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

A male enrollee requested authorization and coverage of Peglyated Interferon (PEGIntron) and Ribavirin (Rebetol) for the treatment of Hepatitis C.  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 therapy is not medically necessary.
Appeal type: Medical Necessity
Decision: Upheld

An 80-year-old female has requested an annual MRI of the back and head for evaluation of her low back pain.  Findings:  The physician reviewer found that the patient presents with a complaint of low back pain without red flags such as infection, tumor, or neurological deficits. Additionally, there is no documented change in her symptoms to justify annual MRI examination. Per the records, the patient has concerns regarding the development of tumors, but there is no known primary malignancy. Routine annual screening of the lumbar spine without significant change in symptoms or neurological deficit is not indicated.The MRA of the patients neck two years ago described no focal narrowing or obstructing lesion. Absent neurological changes suggestive of a transient ischemic attack (TIA), a repeat exam is not indicated. The patients MRI exam of the brain has documented stable deep white matter likely indicative of microvascular ischemic disease. There are no notes in the chart detailing a clinical suspicion of a demyelinating process. Absent any changes of a clinical nature such as weakness or focal neurological deficit annual MRI of the brain is not indicated.
Appeal type: Medical Necessity
Decision: Upheld

A 52-year-old female enrollee has requested for a referral with an acupuncturist for treatment of her tinnitus. Findings:  The physician reviewer found that acupuncture has been studied as a treatment for tinnitus in several controlled trials (see Furugard and colleagues). Preliminary trials reported improvement in symptoms of tinnitus following acupuncture treatment, but this relief was either not permanent or did not reach statistical significance (see Furugard and colleagues) Furthermore, most trials have shown no advantage of acupuncture treatment over placebo for the treatment of tinnitus (see Nielsen and colleagues, Vilholm and colleagues and Axelsson and colleagues). A review of clinical trials concluded that acupuncture is not an effective treatment for tinnitus (see Park and colleagues). All told, there is no evidence to support the contention that acupuncture is as effective or improves functionality or long-term outcomes better than placebo.
Appeal type: Medical Necessity
Decision: Overturned

Gender: FNature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for an MRI. The American College of Radiology (ACR) Appropriateness Criteria state that magnetic resonance imaging (MRI) is considered the gold standard in the evaluation of the shoulder for entities involving the glenoid labrum and rotator cuff, given its excellent depiction of soft tissue structures. In addition to evaluating the rotator cuff, MRI can aid in detecting extra-articular abnormalities, including osseous and soft-tissue findings that may predispose to or be the result of shoulder impingement. (ACR 2018). A study concluded rotator cuff pathology accounts for most presentations of shoulder pain to primary care clinics. History and physical examination are important for excluding other causes of shoulder pain, while imaging assists in confirming the diagnosis and defining the severity of the abnormality. Treatment options include nonsteroidal anti-inflammatory agents, subacromial corticosteroid injections, and exercise therapy. Surgical intervention is generally reserved for those failing nonoperative measures and/or healthy, young, and middle-aged adults with full-thickness rotator cuff tears. In this case, the patient has been diagnosed with impingement syndrome and tear of supraspinatus tendon of the right shoulder. Progress notes indicate the patient had right shoulder pain that was worsening since onset three weeks prior. The pain was worse with repetitive and overhead activities of daily living. The patient received appropriate conservative treatment, including NSAIDs, physical therapy, and injection. X-rays found the acromioclavicular joint space and glenohumeral joint space were maintained. Per the submitted documentation, the patient underwent surgical repair after the MRI was performed. There is sufficient support for the services at issue in this clinical setting. Thus, the MRI performed was medically necessary for evaluation of the patients medical condition.Final Result: The reviewer determined that the service at issue was 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: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested residential treatment services for treatment of his behavioral health conditions. Findings:  The physician reviewer found that the submitted documentation supports the medical necessity of a portion of the services at issue.  In this case, upon presentation the residential setting was reasonably expected to improve the patients condition and prevent a more serious episode of illness.  Subsequently, relapse prevention efforts and therapy to consolidate family issues and recurrent interpersonal strife remained indicated, the patient had no acute psychiatric issues or medical comorbidity.  There was no interpretative summary articulating the clinical rationale for continued residential services beyond the initial projection.  Based on his progress in the program, there was no evidence to suggest that transition to a less restrictive setting would have been inadequate.  Thus, the residential treatment center services at issue were medically necessary initially, but not thereafter.Final Result: The reviewer determined that the services at issue was 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 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

