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

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested authorization and coverage for a chest brace. The medical literature and submitted documentation support the medical necessity of the requested device. Literature and research support the provision of a brace as the standard of care for most carinatum defects. Their conclusions resulted in the hospitals use of this approach as a first-line treatment, with surgery reserved for patients who are either noncompliant or for those who had failed the nonoperative modality. After this research was published, most childrens hospitals adopted the practice of offering bracing as the first line of treatment, with surgery reserved for those who failed bracing or preferred the surgical approach. Patients with pectus carinatum are at risk for a disturbed body image and reduced quality of life, and chest bracing has been shown to improve the psychosocial outcome of these patients. The long-term outcomes of bracing have now been shown to be more than adequate.In this case, forcing the patient to have surgery rather than a brace would be outside of the standard of care for most pediatric surgeons, and the provider in this case recommended a chest brace and never mentioned surgery as an option in his clinic note. The submitted records document subjective and objective findings of an asymmetric pectus carinatum that is correctable with manual pressure. There was no prior failed trial of bracing or issues with non-compliance. Under these circumstances, a chest brace is medically necessary for the treatment of the 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 surgery, with subspecialty certification in pediatric 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

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the right hip arthroscopy with arthroscopically assisted labral repair, pincer osteoplasty, and CAM osteoplasty provided for her treatment of hip pain.  Findings: The physician reviewer found that current peer reviewed literature supports surgical management of femoroacetabular impingement syndrome when nonsurgical treatment methods fail. Hellman and colleagues reviewed five approaches for surgical management of femoroacetabular impingement syndrome, including arthroscopy. They reported that femoroacetabular impingement was a common pathologic disorder of the hip that caused pain and had been implicated in the development of early osteoarthritis in young adults. Harris and colleagues concluded that the outcomes of operative treatment of femoroacetabular impingement are significantly better than nonsurgical management. Surgical treatment significantly improved outcomes, with no consistent significant differences exhibited between open and arthroscopic techniques. This patient presented with a history of progressively worsening and functionally limiting right hip pain for more than one year. She had associated mechanical symptoms, including locking and clicking. Clinical examination findings were consistent with imaging evidence of labral separation and femoroacetabular impingement syndrome. She failed over one year of conservative treatment including activity modification, ice, and anti-inflammatory medications. Therefore, right hip arthroscopy with arthroscopically assisted labral repair, pincer osteoplasty, and CAM osteoplasty provided was medically necessary for treatment of this patients medical condition. Final Result: The reviewer determined that the services at issue 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 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: A enrollee has requested authorization and coverage for a supervised polysomnography in a sleep laboratory for evaluation of the enrollees sleep apnea. Findings:  The physician reviewer found that he submitted documentation fails to demonstrate the medical necessity of the requested services. There was no documentation that there was any significant weight change from the date of her prior study that would suggest she would need any other setting of CPAP.  On 7/12/17, she was alert. There is no documentation that using CPAP at 12 cm of water was no longer effective. Despite the notation that the CPAP machine exceeded its usual life span, there was no documentation that the machine was no longer effective and needed replacement as opposed to repair. The records do not support the medical necessity of another polysomnogram, either at home or at a facility. She has a diagnosis of obstructive sleep apnea, and her optimal level could be easily derived from a smartcard readout from a CPAP. All told, the requested supervised polysomnography in a sleep laboratory is not medically necessary 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 internal medicine with sub-specialty certification in pulmonary disease 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 female enrollee has requested reimbursement for the digital breast tomosynthesis performed. Findings:  The physician reviewer found that in the peer-reviewed medical literature, a study 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, the breast tomosynthesis performed on the date of dispute was likely to be more beneficial for evaluation of this 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: Physician reviewers 1, 2 & 3 are board certified in diagnostic radiology and are actively practicing. The reviewers are all expert sin 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 51-year-old female enrollee has requested continued coverage of cancer treatment with a breast cancer specialist for her follow-up care for breast cancer. Findings:  The physician reviewer found that the negative features associated with triple negative state breast cancer and given her family history, the patient is likely to receive greater benefit from follow-up care with a breast cancer specialist who is knowledgeable regarding the clinical management of triple negative breast cancer. Furthermore, such a specialist is likely to be more knowledgeable of therapies for this subset of breast cancer patients and better informed of potential clinical trials for which she may be eligible should the need arise. Thus, the patient would be best served by a breast cancer specialist versus a primary care physician or gynecologist as proposed in this case.
Appeal type: Experimental/Investigational
Decision: Upheld

