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

Nature of Statutory Criteria/Case Summary: At issue is whether a sacroiliac joint injection procedure (CPT code 27096) is likely to be more beneficial for treatment of the patients condition than any available standard therapy. The patient presented to her provider with complaints of ongoing low back pain associated with intermittent radiation to the lower extremities.Findings:  Two out of three physician reviewers found that researchers determined that there is no single physical examination or historical feature that can reliably identify a painful SI joint; however, studies suggest that a battery of three or more provocation tests can predict response to diagnostic blocks. In this case, the records do not document sacroiliac joint tenderness or other provocative tests that would suggest SI joint dysfunction as a cause of pain. SI joint injections are unlikely to provide additional therapeutic relief in this patients case. In this clinical scenario, the requested sacroiliac joint injection procedure (CPT code 27096) is not likely to be more beneficial for the treatment of the patients condition than any available standard therapy.Final Result: The reviewers determined that the requested sacroiliac joint injection procedure is 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: Physician reviewers 1, 2 and 3 are board certified in anesthesiology with sub-specialty certification in pain management, 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 mother of a 17-year-old male requested authorization and coverage of a referral to a pediatric endocrinologist for treatment of the enrollees medical condition. The Health Plan denied the request indicating that the requested referral is not medically necessary for treatment of the enrollees medical condition.One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer overturned the Health Plans denial on the basis that a referral to a pediatric endocrinologist is medically necessary.
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: Three physician reviewers found that Ttmosynthesis is a technique that was developed as a problem solving adjunct to routine mammography. Specifically, those patients who have dense breasts that can benefit most from tomosynthesis. The ability to separate out the overlapping structures enables the possibility of demonstrating an otherwise occult tumor. Therefore, breast tomosynthesis was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.  Final Result: Three 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 physician 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

Nature of Statutory Criteria/ Case Summary:  The enrollee has requested authorization and coverage for abdominoplasty. The enrollee underwent gastric sleeve surgery and now reports she has excess abdominal skin with recurrent umbilical infections. She presented to a plastic surgeon for a complaint of excess abdominal skin. Findings:  The physician reviewer found that the surgeon noted she has a small panniculus that is not to the degree that a panniculectomy is medically indicated.  At a visit with her family practice physician, she had complaints of pain and a bad odor at the umbilicus. Antibiotics were ordered for possible umbilical cellulitis. At a different plastic surgeon, she indicated she had intermittent rashes and infections around her umbilicus for three years with a constant odor; affecting her quality of life. On examination, she had minimal dermatitis under her pannus. The pannus did not extend to the groin. There was a moderate amount of overhanging skin above the umbilicus. The surgeon indicated she was not eligible for a panniculectomy but would benefit from a full abdominoplasty to address the upper abdominal skin overhang. Subsequently, her family practice physician prescribed antibiotics for the same complaints of pain and irritation to the area and was prescribed more antibiotics.The record indicates enrollee complaints of infection, intermittent rashes and foul odor of her umbilicus treated with antibiotics. However, the record does not provide sufficient evidence of ongoing infection despite the noted antibiotic use. The enrollees ability to function is not impaired by her condition. The record does not provide sufficient evidence that abdominoplasty is medically necessary. The alleged abnormality, upper abdominal skin overhang, does not constitute an abnormal structure of the enrollees body. The surgery will not create a normal appearance to the extent possible and will not provide more than a minimal improvement in the enrollees appearance.  Abdominoplasty is a contouring procedure and is not reconstructive in nature.Final Result: The reviewer determined that the requested service is not medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The physician reviewer is board certified in plastic and reconstructive 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 similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a two-year-old female enrollee has requested speech therapy for treatment of the enrollees speech delay. Findings:  The physician reviewer found that this patient has identified delays in receptive speech and expressive speech which range from 45-73%. Speech therapy is indicated with any delay greater than 25% (Law, et al. and Feldman, et al.). Extensive review of the literature including a meta-analysis by Law and colleagues noted the positive effect of speech and language therapy interventions for children with expressive phonological and expressive vocabulary difficulty. Feldman and colleagues note that treatment for language disorders is predicated primarily on the childs language profile and level of communication skills. Gallagher and colleagues evaluated speech and language interventions for preschool children with specific language impairment. They found statistically greater improvement with intensive direct speech and language therapy delivered by speech and language therapists over an eight-month period when compared to no intervention or nursery-based intervention. All told, speech therapy is medically necessary and appropriate for treatment of this patients speech delay.
Appeal type: Medical Necessity
Decision: Upheld

