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

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for bilateral cervical/thoracic facet joint blocks (CPT 64490). Manchikanti and colleagues concluded that the evidence for therapeutic cervical facet joint interventions is fair for conventional cervical radiofrequency neurotomy and cervical medial branch blocks. Klessinger found that persistent postsurgical neck pain is a common problem for which there are limited therapy recommendations. The authors supported use of therapeutic medial branch blocks. This patient presents with a history of chronic cervical spine pain. She is status post C4-6 fusion with increased pain since surgery. Functional limitations are noted in the patients ability to perform activities of daily living (ADLs). Clinical examination findings have documented restricted range of motion and positive facet provocative testing. There is reported imaging evidence of severe right-sided facet arthritis. She has tried and failed over six months of comprehensive conservative treatment including activity modification, medications, physical therapy, and an epidural steroid injection. Current evidence-based medical literature support the use of diagnostic medical branch blocks in this patients clinical scenario. She has ongoing cervical spine complaints consistent with facet-mediated pain with no apparent radicular component. Given these findings, the requested bilateral cervical/thoracic facet joint blocks (CPT 64490) are 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 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

This case concerns a 13-year-old female with Crohns disease and growth arrest. She was part of a one-year growth hormone (GH) study for children with Crohns disease.  Her treatment ended in February 2005 and she grew 6.8cm during the one-year study.  The enrollee had a period of no growth before GH therapy was initiated and similarly stopped growing after GH therapy was discontinued. The mothers height is 54 and fathers height is 60.   The Health Plan has determined GH therapy is not medically necessary and has denied authorization and coverage.Although GH therapy has not yet reached the standard of FDA approval for Crohns disease, there is growing support in the literature for its use for that indication. In addition, the patients response to GH therapy has been dramatic and convincing in this instance.  Although there were conflicting reports regarding oral steroids, her growth did in fact cease when GH therapy was discontinued, minimizing any possible connection between her growth acceleration and the discontinuation of oral steroids, if indeed they were ever taken. The growth charts attached clearly documented a positive response to GH therapy during the yearlong treatment and they also document a lack of growth both before and after the study. In light of these results, continuation of GH therapy is medically appropriate.Based upon the information set forth above, 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: Upheld

The patient is a 15-year-old male with apparent hypersomnolence and alleged marked decrease in intellectual functioning as a result of a toxic injury secondary to carbon monoxide. Multiple stimulants, antidepressants, and mood stabilizers have been used without significant positive effect on the patients condition. Provigil apparently has been tried and appears to have been somewhat beneficial. The patient also apparently has a history of substance abuse and head injuries prior to his alleged exposure to carbon monoxide.Review of the current medical literature reveals no case-controlled, peer-reviewed literature demonstrating the efficacy of Provigil for improving intellectual performance. Furthermore, the information provided does not provide sufficient documentation of the patients apparent hypersomnolence, depressive symptoms, or attention-deficit hyperactivity disorder. There is no clinical indication for Provigil based upon the provided documentation. Therefore, I have determined that the requested medication is not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Experimental/Investigational
Decision: Overturned

