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

The patient is a male who was diagnosed with bilateral lower extremity paresthesia. An x-ray of the cervical spine was noted to be a normal. The patient reported leg paresthesia and weakness. No upper extremity symptoms were noted. At issue in this case is whether a MRI of the cervical spine without contrast is medically necessary for evaluation of the patients medical condition. Neural injury may be associated with denervation of the muscles supplied by the nerve. Electromyography (EMG) remains the gold standard for diagnosis of denervation. The most recent neurology evaluation noted a diagnosis of peripheral neuropathy and no recommendation for advanced imaging. EMG results were not provided for review. The medical evidence does not support the request in this clinical setting. Therefore, a MRI of the cervical spine without contrast is not medically necessary for the evaluation of this patient.  Final Result: The reviewer determined that the requested service 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 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: Upheld

The parent of a 1-year, 11-month-old female has requested  coverage for 6 doses of Synagis injections for treatment of her asthma.  Findings:  The physician reviewer found that based on review of the available records, Synagis administration is not indicated for this young patient. There are a number of risk factors that increase the chance of morbidity from RSV disease in infants born prematurely, up to 12 months of age. The most striking of these factors is a birth weight less than 2500 grams (Holman, et al). Older infants who are still less than 24 months of age are considered high-risk if they carry a diagnosis of chronic lung disease or hemodynamically significant heart disease. While this ex-premature female infant may have been an appropriate candidate for Synagis administration in the past, she currently does not meet the published criteria or fall within a high-risk population based on the relevant medical literature. For these reasons, the requested administration of Synagis for RSV prophylaxis is thus not medically necessary for this patient.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for continued care at a skilled nursing facility (SNF), including continued physical therapy and occupational therapy. Functional impairments due to acquired brain insults such as stroke can be severe to profound. While functional recovery may be amenable to natural recovery processes and rehabilitative measures, the extent of initial injury is a major determinant of functional outcomes as it defines the residual neuronal reservoir that is capable of engaging in recovery (Alawieh, et al.). Most of the significant neurological and functional recovery following a stroke occurs in the early stages after stroke such as in the first 30 days, and gains are slower to come in the subsequent stages (Kubis). There is a general consensus that initiating rehabilitative measures earlier in the post-stroke course enhances outcomes, but there are generally poor data guiding optimal practices regarding dose, manner and venue of stroke rehabilitation in the more subacute and chronic stages (Belagaje, et al.). Comorbidities, especially controlled diabetes, are associated with poorer outcomes after stroke (Desilles, et al.). In this case, the patient sustained a stroke in early August 2020 that had profound functional impacts on her cognition, speech, motor activity on her dominant side, self-care ability, and basic mobility. Despite multiple bouts of inpatient multidisciplinary rehabilitation, she has made minimal meaningful functional progress. She continues to require maximum to total assistance for her self-care and mobility. Barriers to progress include severe weakness, pain with any type of passive stretch of the stroke affected limbs, apraxia, and problem solving impairments. Based on the records available for review, there is reasonable expectation of benefit with further skilled therapy services. There are no other issues requiring inpatient level skilled nursing services or medical care. For these reasons, the requested continued care at a SNF, including continued physical therapy and occupational therapy, is not medically necessary for 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 physical medicine and rehabilitation 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 Norco for treatment of his medical condition. Findings:  The physician reviewer found that the current medical evidence does not support the requested medication in this clinical setting.  This patient has non-malignant chronic pain.  Chronic pain may worsen or recur as a result of opioid rebound.  The current standard of care for chronic pain is treatment in a multidisciplinary pain management practice to include physical therapy, massage therapy, cognitive behavioral therapy, and injections to help reduce pain.  Researchers reported that high-dose opiates might contribute to pain sensitization via opioid-induced hyperalgesia, decreasing patient pain threshold and potentially masking resolution of a preexisting pain condition.  In this retrospective study, the majority of patients undergoing detoxification of high-dose opiates for chronic pain reported a significant decrease in pain at the end of the study, further supporting the theory of opioid-induced hyperalgesia.  Other researchers reported that prolonged use of opiates might induce tolerance, abnormal pain sensitivity, and hormonal effects.  All told, the requested Norco 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 anesthesiology with sub-specialty certification in pain 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: Experimental/Investigational
Decision: Upheld

A 50-year-old male enrollee has requested submucous resection of the inferior turbinate for the treatment of his sleep apnea. Findings:  Two physician reviewers found that this patient has undergone multiple surgeries in an effort to alleviate his obstructive sleep disorder. He continues to have moderate OSA as documented by polysomnography. His complaint at this time is continued nasal congestion. There is no documentation that medical therapies (in the form of nasal sprays or allergy medications) have been attempted to any extent. While further turbinoplasty may help with this patients congestion and, possibly with his sleep apnea, no real trial of medical therapy has been undertaken. Thus, it is not possible to conclude that further surgery is likely to be more beneficial than standard therapy since we do not know what benefit medical therapy would have for this patient.
Appeal type: Experimental/Investigational
Decision: Upheld

