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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for hydrocodone-acetaminophen (Norco), surgery of the neck and computed tomography (CT) scan of the neck.  Findings:  The physician reviewer found that according to the North American Spine Society (NASS), the criteria for neck surgery require cervical radiculopathy/myelopathy, or fracture, tumor, infection, or severe cervical stenosis with radiculopathy, or herniated nucleus pulposus and failure of conservative management. This patient presents with chronic neck pain. He has no symptoms or signs of a cervical radiculopathy nor cervical myelopathy. He has not responded to some conservative treatment, but has not exhausted all available conservative options. The records do not document the patient has worn a collar, used a TENS unit, or increased his nortriptyline 10 mg to therapeutic doses by 10 mg increments to 50 mg per day. Further, a psychological evaluation could help rule out non-anatomic causes of his pain. Thus, he fails to fulfill criteria for surgery. With regard to the requested CT scan, the patient has already received a CT scan and MRI scan. There is no need to repeat either of these studies based on the guidelines from the American College of Radiology (ACR). He fails to fulfill criteria for the requested CT scan. With regard to the request for Norco, this patient has been appropriately advised that narcotic usage is not appropriate for chronic nonmalignant pain as recommended by the Centers for Disease Control and Prevention (CDC) guidelines. Final Result: The reviewer determined that the requested medication and services are not medically necessary for evaluation or treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in neurological 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

A 60-year-old male enrollee has requested an additional 12 acupuncture treatments for the treatment of his neck pain. Findings:  The physician reviewer found that according to the National Guidelines Clearinghouse guidelines for acupuncture treatment, the recommended frequency and duration for courses of treatment is one to two acupuncture sessions per week for six to eight weeks for a total of twelve sessions. For chronic conditions, extended treatments are recommended to observe response to therapy. This applies to chronic pain of neuromuscular origin. If partial pain relief is achieved after twelve sessions, a follow-up course is recommended for twelve additional sessions. These guidelines were based on the recommendation of the Council of Acupuncture and Oriental Medicine. Based upon the records provided, this patient has obtained some relief with an initial course of acupuncture. As such, an additional course of 12 acupuncture sessions are medically appropriate and consistent with the standard of care.
Appeal type: Medical Necessity
Decision: Upheld

A 55-year-old female enrollee has requested lumbar fusion and/or artificial disc surgery for treatment of her low back pain. Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested services in this patients case.  The current medical evidence does not support lumbar fusion in this clinical setting.  Per the submitted documentation, there is no evidence of instability at L4-5.  Additionally, the records do not demonstrate chronic axial low back pain.  The medical literature does not support artificial disc surgery for the treatment of this patient.  In a case series by Shim and colleagues, the authors compared the clinical and radiologic outcomes of patients who underwent total disc replacement.  The authors noted an aggravation of the degenerative process at the adjacent level in a significant number of patients.  Shim and colleagues reported concerns regarding possible late consequences of total disc replacement.  Additional high-quality randomized controlled trials are needed to demonstrate the long-term safety and efficacy of artificial disc replacement.  All told, neither lumbar fusion nor artificial disc surgery is medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld

The patient is a 36 year-old female who is 53 tall weighing 280 pounds. Review of the submitted clinical information does not demonstrate that the patient has any life threatening comorbidities. The patient does have obesity related comorbidities that will improve with surgery. The submitted information indicates the patient continues to smoke. Evidence of a psychiatric evaluation has not been provided. The patient has requested that she receive a timelier consultation for bariatric surgery. The patient also indicates that she wishes to undergo duodenal switch gastric bypass rather than the Roux-en-Y procedure.A wait of six months for an appointment and up to a year before surgery is not uncommon and is consistent with many bariatric surgical programs. There is no evidence that the patient has Pickwickian syndrome or severe insulin dependent diabetes mellitus that would necessitate immediate surgery. Based upon the information provided, the delay in surgery will not pose a threat to the patient. Furthermore, it will allow time for psychiatric evaluation and smoking cessation. If at the time of the patients bariatric surgery consultation the bariatric surgeon indicates the patient is an appropriate candidate for duodenal switch gastric bypass, then the duodenal switch procedure should be authorized. The duodenal switch procedure requires less postoperative dietary restrictions. Furthermore, the recent report by Anthone, et al. documents excellent weight loss and lower dumping symptoms. Thus, the duodenal switch procedure is a medically reasonable and appropriate alternative to Roux-en-Y gastric bypass.Based upon the information set forth above, I have determined that a timelier bariatric surgery consultation is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. If upon examination by a bariatric surgeon it is determined that the patient is an appropriate candidate for duodenal switch gastric bypass, then the duodenal switch procedure should be authorized depending upon psychiatric clearance and smoking cessation.
Appeal type: Medical Necessity
Decision: Overturned