A 36-year-old male enrollee requested authorization and coverage of gastric bypass with duodenal switch. The Health Plan denied the request indicating that the requested procedure is considered experimental for treatment of the enrollees morbid obesity.Three physician reviewers performed an experimental/investigational Independent Medical Review. Two of the three physician reviewers concluded that the requested therapy is not likely to be more beneficial for treatment of the enrollee's medical condition than any available standard therapy. One of the three physician reviewers concluded that the requested therapy is likely to be more beneficial for treatment of the enrollee's medical condition than any available standard therapy. Because two of the three physician reviewers concluded that the requested therapy is not likely to be more beneficial for treatment of the enrollee's medical condition than any available standard therapy, the Health Plans denial has been upheld.
Appeal type: Experimental/Investigational
Decision: Upheld

A 60-year-old male enrollee has requested artificial disc replacement for the treatment of his cervical spondylitic radiculopathy. Findings:  Two physician reviewers found that the submitted journal article reported that the Prestige disc replacement appeared to be safe and effective in a study spanning about twenty-four months.  However, this should not be confused with a long term follow-up study determining safety and effectiveness. The FDA has provided preliminary approval for the implantation of these devices.  However, the FDA has also demanded a multiyear follow-up study to determine the long term safety and effectiveness of the device. On overview, the long term safety and effectiveness of this device has yet to be proven.  It has not been shown to be more beneficial than traditional anterior cervical discectomy with fusion in the treatment of this diagnosis, particularly in this age group. Cervical disc replacements are properly classified as investigational.
Appeal type: Medical Necessity
Decision: Overturned

The patient is a 44-year-old female with a BMI of 45.5. She has comorbid conditions including degenerative disc disease. She wishes to undergo gastric bypass. Based upon the information provided it does not appear that the patient has undergone a psychological evaluation in order to determine if she is appropriate candidate for weight loss surgery. The patient wishes to undergo gastric bypass. The Health Plan has denied the patients request.With a BMI of 45.5 and comorbid conditions, the patient meets accepted national medical necessity criteria for consideration of weight loss surgery. Roux-en-Y gastric bypass is medically indicated and medically necessary for treatment of this patients morbid obesity. Furthermore, the patient does not require further dietary workup prior to undergoing weight loss surgery. There is no clinical evidence demonstrating that further weight loss is necessary for a successful surgery and there is no scientific evidence supporting this requirement.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for positron emission tomography (PET) with computed tomography (CT) skull-thigh; CT of the abdomen and pelvis, and CT of the thorax with dye.As noted in the current medical literature, PET/CT is a valuable imaging modality in prostate cancer. The primary role for PET/CT is for restaging of patients with biochemical recurrence after radical prostatectomy or external beam radiotherapy. A study is quoted, Gleason score and PSA value, doubling time, and velocity, can influence positivity of PET/CT. Further, Researchers reported that PET/CT is useful in well selected patients. The authors found that the risk factors for patients with positive PET/CT findings included those with a PSA over 3.0 ng/mL, no early radical prostatectomy, and a Gleason score of 8 or greater. This patient does not meet the criteria for PET/CT based on the available documentation. The records report a history of Gleason score 4+3=7 prostate cancer status post radical prostatectomy with a PSA of 1.1 ng/mL. Initial conventional imaging including bone scan and CT scan remain the gold standard. Therefore, the requested CT of the abdomen and pelvis is supported as medically necessary for evaluation of this patients current medical condition and for staging of his prostate cancer. A CT of the thorax is not within the current standard of care for patients with prostate cancer. Thus, the requested PET with CT skull-thigh and CT of the thorax with dye are not medically necessary for this patients medical condition.Final Result: The reviewer determined that some of the requested services are medically necessary for evaluation of the patients medical condition. Therefore, the Health Plans denial should be partially overturned.Credentials/Qualifications: The reviewer is board certified in urology 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