The patient is a 27-year-old woman who underwent an ACL reconstruction. Postoperatively she utilized a CPM machine as prescribed by her orthopedic surgeon.  She is requesting reimbursement for the rental cost of the CPM device. The Health Plan denied coverage based upon their determination that the CPM device was not medically necessary following the patients surgery. A CPM device is commonly prescribed by surgeons for postoperative rehabilitation following ACL reconstruction. The purpose of the device is to help patients regain their range of motion.  The use of the device is not experimental; it is a matter of surgeon preference.  In this case, the patient exhibited decreased range of motion (ROM) for several months and the CPM device was needed so that she could regain full ROM with the injured knee.  Based upon the information set forth above, I have determined the device at issue was medically necessary for treatment of the patients medical condition. The Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the percutaneous cryoablation of the left kidney received and prospective authorization and coverage for future percutaneous cryoablation of the left kidney. The current criteria for kidney percutaneous cryoablation include documentation that the patient has a contraindication to surgery, only one kidney, or decreased renal function. This patients records do not indicate that this patient has a contraindication to surgery, only one kidney, or decreased renal function. Moreover, there is a lack of adequate evidence in the peer-reviewed medical literature demonstrating an improved long-term clinical result in a patient who may be an appropriate surgical candidate for a partial nephrectomy, has two kidneys, and has normal renal function. Thus, the percutaneous cryoablation of the left kidney received and prospective authorization and coverage for future percutaneous cryoablation of the left kidney was not and is not medically necessary for treatment of this patients medical condition. Final Result: The reviewer determined that the services at issue were not and are not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in diagnostic radiology with subspecialty certification in vascular and interventional 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: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for blepharoplasty and reconstructive repair of ptosis for treatment of the enrollees bilateral eyelid ptosis and are not reconstructive in nature. Findings:  The physician reviewer found that in this patients case, the requested services are medically necessary and are reconstructive in nature. Multiple publications have confirmed the functional significance of even mild blepharoptosis. According to the American Academy of Ophthalmology (AAO), blepharoplasty procedures and repair of blepharoptosis are considered functional and reconstructive in nature when certain criteria are met. This patients photographs show that the upper eyelid skin rests on the lashes, and the visual fields demonstrate a 30-degree loss of the upper field of vision that corrects with taping. Marginal reflex distance measurements are less than 2.5 mm based on the submitted record. As such, the AAO guidelines are met.  The visual field tests confirm the presence of functionally significant visual field loss, and the photographs are consistent with the perimetry results. According to the medical literature, dermatochalasis is known to cause visual field defects in many patients. Patients often report that their vision is brighter following upper eyelid blepharoplasty. Cahill and colleagues report the following, Repair of blepharoptosis and upper eyelid dermatochalasis provides significant improvement in vision, peripheral vision, and quality of life activities.  The submitted records support that this patient has functionally significant upper lid dermatochalasis with visual field losses. This condition is an abnormal structure of the body that affects this patients vision. As such, the requested surgeries will improve function as well as provide more than a minimal improvement in appearance. All told, repair of blepharoptosis will provide improvement in this patients vision and quality of life activities. Final Result: The reviewer determined that the requested services are medically necessary for treatment of this patients medical condition and are reconstructive in nature. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in plastic 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: Overturned

The patient is a 46-year-old woman who saw a physician in August 2003 for treatment of fingernail fungus. The patient indicates that some of her fingernails are partially separated from the nail bed and are very painful. The patients provider has prescribed the medication Lamisil. The Health Plan has denied authorization for Lamisil on the basis that it is not medically necessary for treatment of the patients nail condition.The patient indicates that she has partially separated fingernails, which have caused significant pain and therefore, functional impairment. The patient should be evaluated by a dermatologist as soon as possible and undergo a direct microscopic examination and/or fungus cultures. If the tests are positive for fungus, Lamisil is medically indicated for three months provided that CBC and chem panel results, including liver function tests, are normal.Therefore, I have determined that the requested medication is medically necessary for treatment of the patients medical condition pending an evaluation by a dermatologist. As such, the Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Aptiom 800 mg, two pills daily for treatment of the enrollees focal epilepsy. Findings:  The physician reviewer found that a seizure is an uncontrolled electrical disturbance in the brain that can cause neurological symptoms that affect behavior, movements, and levels of consciousness. This patient has been diagnosed with focal epilepsy. There are several U.S. Food and Drug Administration (FDA) approved medications that are designed to manage partial epilepsy. However, there is a lack of evidence supporting the superior efficacy of Aptiom compared with other covered antiepileptic drugs offered by the Health Plan.  There is no documentation that the patient failed or has a contraindication to other medications covered by the Health Plan. Additionally, the active ingredient in Aptiom is equivalent to other medications currently covered by the Health Plan. Therefore, Aptiom 800 mg, two pills daily is not medically necessary for the treatment of this patient. Final Result: The reviewer determined that the 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 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: Upheld