A 52-year-old female enrollee has requested the prescription drug Forteo for treatment of her osteoporosis with bilateral hip fractures.   Findings:  The physician reviewer found that osteoporosis is a skeletal disorder characterized by a loss of bone osteoid that reduces bone integrity, resulting in an increased risk for fracture.  Treatment of osteoporosis involves general measures such as increased calcium in the diet, Vitamin D supplementation, and high impact physical activity.  Forteo stimulates the production of new collagenous bone matrix that must be mineralized.  Patients taking Forteo must have sufficient intake of Vitamin D and calcium.  This medication can increase bone density in most bones.  Following a course of Forteo, a course of bisphosphonates is often considered in order to retain the improved bone density.  This patient has a documented history of osteoporosis and is status post bilateral hip fractures.  Forteo has been recommended to promote bone healing.  The requested medication is an appropriate bone building osteoporosis treatment.  All told, the prescription drug Forteo is medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for treatment by an oncologist who specializes in amyloid light-chain (AL) amyloidosis. Amyloidosis is a neoplastic disorder characterized by the deposition of amyloid in multiple organs, such as the kidneys, marrow, liver and heart. Treatment includes relatively aggressive forms of chemotherapy, or high dose chemotherapy followed by stem cell rescue. The survival results have significantly improved with current chemotherapy and stem cell transplant protocols. Many providers have limited experience with this disease and will refer the patient to a stem cell transplant center for evaluation and consultation about stem cell transplant. In this case, the records document that the patient is planned to undergo evaluation and treatment by the Health Plans transplant team. This is considered the standard of care and does not require further direction from an independent oncologist. Therefore, the requested treatment by an oncologist who specializes in AL amyloidosis 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 internal medicine with subspecialty certification in medical oncology 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 41-year-old female enrollee has requested removal of her bilaterally ruptured breast implants for treatment of her ruptured breast implants. Findings:  The physician reviewer found that the patient had these implants placed for cosmetic reasons and her condition has been present for a lengthy period.  Ruptures of breast implants are a known complication and as stated, are generally not considered medically necessary after cosmetic placement. The patient cites concerns such as interference with mammography, capsular contracture, a family history of breast cancer and inability to rule out neoplasm. However, the treating provider has not noted in the medical record that he has any of these concerns. The provider only notes that the patient complains of pain and that the breast envelopes are soft. There is no objective documentation of the severity of the pain. The providers examination and history do not support a severe capsular contracture or that he is concerned about screening or neoplasm. The effect of implants on mammography is well-known and, as a result, special views are needed to adequately visualize the breast tissue (Rohrich & Reece). There is no medical documentation presented that supports that the breast tissue has not been adequately visualized. All told, there is no medically documented information to support that the patient meets medical necessity criteria for removal of her breast implants. Thus, there is not sufficient medical documentation to warrant that removal of the ruptured implants is medically necessary.
Appeal type: Urgent Care
Decision: Overturned

A 56-year-old male enrollee has requested for emergency services for treatment of her foot pain. Findings:  The physician reviewer found that the patients symptoms met prudent layperson criteria for emergency care. An emergency is generally defined as the sudden onset of symptoms, including pain, of such severity that a prudent layperson would believe his health to be in jeopardy without immediate medical attention. This patient was diagnosed with an acute flare of gout. He had no history of gout, so likely did not know the reason for his symptoms. Although acute gout is not life or limb-threatening, it is extremely painful. The patient required an IM injection for pain relief.
Appeal type: Medical Necessity
Decision: Upheld

A 41-year-old male enrollee has requested a panniculectomy for treatment of his excess skin and fat.  Findings:  The physician reviewer found that panniculectomy only involves removal of the lower abdominal skin without the muscle tightening or the supraumbilical skin tightening via periumbilical and lower abdominal incisions of an abdominoplasty. It would be medically necessary rather than cosmetic in nature if the removed skin has a history of recurrent infections or is necrotic. The mere presence of a pannus and/or its psychological or physical burden on the patient does not automatically make its removal reconstructive in nature in lieu of cosmetic. Given the absence of documentation supporting the existence of a skin condition related to the pannus that is resistant to medical treatment, there is inadequate evidence that support the medical necessity of a panniculectomy. In addition, there insufficient documentation in the patients records that support that improved function or conversion of an abnormal appearance to a normal appearance is the primary goal of the proposed surgery.
Appeal type: Medical Necessity
Decision: Upheld

A 40-year-old male enrollee requested authorization and coverage of the medication Propecia. The Health Plan denied the request indicating that the requested medication is not medically necessary for treatment of the enrollees scarring alopecia.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.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for a continuous positive airway pressure (CPAP) device. The Health Plan has denied this request indicating that the requested device is not medically necessary for treatment of the enrollees obstructive sleep apnea. A review of the submitted records indicates that the enrollee has been diagnosed with obstructive sleep apnea (OSA). Records reflect that the enrollee had a sleep study evaluation and that this study identified the enrollees diagnosis of obstructive sleep apnea. The enrollees sleep medicine specialist has recommended a CPAP device for the enrollee.The submitted documentation supports the medical necessity of the requested device. Current guidelines of both the American Academy of Sleep Medicine (AASM) and the American College of Physicians recommend the use of CPAP as the first line to therapy for OSA. In this case, the patient had a history of snoring and insomnia and she was found to have an REI of 5.3 (greater than 5) on a home sleep test. Therefore, she would have a diagnosis of OSA based on current diagnostic criteria. Although the patient does not present with comorbid conditions, her clinical presentation, history, and sleep study results, as reported in the submitted documentation, meet the diagnostic criteria for OSA. Considering that CPAP is considered the first-line treatment for patients with OSA, and this patient meets the diagnostic criteria for OSA, the provision of a CPAP device and related accessories is within the generally accepted standards of clinical practice. Thus, the requested CPAP device is supported as medically necessary for treatment of this patients medical condition.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 in neurology, with subspecialty certification in sleep 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

