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

Nature of Statutory Criteria/Case Summary:   An enrollee has requested suction assisted lipectomy of the trunk for the treatment of her medical condition.  Findings:  The physician reviewer found that the services at issue were medically indicated for the treatment of this patient.  Based on this patients evaluation and review of the photographs, the appearance of the axillae is related to her treatment of breast cancer.  The patients condition constitutes an abnormal structure of the body.  This abnormal structure of the body was a direct result of her treatment for breast cancer.  The surgery was performed to create a normal appearance to the extent possible.  The level of abnormality was significant and the planned procedure was in an attempt to approximate a more normal appearance.  The liposuction would likely to have offered more than a minimal improvement in the patients appearance.  In sum, suction assisted lipectomy of the trunk was medically necessary and was reconstructive in nature.  Final Result: The reviewer determined that the services at issue were reconstructive in nature and 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 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: Urgent Care
Decision: Upheld

A 28-year-old female enrollee has requested for emergency ambulance services on an emergent basis.  Findings:  The physician reviewer found that this case involves the issue of whether a reasonable and prudent layperson in the patients circumstances would believe she was experiencing an emergency medical condition. An emergency medical condition means a medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain) such that the absence of immediate medical attention could reasonably be expected to result in any of the following: placing the patients health in serious jeopardy, serious impairment to bodily function, or serious dysfunction of any bodily organ or part. This patient was evaluated by an ambulance crew who found complaints of symptoms that could reasonably be attributed to the known medical problem (UTI) that was diagnosed and was already being treated. The other medical complaints that were indicated to have prompted the 9-1-1 call can only be explained as a transient problem and were not evident at the time that ambulance crew evaluated the patient. The patient herself demonstrated her own lack of concern for the seriousness of her condition by refusing ambulance transport for further treatment.
Appeal type: Medical Necessity
Decision: Upheld

The patient is a 31-year-old male who has been diagnosed with sprain of ligaments of cervical spine, strain of muscle, fascia, and tendon at neck level, cervicalgia, sprain of ligaments of lumbar spine, strain of muscle, fascia, and tendon of lower back, low back pain, sprain of ligaments of thoracic spine, strain of muscle and tendon of back wall of thorax, strain of muscle, fascia and tendon of pelvis, unspecified sprain of right shoulder joint, strain of muscle and tendon of the rotator cuff, left shoulder joint sprain, strain of muscles and tendons of the left rotator cuff, and headache. On 10/18/18, the provider noted the patient was injured in a car accident on 10/17/18. He complained of headaches, and pain in the neck, bilateral shoulders, mid-back, and low back. Physical examination findings on 10/18/18, included muscle spasm in the cervical, thoracic, and lumbar areas. Range of motion was decreased in the cervical, thoracic, and lumbar spine with pain. Strength was noted to be normal in the cervical spinal muscles, lumbar spinal muscles, upper extremities, and lower extremities. The patient received manual therapy and electrical muscle stimulation on