive sleep apnea. The alternative, no treatment, would lead to potential harms such as increased medical co-morbidities including hypertension, diabetes, congestive heart failure, myocardial infarction, and stroke. Under these circumstances, the requested surgical implant device hypoglossal nerve stimulation is medically necessary for the patients medical condition.Final Result: The reviewer determined that the requested services are medically necessary for the patient's medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in diagnostic otolaryngology, with subspecialty 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.