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

A 65-year-old male enrollee requested authorization and coverage for the surgical removal of a soft tissue mass in the ball of the right foot. The health plan has denied this request indicating that the requested procedure is not medically necessary for treatment of the enrollees soft tissue mass.One podiatry reviewer performed a medical necessity Independent Medical Review. The podiatry reviewer upheld the health plans denial on the basis that the requested procedure is not medically necessary at this time.
Appeal type: Medical Necessity
Decision: Upheld

A 46-year-old female enrollee has requested authorization and coverage for medical transportation services for treatment of the enrollee, who has been diagnosed with uterine prolapse and systemic lupus erythematosus. Findings:  The physician reviewer found that the requested services are not medically necessary in this patients case.  There is no documented inability to ambulate or any defined orthopedic or neurologic deficits which would preclude the use of public or private transportation.  Per the submitted documentation, there is no evidence of cardiac or respiratory compromise.  The medical records do not indicate the use of assistive devices or a wheelchair.  She has not undergone a physical therapy assessment, and she is not considered homebound.  The patient has medical conditions which are chronic, but stable in nature.  The medical records do not demonstrate an inability to ambulate due to uterine prolapse and chronic pain conditions.  All told, the requested medical transportation services are not medically indicated in this clinical setting.
Appeal type: Medical Necessity
Decision: Overturned

A 53-year-old female enrollee requested authorization and coverage for acupuncture. The health plan has denied this request indicating that acupuncture is not medically necessary for treatment of the enrollees chronic sinusitis.One acupuncture reviewer performed a medical necessity Independent Medical Review. The acupuncture reviewer overturned the health plans denial on the basis that the requested treatment is medically necessary.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/ Case Summary:  The enrollees parent is requesting reimbursement for partial hospitalization program mental health treatment services. The enrollee has a history of attention deficit hyperactivity disorder and depression. His family noticed he was more depressed with a decrease in his self-esteem.  He exhibited agitation and frustration. Per the psychiatric admission note, the enrollee denied manic symptoms, psychotic symptoms, suicidal/homicidal ideation and self-injurious behavior. He denied difficulty with sleep and change in appetite. The enrollee denied substance abuse or drinking alcohol. Medications were started for depression and anxiety. He received psychoeducation and psychotropic medications. He was cooperative and participated in all groups. According to the medical literature, treatment should be provided in the least restrictive setting that is safe and effective for an enrollee. The enrollee had temporary impairment in school functioning due to identifiable stressors with consistent and normal physical functioning. There was no report of medical illnesses that would pose a threat to the enrollees present mental health and no history of mental health hospitalizations. The enrollee lives in a stable household, was cooperative and participating in his treatment. Applying CALOCUS scoring, the enrollees composite score is 12, which correlates with recovery maintenance and health management. Final Result: The reviewer determined that the requested services are not medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The physician reviewer is board certified in psychiatry and 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 similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