A 20-year-old female enrollee has requested residential treatment services for treatment of her eating disorder.   Findings:  The physician reviewer found that according to the admission record, the patient had been binging and purging approximately 20 times per month but had not been drinking for several weeks prior to her admission. She was above her IBW and had no electrolyte, cardiac or other biomedical abnormalities. The patient denied suicidal and homicidal ideation. There is no evidence in the record of a reasonable trial of treatment at a lower level of care prior to her admission to the residential treatment facility.  She did need psychiatric intervention. Her depression had not been evaluated or treated prior to her admission. The opportunity for antidepressant medication and outpatient psychotherapy had not been utilized. The patients alcohol binging, her binging and purging and her depression were likely interrelated no attempt to intervene at a lower level of care is documented. Her binging and purging behaviors were not present during her residential stay. The limited frequency of the patients binge/purge episodes and the lack of electrolyte, orthostatic or cardiac changes argues against the need for residential treatment. An IBW of greater than 100% lends additional support to this conclusion. The patient was admitted to a specialized residential eating disorder program without any attempt to intervene in a less restrictive environment utilizing therapy, medication and guidance. Her admission was not consistent with the guidelines of the American Psychiatric Association for the treatment of an eating disorder.
Appeal type: Medical Necessity
Decision: Overturned

A 66-year-old male enrollee has requested for intravenous immunoglobulin (IVIG) therapy for treatment of his chronic inflammatory demyelinating polyneuropathy (CIDP).       Findings:  The physician reviewer found that the use of IVIG in this instance was clinically appropriate. Although CIDP is often difficult to diagnose, the clinical picture and electro-diagnostic features of this patients history are indicative of this disorder. In addition, the laboratory testing was suggestive of an anti-MAG variant of this disease in which IVIG is one of the few studied therapies. It should also be noted that one of the standard therapies for CIDP, steroids, may not have been appropriate given the possibility of early diabetes.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a one-year-old male enrollee has requested physical therapy (PT) and occupational therapy (OT) services for treatment of the enrollees Down syndrome. Findings:  The physician reviewer found that Down syndrome is associated with hypotonia and increased neurodegeneration in adult life and is thought to be due to the overproduction of chromosome 21 gene products, specifically, dual-specificity tyrosine-(Y)-phosphorylation regulated kinase 1A (Dyrk1A). The literature is unequivocal in supporting the multimodal value of physical therapy and occupational therapy for the motor development of children with Down syndrome. Thus, the medical necessity of physical therapy as well as occupational therapy is clear and apparent for this patient, since toddlerhood is a time of significant neural plasticity and every effort should be made to intervene to maximize the developmental trajectory of this patient.
Appeal type: Medical Necessity
Decision: Overturned

A 35-year-old female enrollee has requested magnetic resonance imaging of the shoulder for evaluation of her left shoulder impingement.  Findings:  The physician reviewer found that this clinical entity is often accompanied by rotator cuff pathology and MRI is the most appropriate imaging test for evaluation of these findings. Despite a negative exam approximately four years ago, the patient has had increasing symptoms, which is an indication for a repeat MRI scan. The physical findings described in this patients case may also be attributed to partial or complete rotator cuff tear, and therapy would depend on an accurate diagnosis. The requested diagnostic procedure is medically necessary for evaluation of the patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary:  An enrollee has requested epidural steroid injections for treatment of her medical condition. Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the services at issue.  Epidural steroid injections are not medically necessary in this case for the patients chronic back and leg pain.  Although MRI does corroborate radiculopathy, there is lack of documentation that the patient has tried and failed conservative therapy including medications (NSAIDs), physical therapy and a home exercise program. The peer-reviewed literature supports the use of epidural steroid injections in patients who have failed conservative therapy.  There is a lack of support for the services at issue in this clinical setting.  All told, epidural steroid injections were not medically necessary for the treatment of this patient.  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 anesthesiology with sub-specialty certification in pain 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: Experimental/Investigational
Decision: Overturned

A 61-year-old female enrollee has requested  hyaluronate (Orthovisc) injections for treatment of the enrollees osteoarthritis.  Findings:  Two physician reviewers found that the evidence based guidelines provide adequate evidence to support the use of intra-articular knee injections, as a valuable intervention in the continuum of management of arthritis between conservative treatments and knee surgeries, as in this patients case. Administration of these injections have demonstrated anti-inflammatory analgesic effects. The injections that this patient has undergone have been beneficial in both increasing function and decreasing pain. The patient has shown to have benefited with 18 months of pain relief from the previous injection. As such, the requested Orthovisc injections are likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.
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 fibromyalgia and chronic pain.  The physician reviewer found that in the medical literature, Andersen noted that the current evidence indicates that immediate, routine lumbar spine imaging in patients with low back pain and without features indicating a serious underlying condition did not improve outcomes compared with usual clinical care without immediate imaging. The author cautioned that in addition to lacking clinical benefit, routine lumbar imaging is associated with radiation exposure. In addition, this patients records do not include any indications for the requested MRI. All told, the requested MRI of the lumbar spine without dye is not medically necessary for evaluation of this patients low back pain.  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 59-year-old male enrollee has requested proton beam radiation therapy for treatment of his prostate cancer.  Findings:  The physician reviewer found that the use of proton therapy is an accepted radiation technology that has proven efficacy and tolerability for certain conditions, such as base of skull chordomas and chondrosarcomas, and pediatric central nervous system malignancies. These conditions are typically best treated with proton therapy due to the sharp dose fall off, allowing high dose delivery to the tumor, while relatively sparing the neighboring normal tissue.Whether proton therapy for prostate cancer affords any advantage over IMRT remains the subject of debate. Most reports, including a systemic review conclude that patients treated with proton therapy fare comparably to patients treated with photon radiation, such as IMRT. Vargas, et al. demonstrated that proton therapy yields improved normal tissue sparing as compared to IMRT. However, other accepted technologies such as image guided radiation therapy (IGRT) with daily CT imaging of fiducials or ultrasound, coupled with IMRT, also reduce normal tissue dosing; these technologies were not investigated in the study by Vargas. There is also the possibility that proton therapy is disadvantageous.  The depth of proton delivery is more susceptible to changes in tissue density, such as changes of air in the rectum. While some assert that proton therapy could lower the risk of secondary radiation-associated malignancies, there is no published clinical data that support this contention. Though proton therapy reduces the low dose deposition, proton therapy results in a greater dose rate and appreciably more neutron exposure, when compared to essentially none with IMRT using 6 MV photons. All told, proton beam therapy for prostate cancer is one of several available treatment approaches that are highly effective and well tolerated. There are no compelling data to suggest that proton therapy is superior to IMRT in this setting. Therefore, since the Health Plan is offering IMRT as a treatment option, proton beam therapy is not medically necessary for treatment of this patients prostate cancer.
Appeal type: Medical Necessity
Decision: Overturned