this date. On 10/24/18 and 11/17/18, the patient received manual therapy, electrical muscle stimulation, and chiropractic adjustment. On 2/2/19, the patient reported improvement in his condition, although he continued to have symptoms. The patient received manual therapy, electrical muscle stimulation, and chiropractic adjustment on this date. There is no documentation of other treatments that were tried and failed. The patient has requested reimbursement for chiropractic services that were provided from 10/18/18 through 2/2/19. The Health Plan denied the request and reported the services at issue were not medically necessary for the treatment of this patient. At issue in this case is whether chiropractic services that were provided from 10/18/18 through 2/2/19 were medically necessary for the treatment of the patients medical condition. A study by Leaver and colleagues reported that there is no evidence to suggest that manipulation is more effective in the treatment of acute and subacute neck pain than mobilization.The physician reviewer found  that neck manipulation did not provide more rapid recovery from an episode of neck pain or better outcomes in terms of pain, disability, function, or global effect than mobilization. Casazza reported that exercises directed by a physical therapist may decrease recurrent pain and the need for health care services. Casazza noted that spinal manipulation and chiropractic techniques are no more effective than established medical treatments, and adding them to established treatments does not improve outcomes. In this case, the patients complete medical history was not noted. The chiropractic treatment reports did not include full physical examination findings.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The parent of a 10-year-old female enrollee has requested reimbursement for chiropractic services received 9/04/17 through 9/22/17. Upon review of the submitted documentation and relevant literature, the medical necessity of the services at issue is not established. The patient has juvenile idiopathic scoliosis. At present, there is insufficient evidence that the efficacy of non-specific manual therapy in the treatment of patients with idiopathic scoliosis can be reliably evaluated. According to a study, it has not been established that chiropractic care provides benefit in terms of slowing progression of curvature of the spine. All told, the services rendered are not consistent with the standard of care for patients with juvenile idiopathic scoliosis. Thus, the chiropractic services received on 9/04/17 through 9/22/17 were 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 chiropractic 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: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the breast tomosynthesis for evaluation of her breast cancer examination. Findings:  Three physician reviewers found that there is sufficient support in the peer-reviewed literature for the services at issue in this clinical setting. According to the a study, the addition of breast tomosynthesis reduces false positives and increases cancer detection when compared to two-dimensional mammography alone. Moreover, Detection rates, including those for invasive and in situ cancers, were 6.1 per 1000 examinations for mammography alone and 8.0 per 1000 examinations for mammography plus tomosynthesis. Given the support above, the services at issue were likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Final Result: The reviewers determined that the service 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 overturned. Credentials/Qualifications: Reviewers 1, 2, and 3 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: Medical Necessity
Decision: Overturned