A 59-year-old female enrollee requested authorization and coverage of angioplasty and stenting of the right intracranial lesions. The Health Plan denied the request indicating that the requested procedure is considered investigational for treatment of the enrollees intracranial lesions.Three physician reviewers performed an experimental/investigational Independent Medical Review. All three physician reviewers concluded that the requested procedure is not likely to be more beneficial for treatment of the enrollee's medical condition than any available standard therapy. Because all three physician reviewers concluded that the requested therapy is not likely to be more beneficial for treatment of the enrollee's medical condition than any available standard therapy, the Health Plans denial has been upheld.
Appeal type: Medical Necessity
Decision: Overturned

A male enrollee requested canagliflozin for medical treatment of his type 2 diabetes.  Findings:  The physician reviewer found that Canagliflozin is the first approved agent in a relatively new class of diabetes medications, subtype 2 sodium-glucose transport protein inhibitors. Many providers and medical organizations currently recommend subtype 2 sodium-glucose transport protein inhibitors as part of a recommended regimen for treatment of diabetes. All told, the requested canagliflozin is medically necessary for this patient.
Appeal type: Experimental/Investigational
Decision: Upheld

A 51-year-old female has requested an artificial disc replacement for treatment of neck and back pain.  Findings:  Two physician reviewers found that artificial discs are unproven as treatments for degenerative cervical disorders.  There is no long-term outcome data to establish the safety and efficacy of this procedure/device over accepted treatments. In addition, there is significant data related to failures and other morbidity. Given the lack of evidence supporting the efficacy and the known rates of morbidity, the procedure remains experimental.
Appeal type: Experimental/Investigational
Decision: Upheld

A 46-year-old female enrollee has requested  radiofrequency neurolysis for treatment of her back pain. Findings:  Three physician reviewers found that lumbar medial branch radiofrequency neurolysis is a well-documented procedure which may help with chronic low back pain due to lumbar facet pain.  However, there is a lack of support for the requested services in this clinical setting.  This patient has chronic low back pain and is status post spinal fusion from L3 to L5.  The medical records document lumbar medial branch blocks at L2, L3, L4 and L5 on two separate dates.  However, the records do not document at least 50% reduction of pain following the intervention.  The current medical evidence does not support the requested services in this patients case.  Thus, the requested radiofrequency neurolysis is not likely to be more effective than other available modalities.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for residential treatment center (RTC) services. The submitted documentation supports that the services at issue were medically necessary. The American Psychiatric Association treatment guidelines for Substance Use Disorders recommend that residential treatment, or similar care that is higher than an outpatient level, is indicated for patients who do not meet the clinical criteria for hospitalization, but whose lives and social interactions have come to focus predominantly on substance use, and who lack sufficient social and vocational skills and drug-free social supports to maintain abstinence in an outpatient setting. In this case, the patient required a safe and stable living environment in order to develop his recovery skills, thus qualifying him for American Society of Addiction Medicine (ASAM) Level III treatment. This is consistent with the level of services that the patient received at the RTC. The severity of the patients illness was evidenced by blackouts, continued relapses, and drinking at work. Residential treatment was in accordance with generally accepted standards of medical practice and was clinically appropriate for the patients illness. Under these circumstances, the residential treatment center (RTC) services at issue were medically necessary to treat 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 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

