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

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for deoxyribonucleic acid (DNA) analysis of stool samples. Findings:  Three physician reviewers found that the records fail to demonstrate the superior effectiveness of the services at issue.  Conventional assessment of colorectal cancer risk largely involves detection of non-dysplastic adenomatous polyps. Toward this end, the efficacy of computed tomography (CT) colonography, of the Cologuard assay, and of detection of occult blood in stool is traditionally compared against the gold standard, optical colonoscopy.  Cologuard is a stool DNA test that includes molecular assays for DNA mutation and methylation biomarkers.  Given the low sensitivity of Cologuard in detecting adenomas, the service under consideration is not as beneficial as any established alternatives.  The available records do not support that effective conventional screening strategies are contraindicated in this case.  In sum, DNA analysis of stool samples performed was not likely to have been of greater benefit than other modalities for evaluating this patient. Final Result: 2 of 3 reviewers determined that the services at issue were 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: All three 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: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for pelvic magnetic resonance imaging (MRI) with and without contrast. Plexopathy will typically manifest as pain with a neuropathic character affecting more than one peripheral nerve distribution. Associated weakness or other neuropathic symptoms may be present. MRI of the lumbar plexus with and without contrast is the appropriate examination to determine if the cause of the plexopathy is intrinsic or extrinsic. In this patients case, her symptoms may be due to a plexopathy. The records document symptoms that may be attributed to both the L2-3 and L5 distribution. Prior MRI of the lumbar spine did not demonstrate findings that would account for the patients symptoms. In this setting, MRI of the pelvis with attention to the lumbosacral plexus is medically indicated. There is sufficient support for the requested services in this clinical setting. Therefore, the requested pelvic MRI with and without contrast is medically necessary for the evaluation of this patient. Final Result: The reviewer determined that the requested services are 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 diagnostic 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

An enrollee has requested skilled nursing care at a rehabilitation center for treatment of her acute pulmonary embolism.  Nature of Statutory Criteria/Case Summary:   The physician reviewer found that the requested skilled nursing care at a rehabilitation center was not and is not medically necessary for treatment of the patients medical condition. Based on the documentation submitted for review, the patient has made progress in the skilled nursing facility to the point where she is nearly to the functional level where she was prior hospitalization.  In this clinical setting, additional physical therapy and occupational therapy evaluations are indicated to determine if skilled services are necessary. For the reasons provided, the services at issue were not and are not medically necessary at this time. Final Result: The reviewer determined that the services at issue were not and are not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.  Credentials/Qualifications: The reviewer is board certified in physical medicine and rehabilitation with sub-specialty certification in neuromuscular 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

Nature of Statutory Criteria/Case Summary: An enrollee has requested Otezla for treatment of his medical condition.   Findings:  The physician reviewer found that there is a lack of support for the requested medication in this patients case.  Per the medical records, he has tried and failed therapy with topical steroids and ultraviolet light.  Based upon the medical records, there is no documentation of contraindication to methotrexate, acitretin, or cyclosporine. Previous history of actinic keratosis is not a contraindication to these aforementioned systemic therapies. The Health Plans alternatives are medically appropriate.  All told, the requested medication Otezla is not medically indicated for the treatment of this patient. Final Result: The reviewer determined that the requested medication is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in dermatology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld

An enrollee has requested authorization and coverage for occipital nerve stimulation for treatment of the enrollees occipital neuralgia. Findings:  The physician reviewers found that the use of ONS is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. While the effectiveness of ONS compared to sham control has been shown in multiple randomized controlled trials, the average effect size is modest and may be exaggerated by bias as achieving effective blinding remains a methodological challenge. Further measures to reduce the risk of adverse events and revision surgery are needed. Based on the lack of adequate support in the peer-reviewed literature, the requested service is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Final Result: Two of three reviewers determined that the requested service is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: Physician reviewers number one, two, and three are board certified in anesthesiology with sub-specialty certification in pain medicine and is 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

