Persius/imr-appeals huggingface dataset:
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for cellular function assay performed.Findings:  The physician reviewer found that there is a lack of sufficient support in the peer-reviewed literature for the testing at issue in this clinical setting. The use of immune cell function assays has been studied in the treatment of ulcerative colitis, however it did not prove to be definitively useful for prediction of actual disease activity . The use of such assays is not recommended for management of Crohns disease per American College of Gastroenterology or American Gastroenterological Association guidelines, which recommend other tests instead . For these reasons, the cellular function assay performed was not likely to be more beneficial for evaluation of the patients Crohns disease than any available standard therapy.Final Result: The reviewers determined that the testing at issue was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: Physician reviewers are board certified in internal medicine with sub-specialty certification in gastroenterology 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 51-year-old male enrollee has requested magnetic resonance imaging (MRI) of the lumbar spine for evaluation of his back pain.  Findings:  The physician reviewer found that this patient has low back pain but there is no detailed medical history or physical examination findings documenting any neurological deficit. In addition, plain film x-rays show degenerative changes but no evidence of fracture. There are no red flags identified within the submitted records such as tumor, infection or fracture that would be an indication for the requested MRI. The records also do not indicate that a conservative trial of therapy has been attempted including physical therapy. Therefore, the records do not demonstrate the medical necessity of the requested MRI of the lumbar spine.
Appeal type: Experimental/Investigational
Decision: Upheld

A 65-year-old male enrollee has requested cervical artificial discectomy (artificial disc replacement) at C3-4 using the ProDisc and single level fusion at C4-5 for the treatment of his stenosis.  Findings:  Three physician reviewers found that  cervical disc replacement is currently being evaluated in clinical studies in an effort to retain intervertebral motion in the cervical spine and to slow adjacent segment deterioration (Peng-Fei and Yu-Hua). Denaro and colleagues indicate that although many disc replacement procedures have been performed to date, the long-term effectiveness and safety remains uncertain. Murrey and colleagues report that early results have been encouraging, but the long-term maintenance of these results has not yet been determined. The problem of heterotopic ossification leading to restricted motion is in need of clarification, and therefore longer follow-up studies are needed to assess the function and benefits of this procedure. At this time, there is inadequate outcome data demonstrating that cervical disc replacement preserves motion and reduces degenerative changes in adjacent segments over time.
Appeal type: Medical Necessity
Decision: Overturned

A 56-year-old female enrollee requested oxycodone, HCl 5 mg for medical treatment of her medical conditions.  Findings:  The physician reviewer found that, based on a review of the documentation submitted, the requested medication is indicated and is a low dose. The medical literature demonstrates that low dose medication avoids multiple adverse consequences including tolerance, dependency, immunosuppression and other side effects. In addition, it appears the patient has fewer complications when acetaminophen is avoided with opioid, thus oxycodone without acetaminophen is recommended. All told, oxycodone HCl 5 mg is medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld

A 67-year-old male enrollee has requested sclerotherapy injections for the treatment of his varicose veins. Findings:  Three physician reviewers found that repeat sclerotherapy injections will not likely be more beneficial than any available standard therapy. Most varicose veins are secondary to venous insufficiency and reflux which most commonly arises in the greater saphenous vein. In the presence of venous reflux, repeat sclerotherapy injections will likely fail due to recurrent varicose veins. Once venous reflux is diagnosed with a duplex exam, treatment of the valvular incompetence of the greater and/or lesser saphenous vein should be performed. As mentioned by the Health Plan, this treatment can be performed with surgical ligation, endoluminal radiofrequency ablation, or endoluminal with ablation. If, after treatment of the incompetent vein, varicosities persist, sclerotherapy could potentially be indicated at that time.
Appeal type: Medical Necessity
Decision: Upheld

A 51-year-old female enrollee requested authorization and coverage of gastric bypass surgery with duodenal switch. The Health Plan denied the request indicating that the requested procedure is not medically necessary for treatment of the enrollees morbid obesity.Three physician reviewers performed a medical necessity Independent Medical Review. Two physician reviewers concluded that the requested procedure is not medically necessary for treatment of the enrollee's medical condition. One physician reviewer concluded that the requested procedure is medically necessary for treatment of the enrollee's medical condition. Because two of the three  physician reviewers concluded that the requested surgery is not medically necessary for treatment of the enrollee's medical condition, the Health Plans denial has been upheld.
Appeal type: Medical Necessity
Decision: Upheld