The enrollee is requesting authorization and coverage for an open magnetic resonance imaging (MRI) scan. The enrollee has a history of ongoing left-sided headaches. The progress note indicates the enrollees pain has been present for four to five months. He complains of mild nausea during severe episodes. Neurology determined the enrollees previous brain magnetic resonance imaging scan from the previous year was negative and prescribed another magnetic resonance imaging scan. The order was for an open magnetic resonance imaging scan, per enrollee request. The enrollee indicates his symptoms have been worsening, with his head hurting every day. However, he cannot participate in a closed magnetic resonance imaging scan due to his anxiety. The last time a scan was attempted, he tried to climb out of it.  Review of the record indicates the enrollees pain is light, dull, aching and constant; with intermittent sharp pain. The enrollee indicated in a telephone conversation that an open magnetic resonance imaging scan was needed due to claustrophobia. According to the medical literature, a magnetic resonance imaging scan of the brain is indicated for enrollees who have headaches with associated neurological findings, or a suspected brain structure abnormality.  The record indicates the enrollee has a two-year history of left-sided headaches and underwent a magnetic resonance imaging scan of the brain the previous year.  However, there is insufficient evidence in the record of the neurology consultation notes and results of the previous magnetic resonance imaging scan. There is no evidence of any neurological deficits on examination or suspected brain structural abnormality that supports the necessity for open magnetic resonance imaging scan at this time.  The clinical records do not support a diagnosis of claustrophobia.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 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 similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has been diagnosed with a uterine fibroid and a left ovarian mass possibly representing a dermoid. A pelvic mass risk assessment revealed an OVA1 of 4.3, which was noted to be low risk.  A pelvic ultrasound revealed a 1.9 cm anterior uterine fibroid and a stable 2.6 cm echogenic mass in the left ovary, which was noted to possibly represent an ovarian dermoid. The patient has requested authorization and coverage for a total hysterectomy (CPT 58571). The Health Plan denied the request and reported the requested surgery is not medically necessary for the treatment of this patient. At issue in this case is whether a total hysterectomy (CPT 58571) is medically necessary for the treatment of the patients medical condition. Borah and colleagues reported, Uterine leiomyomas are a benign and very common gynecologic condition in reproductive-aged women and are associated with significant morbidity including menstrual disorders, anemia, and adverse reproductive outcomes. The authors also noted, The fact that menstrual disorders were associated with higher odds of having uterine-sparing procedures compared with hysterectomy is in line with the current understanding of the effectiveness of uterine-sparing procedures for leiomyoma symptoms. In this case, there is no documentation to support anemia from the patients menstrual periods to indicate surgery as the next step. The patients fibroid is small and located in the anterior uterus. She has not had an assessment of her uterine cavity with endometrial sampling. She has no other factors suggestive of malignancy or high risk for malignancy. The medical evidence does not support the requested surgery in this clinical setting. Therefore, a total hysterectomy (CPT 58571) is not medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested surgery 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 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: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested authorization and coverage for weekly occupational therapy for six months. The submitted documentation supports the medical necessity of the requested services. This patient has difficulty performing age-appropriate activities of daily living, is unable to keep up with family and peers due to deficits in strength and coordination, and is at risk of significant injury because of recurrent falling. With its focus on developing motor planning skills and self-help skills, developing age-appropriate communication skills, processing information, and regulating the response to incoming information, occupational therapy is well suited to affect positive change in this patient. Without appropriate occupational therapy intervention, he is likely to continue to lag behind peers and fail to achieve his functional maximum. All told, weekly occupational therapy for six months 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 pediatrics and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for a sleep study provided in a facility setting. The Health Plan has denied this request indicating that the service at issue was not medically necessary for treatment of the enrollees obstructive sleep apnea and snoring.At issue in this case is whether the requested sleep study; provided in a facility setting was medically necessary for treatment of the enrollees medical condition.Current literature indicates that there has been a shift from the provision of services in the laboratory setting to the ambulatory setting. Unattended and attended testing has been shown to yield equivalent outcomes to laboratory testing in at least two randomized trials.In this case the patient had an elevated body mass index, a large neck and complaints of snoring which raise the concern of obstructive sleep apnea (OSA). Testing would have been indicated to re-establish a diagnosis of OSA. However, provision of services in the attended/laboratory setting would have exceeded the patient's clinical needs in this setting. The performance of testing and treatment in the home setting has also been shown to produce equivalent outcomes to testing in the attended environment. There were no other extenuating circumstances present in this case; that would have otherwise necessitated or warranted an in-laboratory sleep study, concluding the services could have been completed in the home. The patient had no history of frequent, potentially injurious parasomnia. The enrollee had no other medical conditions that would have been a contraindication to provision of services in the home setting. Therefore, an attended study would not have been medically necessary.Final Result: The reviewer determined that the service at issue was not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is board certified in neurology 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.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for facial laser hair removal. The Health Plan has denied this request indicating that the requested services are not medically necessary for treatment of the enrollees gender dysphoria and are not reconstructive in nature. Findings: The requested services are medically necessary in this clinical setting. Facial hair removal is within accepted standards of practice and clinically appropriate for treatment of gender dysphoria. The record notes that hormone therapy has not been effective in treating this patients excessive facial hair. The patient has reported anxiety over being misgendered despite hormone therapy. Therefore, facial laser hair removal is medically necessary for treatment of this patients gender dysphoria.With regards to whether the requested services are considered reconstructive in nature, excessive facial hair in a female is considered an abnormal body structure. It would be abnormal for a female to have terminal hair on the face. The patients abnormal appearance is the result of gender dysphoria, a disease classified in the Diagnostic and Statistical Manual of Mental Disorders. Facial laser hair removal can provide substantial improvement in the appearance of terminal hair and create a normal appearance to the best extent possible. Additionally, facial laser hair removal would also provide more than a minimal improvement in the appearance of this patient as well as improve the patients emotional function. For these reasons, facial laser hair removal is reconstructive in nature. 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 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.