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for a magnetic resonance imaging (MRI) of the lower extremity without contrast. The records provided for review document that this patient has knee pain associated with objective evidence of swelling over the tibial tunnel site two years after an ACL reconstruction and partial medial meniscectomy. The pain is relatively severe warranting a diagnostic work-up. The provider has recommended an MRI scan. The recent medical literature supports an indication for an MRI for persistent knee pain following prior surgery. MRI is the preferred modality for imaging the knee to show soft tissue as well as bone pathology and guide patient management and treatment. Knee pain two years after a torn meniscus and ACL reconstruction requires MRI to make an accurate diagnosis. Diverse knee pathology, multiple pain sources and complex anatomy, as well as the possibility of recurrent meniscal tears and graft related issues, need to be ruled out. The MRI knee protocol and sequences should ensure detection of both soft tissue and osseous structures in detail and with accuracy. Therefore, a MRI of the lower extremity without contrast is medically necessary for evaluation and management of this patients postoperative knee pain and swelling.Final Result: The reviewer determined that the requested services are 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.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a four-year old male enrollee has requested speech therapy services for the treatment of the enrollees autism. Findings:  The physician reviewer found that the medical and psychological literature strongly supports speech therapy combined with play therapy when a child lacks the ability to develop social communication. This patient clearly is of above average intellect and has the facility for expressive and receptive speech, but still fails in his ability to develop social and reciprocal speech interventions.  One provider states that the patient lacks ability for reciprocal social interaction and for conversation. Kasari and colleagues 2008 publication discussed a controlled study of three- to four-year-old autistic children and notes improved language development over 12 months in the treatment group when speech therapy is combined with both joint attention and play therapy. The Landa paper strongly stresses the need for extensive speech therapy at very early ages in autistic children. Further, Yoder and McDuffie also stress the need to combine speech therapy with object play and the teaching of non-verbal communication as the most successful interventions. This literature, in which comparison is made to control group studies, supports the concept that speech therapy as applied in this setting is necessary to develop social speech in this patient. Therefore, all of the services were medically necessary. Also, continued speech therapy (2 individual weekly speech therapy sessions and 1 small group session) is a medically necessary intervention in this autistic patient. Speech therapy should be continued for 12 months with reassessment of the patient after 6 and 12 months of therapy.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested magnetic resonance imaging (MRI) for evaluation of the enrollees knee pain.  Findings: The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested services.  MRI is the most optimal means to evaluate an internal derangement.  Plain x-rays are of only limited value.  The reason that plain x-rays are of only limited value is that the menisci and ligaments are not visible on plain x-rays.  One can assess the degree of degenerative disease and whether there are any acute bony structural abnormalities, but this information is only of limited interest in this patient.  There are many people who have absolutely no degenerative disease who have grossly abnormal menisci, and conversely, there are patients who have gross degenerative joint disease, but relatively intact menisci.  The Health Plans requirement that the patient pursue a trial of conservative management prior to obtaining an MRI is medically appropriate, as acute pain will often resolve without more aggressive intervention.  In this patients case, the records document that she has only been seen one year earlier by a chiropractor, who at that time felt that the symptoms would resolve.  The medical evidence supports a trial of intensive anti-inflammatory therapy prior to pursuing an MRI in this case.  This patient has had symptoms for at least one year, has not had any recent trauma, and there is no indication that she has an infection or other condition that requires immediate attention.  Most cases of knee pain, especially in a young individual, will resolve without surgery.  All told, the requested MRI is not medically indicated for the evaluation of this patient.Final Result: The reviewer determined that the requested services are not medically necessary for evaluation of the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is board certified in diagnostic 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