A 59-year-old female enrollee has requested deep brain stimulation for the treatment of her pain. Findings:  Two physician reviewers found that this patient is status post stroke with resulting right-sided weakness. She now has burning pain on the right side of the body that is not helped by any usual methods of treatment. She has requested coverage for deep brain stimulation. The Health Plan has denied this request, and this is the subject of the appeal. This patient has exhausted standard therapy for her pain. Deep brain stimulation has been used and has some efficacy, but also has significant failure, as noted in the scant literature about this condition. It is medically reasonable and appropriate to perform deep brain stimulation for this patients thalamic pain, as there is a lack of other options.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for skilled nursing care, and authorization and coverage for ongoing skilled nursing care. Findings:  The physician reviewer found that the submitted documentation does not support that the services at issue were, or that the requested ongoing services are, medically necessary for treatment of the patients medical condition. Any patient admitted to a skilled nursing facility must show evidence of benefit from skilled therapy or the need for skilled nursing, such as wound care or IV antibiotics. Specifically, if an admission is for the purpose of rehabilitation, one must anticipate that progress in therapy would be made and that there would be concrete goals with which therapists could work. In this case, the patients limitation of weight bearing in her bilateral lower limbs (heel weight bearing only) and right upper limb weight bearing presents a significant functional logistical challenge for the therapists. Her function remains at the maximal assist level for bed mobility, transfers, dressing, and toileting, and for the near future will remain so. Due to diffuse fractures and weight bearing restrictions, her potential for functional improvement at this time is very limited. She has shown no potential to improve in therapy, and thus an alternate level of care would be appropriate. At a later time when her clinical picture improves, she will likely benefit from skilled nursing facility or acute level rehabilitation. Accordingly, skilled nursing care to the present date was not medically necessary for the patient, and ongoing skilled nursing care is not medically necessary for the patient at this time.Final Result: The reviewer determined that the services at issue and 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: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested bilateral digital breast tomosynthesis for evaluation of the enrollee, who was asymptomatic. Findings: Two physician reviewers found that the submitted documentation demonstrates the medical necessity of a portion of the services at issue.  Breast tomosynthesis provides advantages to radiologists interpreting mammograms. This tomographic method often allows the reader to separate dense glandular elements from underlying mass/architectural distortion, resulting in a decrease in callbacks and increase in detection of small cancers compared to two-dimensional imaging alone. Thus, the addition of breast tomosynthesis to the usual two-dimensional protocol was likely of greater benefit to the patient as part of her screening examination than had the examination been done with two-dimensional imaging alone.  However, once the abnormal area in the right breast had been identified, conventional mammographic imaging including spot compression films followed by targeted ultrasound would have yielded the same diagnostic information without repeating tomosynthesis. Thus, repeat unilateral (right breast) digital breast tomosynthesis was not likely to have been superior over other methods of evaluating this patient.Final Result: Two reviewers determined that a portion of the services at issue was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be partially overturned.Credentials/Qualifications: All three physician reviewers are board certified in diagnostic radiology 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: Experimental/Investigational
Decision: Overturned