The patient is a 28-year-old male who was diagnosed with an overactive bladder (OAB). On 3/27/19, the patient was noted to have a one-year history of urinary frequency and urgency. He was provided with Myrbetriq samples. On 4/30/19, the provider noted the patients voiding symptoms were essentially resolved with Myrbetriq. On 7/10/19, the provider noted the patient tried oxybutynin and Vesicare without success after Myrbetriq was denied. The patient reported voiding seven times during the day and four times at night. The patient also endorsed burning with urination and a strong uncontrollable urge to urinate. The patient has requested authorization and coverage for Myrbetriq 25 mg once daily. The Health Plan denied the request and reported the requested medication is not medically necessary for the treatment of this patient. At issue in this case is whether Myrbetriq 25 mg once daily is medically necessary for the treatment of the patients medical condition. The 2019 American Urological Association/Society of Urodynamics, Female Pelvic Medicine and Urogenital Reconstruction (AUA/SUFU) guidelines noted that the efficacy of mirabegron in patients who had used antimuscarinics compared to treatment-naive patients was similar across doses. Chapple and Siddiqui reported that mirabegron is established as an alternative monotherapy to antimuscarinics for the treatment of OAB symptoms. The authors noted that mirabegron has a favorable safety and tolerability profile compared with antimuscarinics. The physician reviewer found that mirabegron represents a new treatment option for a broad range of patients with OAB. In this case, the patient has failed treatment with Vesicare and oxybutynin. The medical evidence supports the requested medication in this clinical setting. Therefore, Myrbetriq 25 mg once daily is medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/ Case Summary:  The enrollee requested reimbursement, authorization. and coverage for PhysioStim bone growth stimulating device. Findings:  The physician reviewer found that the requested service is not medically necessary for the treatment of the enrollees medical condition. The enrollee injured her left wrist and complained of continued pain, weakness and occasional numbness to the left hand and fingers. An x-ray indicated a fracture of the proximal pole scaphoid with sclerotic margins. A second x-ray demonstrated chronic non-union of the scaphoid. An open reduction internal fixation (ORIF) of the scaphoid non-union, with vascularized bone graft, and scapha capitate pinning were performed. At a follow-up appointment, the physician noted persistence of the non-union. He fitted the enrollee for a bone stimulator to help stimulate bone healing. The medical literature indicates the evidence is lacking for the treatment of nonunion scaphoid fractures with bone growth stimulation. While literature supports the use of stimulation to treat long-bone delayed unions or nonunions, its effectiveness on short bones, such as the scaphoid is lacking. The idea of using electric stimulation in the treatment of nonunion fractures dates back many years and from this, alternative healing methods using electricity, such as extracorporal shock wave therapy and ultrasound were developed to accelerate the healing process of fresh fractures and to treat delayed unions. However, despite these available methods, there has been limited literature that supports its use. Rather, literature indicates that bone healing is a complex metabolic process that can be hindered by excessive early motion of the fracture site, inadequate fracture reduction or fixation, contamination or infection of the fracture site, and patient-specific factors or co-morbidities. The medical literature does not support bone stimulation as the means of correcting nonunion of the scaphoid. Final Result: The reviewer determined that the requested service is not medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The reviewer is board certified in hand 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 similar medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for heart surgery to insert a catheter closure of a patent foramen ovale. Findings:  The physician reviewer found that this procedure is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Based on the records provided, the patient had an embolic colonic ischemic event while on antiplatelet therapy. The patient has an associated atrial septal aneurysm and a patent foramen ovale (PFO), and no other clear source of embolism. In this circumstance of probable paradoxical embolization through a PFO, while already on antiplatelet therapy, there is mounting evidence from long term follow up studies suggesting that PFO device closure is more effective than medical therapy alone for patients who are under 60 years of age. Moreover, the patients who are most likely to benefit from PFO device closure are those with higher volume right-to-left interatrial shunting and atrial septal aneurysm, such as this patient has. These circumstances are associated with an increased risk for paradoxical embolism. Current ACC/AHA guidelines are also consistent with this approach. Therefore, the requested heart surgery to insert a catheter closure of a patent foramen ovale is reasonable, appropriate, and likely to be more beneficial than any other available standard treatments for the patients medical condition.Final Result: Three of the reviewers determined that the requested procedure is likely to be more beneficial for treatment of the patients medical condition than any other available standard therapy. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: Physician reviewer 1 is board certified in internal medicine, with subspecialty certification in cardiovascular disease and interventional cardiology, and is actively practicing. Physician reviewers 2 and 3 are board certified in internal medicine, with subspecialty certification in cardiovascular disease, and are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary:  An enrollee has requested breast tomosynthesis for evaluation of her risk for breast cancer.  Two physician reviewers found that while there is a lack of long-term studies demonstrating increased survival rates correlated with the use of digital breast tomosynthesis as a part of screening mammography, recent data have shown great promise of the technique due to a decrease in repeated imaging and an increase in the detection of small cancers. The technique has been particularly useful in cases of very dense breast tissue where the utility of standard digital mammography alone is limited due to breast density. Accordingly, digital breast tomosynthesis was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Final Result: Two reviewers determined that the services at issue were likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned.  Credentials/Qualifications: All three reviewers are board certified in diagnostic radiology 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: Overturned