The patient has requested authorization and coverage for procedure to repair spinal hardware. Medical literature indicates that failed solid bony fusion, or pseudoarthrosis, is a well-known complication of lumbar arthrodesis. The authors concluded that treatment of lumbar pseudoarthrosis includes a variety of surgical options such as replacing loose instrumentation and interbody fusion techniques. Researchers reported that the results of recent studies suggest that a patients pretreatment psychological state is a major independent variable that affects the ability to detect change in functional outcome. This patient presents with a six-month history of severe low back pain following a low speed rear-end motor vehicle accident. She has a history of T10-pelvis instrumented fusion. Imaging studies have shown fractures of the posterior rods bilaterally at L5-S1 and displacement of the left-sided rod from the left S1 screw bracket, which are reportedly unchanged. There are areas of disruption of the bone graft at the area of the left-sided hardware disruption, but a lack of evidence of pseudoarthrosis. The records provided for review do not include lumbosacral flexion and extension films. Moreover, there is no report of a recent psychological evaluation as recommended in the medical literature. Given these findings, the requested procedure to repair spinal hardware is not medically necessary for treatment of this patient.Final Result: The reviewer determined that the requested services are not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in 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

Nature of Statutory Criteria/Case Summary:   An enrollee has requested Otezla for treatment of her medical condition. Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested medication.  Per the medical records, there is no documented adverse effect or contraindication to the use of methotrexate or cyclosporine.  The records do not demonstrate that the patient has tried and failed therapy with ultraviolet light treatments.  Acitretin is not a favored therapy for women of childbearing age, but there are other systemic options which have not been pursued.  Additionally, the patient does not show an intolerance or contraindication to the use of injectable biologic agents.  As there are several other therapies which are considered first-line, the requested medication Otezla is not medically indicated for the treatment of this patient. Final Result: The reviewer determined that the 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 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.
Appeal type: Medical Necessity
Decision: Upheld

A 53-year-old female enrollee requested a standing breast magnetic resonance imaging (MRI) for medical evaluation of her medical condition.  Findings:  The physician reviewer found that the submitted documentation fails to establish the medical necessity of the requested diagnostic procedure. MRI studies of the breast are highly sensitive, but have a relatively low level of specificity. The medical literature does not recommend the use of breast MRI as a replacement for routine breast mammography and ultrasound.  All told, the medical necessity of the requested diagnostic procedure has not been established in this clinical setting.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for residential treatment center (RTC).  Applying LOCUS, this patient did not meet the criteria for the RTC level of care services. The patient was at moderate risk of harm (score 3), as he voiced suicidal ideation without intent or conscious plan, and he had no prior history of suicide attempts. The patient demonstrated mild functional impairment (score 2) due to conflict in his marital relationship. The provider noted that the patients hygiene, level of activity, sleep, and appetite were normal. In addition, the patient was able to participate in socially constructive groups while on the unit. In terms of comorbidities, the patient has stable non-insulin dependent diabetes mellitus (score 3). There was no concern for active substance use or withdrawal. The patients recovery environment was highly stressful (score 4) given his serious marital conflict. The provider noted concern regarding the patient returning to live at home due to this tension. The level of support available to the patient was minimal (score 4), as his primary support was his wife and they were experiencing discord. He did have therapeutic support, as he was engaged in outpatient therapy. The patient demonstrated limited response to treatment (score 3), as the current RTC did not help him achieve optimal control of his symptoms. The patients fear of leaving the RTC facility intensified his symptoms of depression and anxiety. The patient was constructive in treatment (score 2) with positive engagement. The provider described the patient as an active participant in treatment groups. He was cooperative with his medications and capable of developing therapeutic relationships with his providers at the RTC. He had also previously developed therapeutic relationships with his outpatient mental health providers. This gives the patient a composite score of 21, which is consistent with medically monitored community-based services. Given these findings, the RTC services were not medically necessary for 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 45-year-old male enrollee requested a high resolution anoscopy including screening, specimen collection and cytopathology evaluation (CPT codes 0226T, 0227T, and 88112) for medical evaluation of his carcinoma in situ of the anal canal. Findings:  Two physician reviewers found that this patient is at high risk for the development of anal cancer. Thus, the high resolution anoscopy including screening, specimen collection and cytopathology evaluation (CPT codes 0226T, 0227T, and 88112) was likely to have been more beneficial for evaluation of this patients medical condition than any available standard therapy.
Appeal type: Medical Necessity
Decision: Upheld

The parent of an 11-year-old male enrollee has requested speech therapy for treatment of the enrollees autism. Findings:  The physician reviewer found that although pragmatic in nature, the goals documented in this case by the patients speech therapist are not related to community function and appear educationally based. Furthermore, the goals have not changed substantially over time. Based on the documentation provided, the patients speech therapy does not appear to have been coordinated with a behavioral program working toward social communication. All told, there is insufficient evidence supporting the medical necessity of past or future speech therapy in this case.