An 18-year-old male enrollee has requested residential treatment services for the treatment of his major depressive disorder, recurrent, severe, without psychotic features, anxiety disorder, not otherwise specified, attention deficit/hyperactivity disorder, rule out dysthmic disorder, and parent/child relational problem. Findings:  The physician reviewer found that in this patients case, the submitted documentation supports the medical necessity of the services at issue.  This patient continued to have frequent suicidal ideation and the psychiatrist added an atypical antipsychotic to his medication regimen.  Per the medical records, he had not consolidated the treatment gains necessary to succeed in a less restrictive setting.  During his course of care, the staff engaged the patient with a variety of well-accepted psychotherapeutic modalities and educational interventions. Placement at the residential setting, with the comprehensive services and 24-hour structure afforded by the setting, remained the most appropriate venue and the one that offered the patient the best chance to rectify underlying issues and correct self-destructive behaviors with the goal of imparting meaningful treatment gains and ultimately fostering harmonious autonomy.  All told, residential treatment provided during the dates of service at issue was medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld

The parents of a three-year-old male enrollee requested authorization and coverage of speech therapy three times per week for treatment of the enrollees medical condition. The Health Plan denied the request indicating that the requested therapy is not medically necessary for treatment of the enrollees verbal apraxia.One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer upheld the Health Plans denial on the basis that the requested therapy is not medically necessary.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement and prospective authorization and coverage for Malarone. The current diagnostic strategy for Babesiosis includes blood smear evaluation and specialized nuclear acid testing. The records provided for review do not include evidence that testing was needed in this patients evaluation and treatment. In addition, the treatment for Babesia is atovaquone and azithromycin. Currently, there is inadequate data in the peer-reviewed medical literature to support an indication of Malarone in this clinical setting. Overall, there is a paucity of evidence significant evidence for the standard treatment of Babesiosis with Malarone. For these reasons, Malarone was not and is not more likely to be beneficial for treatment of this patients medical condition than any available standard therapy.Final Result: The reviewers determined that Malarone was not and is not more likely to be beneficial for treatment of this patients medical condition than any available standard therapy.Credentials/Qualifications: Physician reviewers 1, 2 and 3 are board certified in internal medicine with subspecialty certification in infectious 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: Upheld

Findings:  The physician reviewer found that The patient has requested reimbursement for a hysterectomy (CPT 58571). Speer and colleagues note that often no specific etiology can be identified for chronic pelvic pain in women. The authors further note that diagnosis is based on findings from the history and physical examination, a pelvic ultrasonography to rule out anatomic abnormalities, and that referral for diagnostic evaluation of endometriosis by laparoscopy is usually indicated in severe cases. In this case, the indication for the hysterectomy is unclear. If the indication for the hysterectomy was bleeding, the submitted clinical information did not document heavy or abnormal bleeding or of anemia. There was no workup for vaginal bleeding. There was no documentation of an endometrial biopsy to rule out malignancy. An ultrasound showed a possible polyp, indicating that the next step would have been a polypectomy rather than a hysterectomy. The records did not document that the patient had tried and failed conservative options to manage bleeding including nonsteroidal anti-inflammatory drugs (NSAIDs), progestins and oral contraceptive pills, hormonal treatments, a levonorgestrel-releasing intrauterine system, tranexamic acid, or endometrial ablation. If the indication for the hysterectomy was pain, a further workup was needed to evaluate if the cause of the pain was gastrointestinal or genitourinary. Again, the records did not show that the patient had tried and failed pain management with NSAIDs or hormonal treatments. Upon failure of conservative measures, a diagnostic laparoscopy to diagnose and to treat the cause of the pain would have been the next step rather than a hysterectomy. Therefore, a hysterectomy (CPT 58571) was not medically necessary for the treatment of this patient.Final Result: The reviewer determined that the service at issue was not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.