The parent of a 10-year-old female has requested coverage for speech therapy for treatment of her lisp.  Findings:  The physician reviewer found that children with articulation disorders have mild to moderate deficits in speech, and most of their speech may be intelligible to unfamiliar listeners despite the errors. These children often benefit from speech therapy to correct inaccurate sound productions.  Children and adults with speech disorders often experience poor self-esteem and embarrassment. Therapy is designed to reduce the negative psychological consequences of the articulation disorder and to provide remediation.  The patients parent has reported that the patient has a lisp.  However, the submitted medical records do not substantiate this stated diagnosis.  Thus, the submitted documentation fails to establish the medical necessity of the requested speech therapy at this time.  In this patients case, a speech and language evaluation is needed to determine the extent of her articulation disorder. The medical necessity of the requested speech therapy cannot be established absent this documentation.
Appeal type: Medical Necessity
Decision: Upheld

The patient is a three-year-old male who has been diagnosed with childhood apraxia syndrome by a speech-language therapist. The patients birth history was within normal limits and no other neurological deficits are documented in the submitted records. The patients hearing was tested and was found to be within normal limits. The speech-language therapist has documented that the patients receptive language skills are within normal limits for his age. Review of the speech therapy progress notes reveals improvement in the patients speech. A request has been made for continued speech therapy. The Health Plan has denied the request on the basis that the patient is experiencing a developmental delay and therefore, speech therapy is not medically necessary.The Health Plans denial should be upheld. Upon review of current medical literature the definition of childhood apraxia disorder is not uniform and remains controversial. Childhood apraxia disorder is related to a nervous system disorder or underdevelopment. There is no literature or consistent neurologic finding to date to verify that childhood apraxia syndrome is an isolated disease. Therefore, under current definitions it appears the patients condition is considered a developmental delay rather than a medical condition. In light of this, treatment of the patients condition is not medically indicated.Based upon the submitted information, I have determined that the requested therapy is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld

The patient is a 35-year-old male with a history of refractory major depressive disorder. The submitted information indicates the patient has been in treatment for several years.  The patients psychiatrist notes that the patient has failed to respond to multiple medications. The patients provider has prescribed Zoloft 500mg. The Health Plan has denied authorization and coverage for the requested dosage of Zoloft on the basis that it is not medically indicated. A dose of Zoloft this high could only have theoretical utility in the treatment of obsessive-compulsive disorder. Given that this patient has been diagnosed with major depressive disorder, augmentation strategies (the use of Zoloft with a second agent such as bupropion, protriptyline or mirtazapine) represent the appropriate psychopharmacologic intervention. Combining multiple antidepressants from different categories is the standard of care for patient such as this patient. The safety and efficacy of the requested dosage of Zoloft for treatment of major depressive disorder has not been established. As such, the requested prescription is not medically indicated for treatment of the patients disorder.Based upon the information set forth above, I have determined that the requested prescription is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned

A 46-year-old male enrollee has requested for Lunesta for treatment of his insomnia. Findings:  The physician reviewer found that Ambien CR and Ambien are essentially the same compound, but with different release mechanisms. It is not reasonable to require that the patient try the same medication, even if it is released in a different fashion, if he has already experienced a side effect from it.
Appeal type: Medical Necessity
Decision: Overturned

A 55-year-old male enrollee requested authorization and coverage of hydrocodone for treatment of pain caused by severe intractable failed knee surgery syndrome.  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 overturned the health plans denial on the basis that the requested medication is medically necessary.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for bilateral Euflexxa injections. There is adequate data in the medical literature to support an indication for hyaluronic acid injections to diminish osteoarthritic knee pain. However, in this case, the documentation does not support a diagnosis of knee osteoarthrosis. The records attribute the patients knee pain to chondromalacia patella. Currently, there is a paucity of studies supporting a clinical indication of hyaluronic acid injection for anterior knee pain attributed to chondromalacia patella. Studies of hyaluronic acid injection for pain attributed to osteoarthrosis in the primary femoral-tibial articulation have reported mixed results. Currently, hyaluronic acid injections are considered second-line treatment for osteoarthrosis after independent exercise, weight loss and simple medications such as nonsteroidal anti-inflammatory medications and/or acetaminophen. In this case, there is no documentation of knee osteoarthrosis or that the patient has exhausted standard first-line treatments for nonspecific knee pain. For these reasons, the requested Euflexxa injections are not medically necessary for treatment of this patients knee pain. 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: The patient has requested authorization and coverage for one-day hospital stay following body contouring surgery. The records provided for review document that this patient has a history of gender dysphoria. The patient is planned to undergo abdominoplasty with liposuction and fat injection to buttocks and hips. The provider has recommended a one-day hospital admission following the procedure. Per Boudreault and Sieber, abdominoplasty operations are routinely performed in the outpatient setting. Swanson and colleagues noted that, Although abdominoplasties have been traditionally done in a hospital setting with an overnight stay, today they are done more commonly in ambulatory surgery centers and accredited office surgical facilities. The authors commented that these changes are due to advances in technique and anesthesia to reduce surgery times, limit blood loss, improve pain management, and shorten recovery times. Based on these reports, abdominoplasty is commonly carried out as an outpatient with or without an overnight observation level of care stay at a hospital or an outpatient surgery facility. In addition, inpatient hospital care is reserved for patients who have identifiable risk factors that require either an advanced level of observation or intensive postoperative care and monitoring. For this patients, there is a lack of report of a clinically significant increased risk during recovery from the planned surgical procedure. Thus, outpatient surgery, including a less than 24-hour observational stay, is accepted medical practice for abdominoplasty with fat grafting. All told, the requested one-day hospital stay following body contouring surgery 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 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: Upheld