The parent of a 15-year-old male enrollee has requested for subtalar arthroereisis surgery for treatment of the enrollees bilateral pes planus. Findings:  Two physician reviewers found that Subtalar arthroereisis has proven efficacy in the treatment of pediatric flatfoot with overpronation syndrome. One of the major benefits of the procedure is that it is minimally invasive and reversible. A study by Forg and colleagues reported on the use of the Smith subtalar arthroereisis implant (STA-peg) to correct severe collapsing pes valgoplanus in children. Twenty-one patients with a total of 40 STA-peg procedures were evaluated subjectively and objectively. The average age at the time of surgery was 9.7 years (4 to 16 years). The follow-up period averaged 36 months (12 to 90 months). The authors concluded that subjective, objective, and radiographic results were positive and the complication rate was low.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for eye surgery (orbitotomy with removal of a mass in the orbit). The submitted documentation supports the medical necessity of the requested services. Physical examination demonstrated orbital fat herniation which was causing malposition of the conjunctiva and eyelids at the lateral commissure.  The patients tearing and vision loss symptoms are likely caused by the malformation. The standard of care in this clinical setting is to excise or debulk the mass for better lid apposition and improved functioning. Therefore, the requested eye surgery (orbitotomy with removal of a mass in the orbit) 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 ophthalmology 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 partial hospitalization program for treatment of the enrollees behavioral health condition.  Findings: The physician reviewer found that the submitted documentation supports the medical necessity of a portion of the services at issue.  Discharge would have been premature, but the records do not support continued treatment at the partial hospital level of care. Considering the patients illness burden, anxiety and mood symptoms, a conservative treatment course was to be expected. The patient was anxious, overly-detailed and circumstantial. The treating provider increased her antidepressant medication. The patient endorsed somatic symptoms and skepticism regarding her ability to maintain a meal plan outside of a structured environment.  The patient needed encouragement and staff support to complete her midday meal.  The patient was noted as making progress, and her insight and judgment were improved as she entertained that some of her physical symptoms may be secondary to her anxiety.  The patients weight was up upon admission. The patient had no issues with eating her meals. The patient was motivated and more assertive. The patient was tolerating her medications well.  The patient was both psychiatrically and medically stable, and she was future oriented. Upon admission, this patients eating disorder necessitated comprehensive specialty care, and the partial hospitalization services were safe, appropriate and consistent with good medical practice.  However, based on the patients progress and clinical stability despite the chronicity of the illness, there was no evidence to suggest that partial hospitalization would further improve the patients condition and/or prevent a more serious episode of illness superiorly to well-coordinated services delivered in a less restrictive setting. In sum, the services at issue were medically necessary for treatment of this patient, but not thereafter.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 partially overturned.  Credentials/Qualifications: Physician 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 a nutritional drink supplement for treatment of her medical condition.  Findings: The physician reviewer found that the documentation indicates that this patient is not having any problems with swallowing or nausea with vomiting. She complains of feeling a loss of appetite when starting a meal. The history of a patient with unintentional weight loss includes documenting the weight loss, assessing the pattern of weight loss, evaluating for eating disorders and possible intentional weight loss, and eliciting other factors that may be related to the weight loss. In this case, the documentation does not support that the patient has had significant weight loss. Her BMI is within normal limits for her height. She does not have a medical condition that would cause any mechanical difficulty with eating. All told, the requested nutritional drink supplement is not medically necessary for treatment of this patients medical condition.  Final Result: The reviewer determined that the requested nutritional drink is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.  Credentials/Qualifications: The physician reviewer is board certified in internal 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 E0694 ultraviolet multidirectional light therapy for home use. There is sufficient support for the requested device in this patients case. She has tried and failed therapy with topical steroids and topical immunomodulators. Atopic dermatitis is known to be a chronic condition. Phototherapy has been shown to be useful in the treatment of atopic dermatitis. Per the records, she has shown improvement with in-office treatments.  The medical evidence supports the requested device in this clinical setting. Therefore, E0694 ultraviolet multidirectional light therapy for home use is medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested device is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified 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: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Afrezza. This patient with type 2 diabetes has been placed on a treatment regimen centered on maintaining strict glycemic goals. The patients provider has recommended treatment with Afrezza. As noted in the medical literature, Afrezza is a technosphere insulin in powder formulation of short-acting insulin taken by oral inhalation with meals (Mikhail). Pulmonary administration of Afrezza as a prandial insulin has been beneficial to help patients overcome many of the limitations of subcutaneous insulin formulations. Afrezza tends to have a more rapid onset of action and faster return of action to baseline levels, combined with lower intra-patient variability of insulin action (Heinemann and Parkin). While Afrezza may cause acute bronchospasm in patients with asthma and chronic obstructive pulmonary disease (COPD) and may be affected by smoking, the records document that this patient is a non-smoker without a history of chronic lung disease (Mohanty and Das). For these reasons, the requested Afrezza is medically necessary for treatment of this patient. Final Result: The reviewer determined that the requested medication is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in internal medicine with subspecialty certification in diabetes, endocrinology, and metabolism 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 59-year-old male enrollee has requested TEC System (Iceless cold compression device) for treatment of his lumbar stenosis, spondylolisthesis, and intractable radiculopathy.  Findings:  Three physician reviewers found that this patient has been prescribed a treatment for his post-operative care, the TEC System. Overall, there is a paucity of clinical data demonstrating superior health outcomes in patients following spinal surgery. This system and similar devices have shown some success in the care of post-operative knee and hip patients (Woolf, et al; Su, et al). However, there is a lack of documentation, indications, and evidence of the effectiveness of the TEC System for post-operative spinal care. Therefore, the device at issue was not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.
Appeal type: Experimental/Investigational
Decision: Upheld

A 71-year-old male enrollee has requested for CyberKnife stereotactic radiosurgery for treatment of his prostate cancer. Findings:  Three physician reviewers found that the guidelines are developed through an explicit review of the evidence integrated with expert medical judgment by multidisciplinary panels from NCCN member institutions. Treatment recommendations are specific and are implemented through performance measurement. In reviewing current NCCN guidelines, this patient would be deemed a low recurrence risk.  Based on a life expectancy of greater than ten years, options regarding initial therapy would be active surveillance, radiation therapy or radical prostatectomy.  Additionally, these guidelines state that 3D conformal or IMRT technique should be employed.  Doses of 70 to 79 Gy in 35 to 41 fractions to the prostate appear to be appropriate for patients with low risk cancer, such as this patient.  Alternatively, this patients radiation oncologist has recommended 38 Gy delivered in four fractions.  This dose fractionation is not compatible with the NCCN guidelines. We do not have long-term data regarding this dose fractionation.
Appeal type: Medical Necessity
Decision: Upheld

A 28-year-old female enrollee requested authorization and coverage of acute inpatient rehabilitation services. The Health Plan denied the request indicating that the requested services are not medically necessary for treatment of the enrollee status post motor vehicle accident.One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer upheld the Health Plans denial on the basis that the requested services are not medically necessary.