Nature of Statutory Criteria/Case Summary:  An enrollee has requested magnetic resonance imaging (MRI) of the lumbar spine for evaluation of her medical condition.  Findings:  The physician reviewer found that the submitted documentation fails to establish the medical necessity of the requested services. The clinical documentation submitted for review does not demonstrate focal weakness, sensory changes or abnormal reflexes on physical examination. There is no documentation supporting an abnormal electromyography (EMG) test in the setting of radicular symptoms. Moreover, there is a lack of documentation demonstrating the patient has trialed six weeks of conservative therapy without evidence of improvement.  Based on the medical literature and clinical documentation provided, the request for MRI of the lumbar spine is not medically necessary for evaluation of the patients medical condition.  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 diagnostic radiology with sub-specialty certification in interventional radiology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary:  An enrollee has requested a repeat or second bariatric surgery for treatment of her medical condition. Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested services.  The medical records do not document any obvious complication of her prior gastric bypass that requires surgical intervention to treat.  There is no documentation of any anatomic complications of the prior gastric bypass.  Additionally, the records do not document ongoing dietary or behavioral follow-up since her gastric bypass.  There is a lack of support for the requested services in this clinical setting.  All told, the requested repeat or second bariatric surgery is not medically necessary for the 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 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 39-year-old male enrollee has requested acute psychiatric inpatient hospitalization for treatment of his chemical dependency and depression.  Findings:  The physician reviewer found that applying the American Society of Addiction Medicine (ASAM) treatment guidelines, the acute psychiatric inpatient hospitalization services provided to this patient from the date indicated and forward are not medically necessary for history of his medical condition. The patient was admitted on the date indicated on a 5150 hold for being a danger to himself. His substance abuse history is somewhat unclear as there are some interviews that document daily binging, and others document weekends only. From the subsequent date indicated and forward, the patient denied suicidal and homicidal ideation, and there was no evidence of psychotic ideation in any modality. His vital signs were stable. There was no clear cut evidence of alcohol withdrawal described in terms of gastrointestinal disturbance, tremors, or diaphoresis. The patient denied cravings for alcohol or drugs. He did not require 24-hour monitoring in an inpatient setting for his substance abuse issues. Thus, the patient could have been treated at a lower level of care such as outpatient with community based resources such as 12-step programs. All told, the services at issue were not and are not medically necessary for treatment of this patients medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Cartiva synthetic cartilage implant surgery.Findings:  Two of the three physician reviewers found Advanced stages of first metatarsophalangeal arthritis have traditionally been treated with various arthroplasties or arthrodesis. While the medical literature does show some early promising results with the use of the Cartiva synthetic cartilage implant for the treatment of hallux rigidus, there is a lack of long-term high-quality studies demonstrating safety and efficacy. The gold standard for treatment of hallux rigidness remains arthrodesis. Per the records, this patient has mild to moderate intermittent symptoms. There are no submitted reports of radiology studies which grade the severity of the degenerative changes of the great toe metatarsophalangeal joint. In sum, Cartiva synthetic cartilage implant surgery is not likely to be superior over other treatment options. Final Result: The reviewers determined that the requested services are not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: Physician reviewers 1, 2 and 3 are board certified in orthopedic surgery 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 a reimbursement for occipital nerve block injection. The Health Plan has denied this request indicating that the services at issue considered investigational for treatment of the enrollee who has a history of vertigo and dizziness. Neuralgia is a type of neuropathic pain. It can be lightening like, burning, dull or ache type pain that follows a peripheral or cranial nerve area that can also spread to other areas. There cannot be a neurologic deficit correlating with the nerve affected. Attacks either can be spontaneous or provoked by direct stimulation or palpation of other trigger point zones. Occipital neuralgia can specifically refer to pain and/or headache in the occipital region in the greater, lesser, or third occipital nerve areas, which can also be accompanied by dysesthesia or decreased sensation in the nerve distribution. On examination, the provider documented tenderness with palpation over the occipital area. Another key element to the diagnosis is response to occipital nerve blocks, which the patient also exhibits. The treatment of choice for occipital neuralgia is a local occipital nerve block due to its ability to relieve pain and act as a diagnostic marker as well as being a relatively safe procedure. Considering the information provided by the provider, the patient has several neurological diseases, one being occipital neuralgia. The treatment she has undergone has served as a diagnostic aid as well as therapeutically. According to the current data, guidelines, and recommendations the occipital nerve block injection provided was likely to have been more beneficial for treatment of this patients medical condition than any available standard therapy.Final Result: The reviewers determined that the services were likely to be more beneficial for treatment 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 neurology 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.