The parent of a 15-year-old female enrollee has requested a bunionectomy for the treatment of the enrollees bunion on the left foot. Findings:  The physician reviewer found that the requested bunionectomy is medically reasonable and necessary for treatment of this patients condition. The patients initial complaint upon visiting the provider was foot pain. There was mention in his notes of the patient trying different shoes and complying with the Health Plans requirements without positive results. Bunions are congenital deviations at the first metatarsal phalangeal joint (MPJ), and can only truly be corrected with surgery. At 15 years of age, this patients growth plate should be closed, enabling her to undergo bunion correction. The standard of care in this setting is surgical correction if the bunion remains painful and does not respond to conservative care. The records indicate that this is in fact the situation with this patient and therefore surgical correction is warranted.
Appeal type: Medical Necessity
Decision: Overturned

A fifty-six year-old male with chronic asthma is requesting Xolair.  The patient requires frequent oral steroids and inhaled steroids.  The patients optimum FEV1 is supranormal despite a maximized therapeutic regimen. Reviewers Findings:The reviewing physician found that the submitted records demonstrate the patient has reversible lung disease.  The patient is on a number of therapies and yet still is not controlled.  Therefore, the reviewer found that the Health Plan denial should be overturned.
Appeal type: Medical Necessity
Decision: Upheld

A 27-year-old male has requested Bicillin L-A 1.2mil/2mL twice per week for treatment of his diagnosis of Lyme disease.  Findings:  The physician reviewer found that based on review of the available records, there is inadequate evidence that the patient has Lyme disease. We have no medical history or physical assessment in the records provided for review. The patients letter does not mention a tick bite or the rash seen in most patients with early Lyme disease. The laboratory findings also do not support the diagnosis. The positive IgM Western blot is most likely a false positive test. The patients symptoms are not those typically seen in cases of documented Lyme disease. In addition, there is a lack of support for long-term therapy with benzathine penicillin in this clinical setting. Overall, there is no reliable data to suggest this therapy would be appropriate. Further, parenteral antibiotics are not indicated for use longer than 30 days in the treatment of Lyme disease (Wormser, et al). All told, the requested Bicillin L-A 1.2mil/2mL twice per week is not medically necessary for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned

A 64-year-old female enrollee has requested outpatient therapy sessions at a frequency of once per week for treatment of her depression and anxiety. Findings:  The physician reviewer found that the therapeutic resolution of an adjustment disorder involves patient identification and understanding of the stressor.  The literature supports an array of interventions including cognitive therapy, family therapy, patient-centered therapy, supportive therapy, psychodynamic therapy, and time-limited, targeted psychotropic medication management.  Considering this patients emotional fragility and poor sense of self, and reluctantly estranged relationship with her son, weekly therapy was indicated through the date indicated.  During the session on the date specified, the patient was stable.  She was committed to treatment and self-improvement.  The therapist made a point to commend her on the progress she had made.  There was no evidence of specific functional impairment, grave disability, or imminent threat.  The medical records do not include longitudinal documentation including treatment history, quantifiable goals, barriers to progress, multidisciplinary contributions, physical examination, or supportive community interventions.  In this patients case, scaling back frequency of sessions to every two weeks as of the date specified to bolster autonomy and resiliency while mobilizing the patient towards remission within her community would have been medically appropriate.  Thus, weekly outpatient therapy sessions were medically necessary from the time frame specified.  However, the medical necessity of weekly outpatient therapy sessions from the date indicated forward has not been established.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested breast tomosynthesis for evaluation of the enrollees risk for breast cancer.  Findings: Three reviewers found that Tomosynthesis was approved by the U.S. Food and Drug Administration (FDA) for clinical use. Despite the lack of long-term studies proving an increased survival rate when tomosynthesis has been used as part of screening mammography, the American College of Radiology (ACR) urged the technique be removed from the investigational category due to the advantages this new tomographic technique brings to radiologists interpreting mammograms. This technique often allows radiologists to separate dense glandular elements from underlying masses and architectural distortion resulting in a decrease in callbacks and increased detection of small cancers. Thus, the addition of tomosynthesis to the usual two dimensional protocol was likely of greater benefit to this patient than had her exam been done with two dimensional imaging alone. Accordingly, the breast tomosynthesis was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Final Result: Three reviewers determined that the diagnostic procedure 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 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: Medical Necessity
Decision: Upheld

A 49-year-old male enrollee requested authorization and coverage for Nexium.  The health plan has denied this request indicating that the requested medication is not medically necessary for treatment of the enrollees gastroesophageal reflux disease.One physician reviewer performed a medical necessity Independent Medical Review.  The physician reviewer upheld the health plans denial on the basis that the requested medication is not medically necessary.