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

Nature of Statutory Criteria/Case Summary:  An enrollee has requested breast tomosynthesis for evaluation of her medical condition.  Findings:  Two physician reviewers found that in the peer-reviewed medical literature, Skaane and colleagues found that the addition of three dimensional digital breast tomosynthesis to two dimensional full field digital mammography resulted in a significantly higher cancer detection rate and enabled the detection of more invasive cancers. Thus, although additional studies are needed to confirm these findings, there is adequate data to support the utility of three dimensional digital breast tomosynthesis in this clinical setting. For these reasons, breast tomosynthesis was likely to be more beneficial for evaluation of this 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: Upheld

The patient is a 53-year-old man who has had two surgeries and radiation for a recurrent pituitary macroadenoma. He has requested growth hormone (GH) for presumed adult GH deficiency (AGHD) based on non-specific symptoms and a low IGF-1 concentration. The patient is on replacement therapy for presumed deficiencies of LH/FSH and TSH with testosterone and thyroxine. The symptoms are a generalized sense of loss of well-being and difficulty maintaining muscle mass despite full replacement of the other hormones.Based upon the information provided, it is likely this patient has AGHD. The diagnosis is usually made based on the clinical context, which is suggestive of some disorder of the hypothalamic-pituitary axis. In this case the patient has a structural reason for suspecting AGHD based on his recurrent pituitary tumor and its treatment. The low IGF-1 level is also suggestive of AGHD. However, he has very little in the way of clinical symptoms of GH deficiency. It appears the patient has not had a GH stimulation test. The diagnosis of AGHD should be based on the results of a dynamic GH stimulation test. The possibility that a patient with a low IGF-1 and two trophic hormone deficiencies, (TSH and gonadotrophin (LH/FSH)) will fail the test, has a positive predictive value of 83% in one large series of patients collected by the US Hypopituitary Control and Complications Study Group. If the patient fails a dynamic GH stimulation test, GH therapy would be medically indicated.Based upon the information set forth above, I have determined that the requested therapy is not medically necessary for treatment of the patients medical condition at this time. The Health Plans denial should be upheld at this time. However, if the patient fails a dynamic GH stimulation test, GH therapy should be authorized.
Appeal type: Medical Necessity
Decision: Upheld

A 58-year-old female enrollee has requested a two-level decompression, stabilization, and fusion with connection to inferior instrumentation for treatment of her back pain.  Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested services for the treatment of this patient.  The current medical evidence does not support the requested services in this clinical setting.  Resnick and colleagues noted that lumbar spinal fusion was recommended as a potential surgical adjunct in patients with a herniated disc in whom there is evidence of preoperative lumbar spinal deformity or instability.  Based upon the radiologists report, there is no evidence of spinal instability at L1-2 and L2-3.  The American Pain Society has developed evidence-based recommendations on the use of interventional diagnostic tests and therapies, surgeries, and interdisciplinary intervention for low back pain of any duration, with or without back pain.  The authors noted that intensive interdisciplinary intervention with a cognitive/behavioral emphasis should be considered for patients with non-radicular low back pain who do not respond to non-interdisciplinary interventions.  Based upon the medical records provided, this patient has not received this therapy.  All told, the requested two-level decompression, stabilization, and fusion with connection to inferior instrumentation is not medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: A female enrollee has requested authorization and coverage for a computed tomography (CT) of the head/brain with and without dye. The records provided for review document that this patient presents with a history of chronic headache condition of at least five months. The patient reports that her headaches resolve with a change in position. There is no evidence of thunderclap headaches or a history of malignancy, trauma, symptoms of meningitis, or sinus infection. In addition, the patients neurological examination has been normal. Applying the American College of Radiology (ACR) appropriateness criteria, the requested CT of the head/brain with and without dye (CPT code 70470 is not supported as medically necessary for evaluation of this patients medical condition. Final Result: The reviewer determined that the requested diagnostic procedure is 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