Findings:  The physician reviewer found that The patient has requested authorization and coverage for admission to a skilled nursing facility. Alexiou and colleagues note that hip fractures are known to substantially impact functional performance and negatively impact both short-term and long-term health-related quality of life. This condition generally requires skilled rehabilitation services to optimize outcomes, including mobility and self-care abilities.  Skilled rehabilitation services can be provided in various settings, including the inpatient, home, or outpatient setting. Recent research has shown that community-based home and outpatient rehabilitation can be as effective as inpatient rehabilitation for this condition. Freitas and colleagues report that both outpatient and home-based rehabilitation seem to be reasonable options for hip fracture rehabilitation. In this case, the patient sustained an acute right hip fracture at the femoral neck due to a ground level fall while hiking without other significant injuries. The patient underwent hip fracture surgery without complications. Postoperatively, the records noted some mild orthostatic hypotension that resolved.  The patient participated in therapies and improved to ambulating up to 800 feet with a walker at the supervision/stand by assistance level without loss of balance.  He was negotiating 12 stairs using a railing at a supervision/stand by assistance level.  He was able to return to and was discharged to the community. In this case, while the patient is expected to have a long recovery course due to the condition, given that current medical literature does not support a significant difference in functional course or outcomes with the service in question versus community-based and ambulatory care, the requested service is not medically indicated. Therefore, admission to a skilled nursing facility is not medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested service is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary:   An enrollee has requested advanced lipoprotein testing for evaluation of her medical condition.   Findings:  Three physician reviewers found that in this circumstance, prevention guidelines for the management of cardiac risk and dyslipidemia have been established. These guidelines are periodically updated by expert committees and are endorsed by several national organizations. These guidelines currently do not recommend routine performance of specialized tests in the context of assessing coronary risk including lipoprotein-associated phospholipase A2 (Lp-PLA2), sub-classifications of low density lipoprotein (LDL), high density lipoprotein (HDL) subclasses, lipoprotein(a), C-reactive protein (CRP), high sensitivity CRP, insulin, fibrinogen, genetic testing and homocysteine (Greenland, et al). Treatment change or addition based on the results of screening with these specialized tests has not been shown to improve cardiac outcome incremental to that achievable by treatment based on standard risk factor profiling and basic lipid analysis. Even though results of some of these specialized tests may be abnormal and considered independent risk markers for coronary disease, there is a lack of controlled trials that demonstrate outcome benefits by treating routinely obtained abnormal results. For these reasons, advanced lipoprotein testing was not likely to be more beneficial for evaluation of the patients medical condition than any available standard modality.  Final Result: Three 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:  All three reviewers are board certified in internal medicine with sub-specialty certification in cardiovascular disease 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 four-year-old male enrollee has requested for speech/language therapy for treatment of the enrollees expressive language disorder. Findings:  The physician reviewer found that speech and language development is considered by experts to be a useful indicator of a childs overall development and cognitive ability. They noted that intervention services are helpful at a young age when chances for improvement are best. The long-term consequences of speech and language delay may be substantial. Law and colleagues concluded that there is a positive effect of speech and language therapy interventions for children with expressive phonological and expressive vocabulary difficulties.
Appeal type: Experimental/Investigational
Decision: Overturned

An enrollee has requested reimbursement for dual energy x-ray absorptiometry (DEXA) scan. Per the National Osteoporosis Foundation (NOF), DEXA scans are recommended for Women age 65 years and older and men age 70 years and older, regardless of clinical risk factors. The guidelines suggest that providers perform bone mineral density (BMD) testing every two years thereafter. Medical literature noted that more frequent BMD testing may be warranted in certain clinical situations. The interval between repeat BMD screenings may be longer for patients without major risk factors and who have an initial T-score in the normal or upper low bone mass range. In this case, the patient has a history of osteoporosis and she is on medical therapy. Her fracture risk was noted to be moderate. The current national guidelines recommend DEXA every two years while on therapy. Therefore, the DEXA scan was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.
Appeal type: Experimental/Investigational
Decision: Overturned

A 59-year-old male enrollee has requested Myobloc (botulinum toxin type B) injections for the treatment of his cervical dystonia. Findings:  Two physician reviewers found that cervical dystonia is well treated with botulinum toxin injections. This therapy is FDA approved for the treatment of cervical dystonia and has been effective for this patient. Other interventions would not be expected to provide the same level of symptom relief.