A 52-year-old female enrollee has requested a spinal cord stimulator (SCS) for the treatment of her lower extremity pain. Findings:  The physician reviewer found that it is unclear if the decrease in beneficial effect from the spinal cord stimulator is due to battery depletion or persistent paresthesia coverage with no analgesia. The patient is being considered for a spinal cord stimulation trial for lower extremity pain seemingly based on the diagnosis of complex regional pain syndrome.  However, the information provided does not mention any details on the physical findings.  Moreover, the patient has significant psychological issues and she complains of whole body pain.  It is medically necessary to obtain a thorough psychological evaluation before considering this particular patient for a spinal cord stimulator trial to manage lower extremity pain.  Additionally, the patient may be due for a battery change.  The Synergy battery that was implanted is probably at the end-of-life.  Battery replacement is recommended.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the sestamibi single photon emission computed tomography/computed tomography (SPECT/CT) scan for evaluation of the enrollees multi-nodular thyroid nodule. Findings:  The 3 physician reviewers found that the records provided for review document that the sestamibi SPECT/CT scan was done to help plan the patients surgery. If an adenoma was localized, a minimally invasive procedure would have been performed. Since an adenoma was not localized on imaging, four glands were localized at surgery and the other three were biopsied. Thus, when the study was ordered, it was appropriate. Accordingly, the sestamibi SPECT/CT scan provided was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Final Result: The 3 reviewers determined that the diagnostic procedure 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 reviewer number one 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.Physician reviewer number two 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.Physician reviewer number three 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: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested cervical total disc arthroplasty for treatment of her medical condition. Findings:  Three physician reviewers found that the services at issue were not likely to be more effective for this patient than other available options. Based on the documentation submitted for review, the patient has undergone prior cervical surgery and has significant degenerative disc disease. Prior surgery and degenerative disc disease at more than one level are contraindications for total disc replacement. Moreover, there is a lack of documentation demonstrating that the patient has failed six weeks of conservative management. All told, the services at issue were not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: Three reviewers determined that the services at issue were 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: Two reviewers are board certified in neurological surgery and are actively practicing. The third reviewer is board certified in orthopedic surgery and is 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: The patient has requested The patient has requested reimbursement and prospective authorization and coverage for (1) paravertebral facet joint injection/blocks (CPT 64493) and (2) paravertebral facet joint injection/blocks (CPT 64493). Baroncini  and colleagues report that facet joint injections and medial branch blocks can be employed for chronic low back pain. The authors conclude, Injections for chronic low back pain deriving from facet joints osteoarthritis are encouraging, especially when considering medial branch blocks. Seo and colleagues also note that medial branch nerve blocks and facet joint injections may reduce axial low back pain and improve secondary functional degradation. In this case, the patient has degenerative disc disease, facet arthritis at L5-S1, and a history of chronic low back pain. The records noted management with facet and medial branch block injections of local anesthetic and corticosteroids. Given that current medical literature supports the safety, efficacy, and significant benefit from these injections, the services at issue were and are medically indicated. Therefore, (1) paravertebral facet joint injection/blocks (CPT 64493) and (2) paravertebral facet joint injection/blocks (CPT 64493) were and are medically necessary for the treatment of this patient.Final Result: The reviewer determined that the services at issue were and 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: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary:  An enrollee has requested automated nerve conduction testing for treatment of her medical condition. Findings:  Three physician reviewers found that the requested services are not likely to be more effective for this patient than other available options. There is a lack of scientific, large number automated nerve conduction testing studies in the peer-reviewed literature showing its safety and effectiveness. There are smaller studies which have questioned its validity and efficacy. All told, the requested services are not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.  Final Result: Three 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: All three reviewers are board certified in neurological surgery 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: Experimental/Investigational
Decision: Upheld

A 52-year-old female enrollee has requested MammoSite brachytherapy for the treatment of her ductal carcinoma of the left breast. Findings:  The physician reviewer found that the main advantage with MammoSite brachytherapy is brevity of treatment for patients meeting selection criteria. While there is growing interest in this form of therapy, the medical literature does not support the conclusion that MammoSite brachytherapy is superior to standard treatment. Although the use of MammoSite brachytherapy is becoming more widespread, the clinical data has not established the superiority of MammoSite for delivery over alternative more standard methods. There are other well-established therapies available in this setting.
Appeal type: Medical Necessity
Decision: Overturned

A 56-year-old female enrollee has requested a laparoscopic gastric reduction with duodenal switch procedure for the treatment of her morbid obesity. Findings:  The physician reviewer found that this patient had multiple comorbidities that will likely be ameliorated or eliminated by bariatric surgery.  PBB/DS is one of the procedures endorsed by ASBS and is a component of the LABS trial currently funded by NIH.  This was an appropriate procedure for treatment of this patients obesity.  The patient has benefitted from this surgery.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for cardiac ablation procedure utilizing the minimal fluoroscopy approach.  Findings:  Two of the three physician reviewers found there is a lack of support for the requested services in this clinical setting. This patient is being evaluated for cardiac ablation of atrial fibrillation/flutter. In this circumstance, if ablation were thought to be necessary, then standard ablation protocols using fluoroscopy have been shown to be safe and efficacious. Therefore, the requested cardiac ablation procedure utilizing the minimal fluoroscopy approach is not likely to be of greater benefit than 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 internal medicine with sub-specialty certification in cardiovascular disease 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