A 51-year-old female enrollee requested a cardiac computed tomography angiography (CCTA) for medical evaluation of her chest pain, palpitations, and hypertension.   Findings:  The physician reviewer found that in the clinical circumstance of a reported normal coronary angiogram and unequivocally normal nuclear stress test performed fairly recently for similar symptoms, additional cardiac evaluation with CCTA is not medically necessary and is not considered standard accepted practice in the medical community. Current guidelines that are endorsed by several national organizations also do not consider CCTA appropriate as a sequential test after an unequivocally normal stress imaging procedure (Taylor, et al). All told, the requested CCTA is not medically necessary for further evaluation of this patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for residential substance abuse treatment he received. Findings:  The physician reviewer found that, to objectively determine if the patient met the criteria for residential substance abuse treatment, the Level of Care Utilization System (LOCUS) guidelines are applicable. This is an accepted, national standard for determining the appropriate level of care for adults. On the date of service in question, the patient demonstrated a low risk of harm (score 2) as there was no documentation of prior suicide attempts and the patient did not have any suicidal ideation on that date. The patient demonstrated moderate functional impairment (score 3) as he has conflicted relationships with others, he has never had employment, is unable to engage in socially constructive activities, and his hygiene falls below usual standards on a frequent basis. The patient has a co-morbidity of amphetamine use disorder and cannabis use disorder (score 3) and there is also a chart history of bipolar disorder and paranoid schizophrenia. The patient has a moderately stressful recovery environment (score 3) as he has significant discord with family members over substance use. The patient has limited support (score 3) as his parents are supportive, but it appears that the patients parents have caregiver fatigue. The patient has had prior history of intensive outpatient program (IOP) treatment as well as Alcoholics Anonymous (score 3) which demonstrates equivocal response to treatment and recovery. The patient has shown positive engagement and is willing to participate in treatment (score 2). These findings give the patient a composite score of 19 which is consistent with IOP level of care services. The patient requires treatment for his amphetamine use disorder and cannabis use disorder, but this could have been safely and adequately provided in a less restrictive treatment environment. Therefore, the residential substance abuse treatment provided was not medically necessary for treatment of the patients behavioral health condition. 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 psychiatry with expertise in child and adolescent 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: Overturned

A 57-year-old female enrollee has requested acute hospital services for the treatment of her nonunion of left distal radius with retained hardware. Findings:  The physician reviewer found that the patients physician has reported concern regarding the patients level of pain given her history of reflex sympathetic dystrophy. The physician recommended a second day of hospitalization, and the patient complied with this recommendation. It was imperative that pain relief was adequate after the patients nerve block wore out and prior to discharge. The acute hospital stay services provided on the dates in question were medically indicated and appropriate for this patients postoperative care.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Praluent Pen every two weeks for treatment of her mixed hyperlipidemia, atherosclerotic disease, and family history of coronary artery disease.Findings: The physician reviewer found that the provider documented that the patient in this case has been treated with atorvastatin, rosuvastatin, simvastatin, simvastatin in combination with Zetia, and fluvastatin, all of which were either not tolerated due to myalgias, myositis, or liver function test abnormalities. In addition the patient has a documented history of carotid atherosclerosis and a family history of coronary artery disease. The patient is in need of lipid lowering therapy. Thus, the requested Praluent Pen 75 mg every two weeks (two pens every 28 days) is medically necessary given the need to lower the patients total cholesterol and LDL. 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 sub-specialty certification in endocrinology, diabetes 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: Medical Necessity
Decision: Overturned

A 46-year-old male enrollee has requested for facet joint injections for treatment of his back pain.  Findings:  The physician reviewer found that the treatment plan of an isolated specific targeted low risk diagnostic facet injection is reasonable and will provide valuable diagnostic and potentially therapeutic relief that will allow further elucidation of a comprehensive management plan including medication and physical modalities. All told, the patient meets all reasonable criteria for facet injection, described as axial non-radicular, has no evidence of compressive lesion or neurologic sequelae, and has no contraindication to the block. The patient has also failed conservative management and has had no previous posterior fusion at the affected level. Therefore, the requested diagnostic facet injection should be approved for this patient based on medical necessity.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested residential behavioral health services for treatment of the enrollees behavioral health conditions.   Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the services at issue.  This patient was not a threat to herself or others and there was no evidence to suggest that returning to the community would lead to decompensation or deterioration. She had improved and no longer required 24-hour supervision.  During the dates of service at issue, she could have been safely treated at a lower level of care.  All told, residential behavioral health services were not and are not medically indicated for the treatment of this patient. 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 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: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Monovisc injection in the right knee.An exhaustive review of the current medical literature pertaining to viscosupplementation reveals mixed results. Evidence from eight systematic reviews and six randomized controlled trials indicates that although viscosupplementation may relieve knee pain in some individuals with osteoarthritis, it is not known as to which individuals will benefit. Different studies have tried mixing hyaluronic acid with corticosteroids, platelet rich plasma, and other agents to make it more effective. The current evidence is limited, and guidelines from organizations such as the American Academy of Orthopedic Surgeons indicate that the evidence is not conclusive. In light of the foregoing, viscosupplementation can only be recommended in individuals with a history of lasting benefit from prior injections, and in carefully selected cases where everything else has been tried, and the options are limited. In this case, there is a history of lasting relief with viscosupplementation using Monovisc seven months ago. Furthermore, the options are limited. The patient has tried and failed other treatments, including physical therapy, a home exercise program, and topical and oral nonsteroidal anti-inflammatory drugs. Therefore, the requested Monovisc injection for the right knee is medically necessary for the treatment of the patients medical condition.Final Result: The reviewer determined that the requested service 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 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: Experimental/Investigational
Decision: Upheld