Nature of Statutory Criteria/Case Summary:   An enrollee has requested genetic testing for evaluation of her medical condition.  Findings:  Three physician reviewers found that there is a lack of support for the services at issue in this patients case.  It was then noted that the patient was taking a specific dosage of a prescribed medicine, was previously taking the same medication at a greater dosage and did much better.  She noted her depression did not feel well controlled.  It was noted that the patient had been weaned off of the prescribed medication, and she still had anxiety.  There is support for the use of MTHFR testing for prescribing carbamazepine, tetrabenazine, eliglustat, Ziagen, and Olysio.  These medications are not indicated for anxiety disorders.  In this patients case, switching to another medication did not require this specialized testing.  In sum, genetic testing was not likely to have been of greater benefit than other methods of evaluating this patient.  Final Result: Three 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 reviewers are board certified in psychiatry 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

A 57-year-old female enrollee has requested physical therapy for the treatment of her thoracic outlet syndrome, degenerative cervical disc disease and fibromyalgia. Findings:  The physician reviewer found that with respect to thoracic outlet syndrome, if an individual has thoracic outlet syndrome, the initial conservative approach is a course of therapy for periscapular stretching, strengthening, and shoulder stabilization. After four to six weeks an individual should be advanced to a home exercise program. For cervical degenerative disc disease as well as fibromyalgia, both of which could result in ongoing subjective complaints of pain, an individual could be treated with a four to six week course of therapy with advancement to a home exercise program. A four to six week course of therapy for the various diagnoses would have been appropriate, after which an individual should be advanced to a home exercise program.
Appeal type: Medical Necessity
Decision: Upheld

A 21-year-old male enrollee has requested coverage for past substance abuse sub-acute rehabilitation provided for treatment of his polysubstance dependence.  Findings:  The physician reviewer found that the submitted documentation fails to establish the medical necessity of substance abuse sub-acute rehabilitation provided during the time period at issue.  There was no evidence of physician involvement in the patients treatment, and only minimal notes from a nurse practitioner during the dates of service at issue.  The patient showed no evidence of risk to self or others.  At the time of admission, the patient was already involved in an intensive treatment program and had achieved sobriety for 30 days. His parents were supportive of recovery, and there is no indication of any significant medical comorbidity. Per American Psychiatric Association guidelines, the patient could have been safely and effectively managed in the context of a less intensive treatment setting.  The services at issue were not clinically compatible with current evidence-based practice standards and expert consensus as set forth by the American Psychiatric Association and American Society of Addiction Medicine.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested Botox injections for treatment of her medical condition. Findings:  Two physician reviewers found that review of the submitted documentation and relevant literature supports the use of Botox injections in this clinical setting. The records submitted for review document the patient has daily migraine headaches that have been refractory to standard therapies. In addition, she has had a positive response to Botox in the past. Thus, a trial of Botox is clinically indicated. The literature cited above supports the use of Botox for chronic headache patients. In addition, undertreated headaches can cause unnecessary significant morbidity to a patient.  For the reasons provided, Botox injections are likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Final Result: Two reviewers determined that the requested services are 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. 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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Synvisc-One (hyaluronan) injection. Findings:  The physician reviewer found that there is sufficient support for the requested services in this clinical setting. This patient presents with chronic right knee pain with associated popping, locking, and giving way. Functional limitations are noted in activities of daily living. Clinical examination findings are consistent with radiographic evidence of bicompartmental osteoarthritis, worse in the medial compartment. He is status post left total knee replacement with postoperative blood clots requiring hospitalization. He is indicated for right total knee replacement but wants to delay this due to his deep vein thrombosis/pulmonary emboli risk factors. Literature supports the use of viscosupplementation injections for the treatment of pain in patients with osteoarthritis of the knee. Repeat viscosupplementation injections have been found to be safe and effective and allow for delay of knee replacement surgery. Given the previous response and to assist in delaying total knee replacement, a repeat Synvisc-One injection is indicated. Therefore, Synvisc-One (hyaluronan) injection is medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested services are 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: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested residential treatment center services for treatment of the enrollees behavioral health condition.  Findings: The physician reviewer found that based on the documentation submitted for review, residential treatment center services were medically necessary for treatment of the patients behavioral health conditions. The patient met American Psychiatric Association guidelines for services at this level.  The patient needed supervision to complete her meals. When outside of the facility, she showed signs of resistance to her eating plan and regression.  She continued to need support to prevent excessive exercising and purging.  In addition, her home environment was not stable and did not provide the full support she needed. Given the above, the services at issue were medically necessary for treatment of the patients medical condition.  Final Result: The reviewer determined that the services at issue were medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.  Credentials/Qualifications: The physician reviewer is board certified in psychiatry with sub-specialty certification 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.