The parent of a six-year-old male enrollee has requested speech therapy for treatment of the enrollees mild to moderate delay in expressive language skills. 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 and is related to school success. Identification of children at risk for developmental delay or related problems may lead to intervention services and family assistance at a young age when chances for improvement are best. Speech and language delay must be taken seriously in young children because the long-term consequences may be substantial. While there is some controversy regarding the role that recurrent otitis media has on language development, the literature acknowledges the presence of speech and language delay in this population. This patient has a history of frequent otitis media with resultant conductive hearing loss, attention deficit/hyperactivity disorder, and articulation deficits. These challenges are negatively impacting his ability to communicate effectively with peers and adults.  All told, speech therapy was and is medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patients parent has requested authorization and coverage for Huggies brand incontinence diapers. Daytime urinary incontinence is common in the pediatric population and affects approximately 7-10% of children aged five to thirteen years. Risk factors for incontinence can be genetic, demographic, environmental, behavioral, or physical. In this case, the patient is 17 months old, and is not yet expected to be continent. As part of routine infant and toddler care, diapers are not medically indicated for the patient at this time. Therefore, Huggies brand incontinence diapers are not medically necessary to treat the patients condition for any of the following: to prevent disease, disability, and other health conditions or their progression; to prolong life; to promote physical and mental health and efficiency; to correct or ameliorate any physical or behavioral conditions.Final Result: The reviewer determined that the requested supplies 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 pediatrics with sub-specialty certification in pediatric critical care 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: Urgent Care
Decision: Upheld

A 52-year-old female enrollee has requested emergency services for the treatment of her itchy eyes. Findings:  The physician reviewer found that for the previous week her eyes had been extremely itchy and somewhat red. She came to the ED because she could no longer tolerate the itchiness. However, the patients symptoms did not meet prudent layperson criteria for emergency care. A prudent layperson with an average knowledge of medicine and a history of Sjogrens syndrome with a five-day history of itchy eyes would not reasonably expect the absence of emergency care to jeopardize her health.
Appeal type: Experimental/Investigational
Decision: Overturned

A 31-year-old female enrollee has requested magnetic resonance guided high-intensity focused ultrasound (MRgFUS) for treatment of her desmoid tumor. Findings:  Two physician reviewers found that MRgFUS is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. In this case, the patient presents with a desmoid tumor that has demonstrated interval growth. Given the rarity of her tumor, there is no generally accepted standard of care demonstrated in the peer-reviewed literature. Moreover, possible treatment options with the exception of the requested MRgFUS have significant downsides with respect to recurrence, side-effects and poor clinical response.  Thus, given the rarity of this disease, as well as the lack of standard of care treatment, the requested services are likely to be more beneficial for treatment of the patients medical condition than other modalities.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested a wearable cardiac defibrillator for treatment of his medical condition.    Findings:  Three physician reviewers found that based on the records provided, the patient presented with symptoms of congestive heart failure. In this circumstance, there is potential for recovery of left ventricular function over time with medical therapy and there was no indication for immediate placement of a defibrillator such as sustained or inducible ventricular tachycardia, syncope or aborted sudden cardiac arrest. Placement of a prophylactic defibrillator is not recommended until a period of time of more than 90 days where continued left ventricular dysfunction is documented to persist in spite of appropriate treatment.  A prophylactic defibrillator (wearable or implantable) before this time has not been demonstrated to improve outcome. Studies evaluating wearable defibrillators during periods of increased risk where criteria for implantable defibrillators have not yet been met are largely comprised of registry data without adequate control groups. At this time, prophylactic wearable external defibrillator would be indicated only if accepted criteria for an implantable defibrillator were met and an implantable defibrillator could not be placed, needed to be significantly delayed (due to infection, for example) or required explanation. Therefore, the wearable defibrillator in this circumstance has not yet been demonstrated by existing scientific literature to be more beneficial for treatment of the patients medical condition than any available standard therapy.  Final Result: Three reviewers determined that the services at issue were 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:  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: Upheld

A male enrollee requested a hospital stay for medical treatment of his diverticular bleeding.  Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the services at issue.  In this clinical setting, a patient generally would be admitted for acute inpatient care for two days.  Because of the anticoagulation factor, management as an outpatient would have not been standard of care.  However, the prep for colonoscopy could have been given on one day, and the colonoscopy could have been completed the next day.  There is a lack of support for hospital services provided after the completion of the colonoscopy.  All told, the services at issue were not medically indicated for the treatment of this patient.