A 64-year-old female enrollee has requested total ankle replacement for the treatment of her right ankle pain. Findings:  Three physician reviewers found that total ankle replacement (arthroplasty) is a procedure which has not yet found good long-term results in the literature. Haddad indicates that the intermediate outcome of ankle arthroplasty appears similar to that of ankle arthrodesis. The report authored by McKee does not demonstrate that one operation has a benefit over another operation. Historically, patients who undergo total ankle arthroplasty have an increased risk of infection, need for revision, and other complications, and the procedure is only appropriate for a very-limited population.
Appeal type: Medical Necessity
Decision: Overturned

A 44-year-old female enrollee requested authorization and coverage of Botox injections. The Health Plan denied the request indicating that the requested therapy is not medically necessary for the treatment of the enrollees migraine headaches.One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer overturned the Health Plans denial on the basis that the requested therapy is medically necessary.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: A patient has requested authorization and coverage for tramadol HCL. According to research, the use of a weak opioid in combination with an NSAID for pain control is indicated for mild to moderate pain and represents only the second step in the four-step ladder. Researchers have stated that medical necessity for chronic opioid therapy may be established on average moderate to severe pain (equal to 4, on a scale of 0 to 10) and/or disability. With regard to determining opioid dosage, researchers consider up to 40 morphine milligram equivalent (MME) as a low dose, from 41 to 90 MME as a moderate dose, and greater than 91 MME as a high dose. Medical literature states that clinicians should continue opioid therapy only if there is clinically meaningful improvement in pain and function that outweighs risks to patient safety. Furthermore, medical literature suggests that if opioids are used, they should be combined with non-pharmacologic therapy and non-opioid pharmacologic therapy, as appropriate.In this case, the patient has verified evidence of multiple painful conditions that cause disability related to limited finger and elbow mobility. She has documented end stage osteoarthritis affecting the joints in her hand and elbows. She also has nerve conduction findings of severe nerve entrapment of the median and ulnar nerves. She also complains of elbow pain related to osteoarthritis of the elbows, which is associated with reduced extension of her right elbow. The patients provider notes state that she has tried and failed several conservative therapies including NSAIDs, physical therapy, splinting, and joint injections. The patient has signs and symptoms consistent with chronic pain due to longstanding severe osteoarthritis and nerve entrapment syndromes. Submitted documentation indicates that in addition to turmeric and Celebrex, the patient uses tramadol. In this case, the patient is well within the range consistent with low dose opioid therapy for a chronic non-cancer pain-related condition. The patient has not displayed signs of aberrant opioid use behavior, and she has tried and continues to pursue other treatment modalities, including surgical treatments. The patients records reflect that she is using the tramadol to allow her to perform activities of daily living. Under these circumstances, the requested tramadol HCL is medically necessary for treatment of the patients medical condition.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 anesthesiology, with subspecialty certification in pain management. The reviewer is an expert in the treatment of the patients 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 17-year-old male enrollee has requested authorization and coverage for orthognathic surgery (mandibular osteotomy and molar extractions) for the treatment of the enrollees mandibular hyperplasia. Findings:  The physician reviewer found that this patients condition constitutes an abnormal structure of the body caused by a congenital defect. He has a maxillofacial skeletal deformity which has resulted in an abnormal relationship between his upper and lower jaws. The etiology of maxillofacial skeletal deformities can be congenital in nature. The requested procedure is being performed to improve function. Surgical function will result in improved mastication and swallowing and improved musculoskeletal, dento-osseous and soft tissue relationships. This surgery will result in more than a minimal improvement in the appearance of the patient, as he has a significant anterior over bite and negative overjet. Orthognathic surgery (mandibular osteotomy and molar extractions) is medically indicated for this patient.