A 61-year-old female enrollee has requested bilateral mastopexy for treatment of her breast fold infection.  Findings:  The physician reviewer found that  based upon the submitted documentation the patients condition does not meet criteria for reconstructive surgery. The documentation provided does not support the presence of an abnormal structure of the body. The patients current condition of ptotic mildly asymmetric breasts would not be considered abnormal. All told, the requested procedure is not medically necessary or reconstructive in nature.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: an enrollee has requested reimbursement for residential treatment center services provided. Findings:  The physician reviewer found that the patients post-acute withdrawal symptoms were not severe in nature. the patient was not a danger, nor was the patient aggressive or violent. The patient was cognitively intact and was not gravely disabled. There were no emotional, behavioral, cognitive, or impulsive symptoms that would warrant residential level of care. The patient was medically and psychiatrically stable. The patient's medication management could have been performed in an ambulatory setting. There was no evidence of a high degree of impulsivity, agitation, depression, mania, hallucinations, or any other significant symptom that would interfere with the patient's care. The patient was internally motivated and working the program and he had a sponsor. The patient was cooperative and participating in his treatment plan. Although the patient continued to struggle with emotions and required further treatment to help develop coping skills, this did not require the structured environment of a residential setting and could have been stepped down to an ambulatory level of care. 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 physician reviewer is board certified in psychiatry with sub-specialty certification in addiction 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: Upheld

A 52-year-old female enrollee has requested a power wheelchair for treatment of her status post fracture of the right leg. Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested equipment in this patients case.  The submitted records do not establish that the patient would be bed or chair confined without a power mobility device.  The records indicate that she ambulates in the home with a walker.  In addition, the records do not establish that the patients mobility needs, including community mobility needs, could not be met with a manual wheelchair.  The patient has multiple chronic health conditions, such as heart disease and vascular disease, which would benefit from increased physical activity and exercise.  Manual wheelchair use has been shown to provide significant health benefits use over power wheelchair use for individuals with mobility impairments.  All told, the requested power wheelchair is not medically indicated in this clinical setting.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for the magnetic resonance imaging (MRI) of the right ankle. Welck and colleagues report that there are numerous stress fractures about the foot and ankle, including metatarsal, tibia, calcaneus, navicular, fibula, talus, medial malleolus, sesamoid, cuneiform and cuboid. The authors further note that late identification can be associated with protracted pain and disability, may predispose to non-union, and therefore necessitate operative intervention. Stress fractures are typically not visualized radiographically, and often diagnosed by MRI. Callachand and colleagues note that a diagnosis of avascular necrosis (AVN) should be considered in patients with atraumatic foot and ankle pain, especially in the presence of risk factors such as alcohol excess and smoking. In this case, the patient reported a painfully swollen, erythematous ankle that was unable to bear weight. There was no a history of trauma.  X-rays were unremarkable except for moderate soft tissue swelling.  Given that the records noted a history of alcoholism, the patient was predisposed to AVN. While AVN of the talus is relatively common in occurrence, such a lesion may not be evident on x-rays or on an ultrasound. Other occult lesions of the foot and ankle requiring advanced imaging may include osteomyelitis, septic joint, soft tissue infection,  osteochondritis ossificans, tenosynovitis among others. In this case, an MRI of the patients ankle showed subcutaneous edema at the dorsal and lateral margin of the ankle, moderate effusion, and moderate edema in and enhancement within the sinus tarsi, involving the adjacent talus and calcaneus, consistent with sinus tarsi syndrome. Given that these findings would not be evident with X-rays or ultrasound, the service at issue was medically indicated. Therefore, MRI of the right ankle was medically necessary for the evaluation of this patient.Final Result: The reviewer determined that the service at issue was medically necessary for evaluation 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.