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 Magnetic Resonance Imaging (MRI) testing of the back, abdomen, and head. The Health Plan has denied this request indicating that the requested testing is not medically necessary for treatment of the enrollees headache, back pain, abdominal pain, and urinary tract infection. At issue in this case is whether the requested MRI testing of the back, abdomen, and head is medically necessary for treatment of the enrollees medical condition. Chronic daily headache is characterized as headaches for at least 15 days per month. In this setting, without change in the characteristic of the headache or focal neurological findings, neuroimaging is usually not warranted according to some findings. In the setting of hematuria with or without flank pain, the standard first imaging examination is CT urography. Magnetic resonance urography is only recommended in the setting of indeterminate CT findings or in patients with a CT contrast allergy. According to studies found appropriateness criteria for the evaluation of uncomplicated low back pain, radiographs are the initial recommended imaging examination. MRI is considered usually not appropriate. In review of the patients medical records, the patients headaches do not qualify as chronic daily headache. She also had negative CT imaging. MRI is not currently indicated. The patient also has had negative abdominal CT scans. MRI of the abdomen would not add further information and is not indicated. Lumbar MRI is also not indicated, radiographs are first recommended as well as conservative therapy. In this patients case whole body MRI is not medically necessary. Therefore, the requested MRI testing of the back, abdomen, and head is not medically necessary.Final Result: The reviewer determined that the requested testing is 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 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: Experimental/Investigational
Decision: Overturned

A 51-year-old female enrollee has requested a breast MRI for an evaluation of her medical condition. Findings:  Three physician reviewers found that in this case, the MRI in dispute was not performed for screening purposes, but was diagnostic.  Indeed, had it not been performed the lesion in the right breast would not have been detected.  The MRI was appropriately part of a thorough evaluation in light of an abnormal mammogram and ultrasound which were discrepant.  The suspicious nature of the screening mammogram suggested a high probability of cancer and this, combined with other worrisome findings on the ultrasound, made the MRI diagnostic.  The American Cancer Society endorses breast MRI in this circumstance.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement and prospective authorization and coverage for residential treatment center (RTC) level of care services. Per the American Society of Addiction Medicine (ASAM) criteria, this patient meets Level 3.5 criteria for Clinically Managed High-Intensity Residential Services. ASAM criteria focuses on six dimensions to determine the appropriate level of care including: (1) intoxication and withdrawal potential; (2) biomedical conditions; (3) emotional, behavioral and cognitive conditions; (4) readiness to change; (5) relapse, continued use, or continued problem potential; and (6) recovery environment. For dimension 1, the patient has been at moderate to severe withdrawal per Clinical Institute Withdrawal Assessment (CIWA) scores. The patient does not meet the criterion for dimension 2. For dimension 3, the patient has comorbid post-traumatic stress disorder (PTSD), attention deficit hyperactivity disorder (ADHD), depression, and agoraphobia. Dimension 4 is satisfied as the patient is willing to change, but is not ready as evidenced by his variable engagement and his lack of coping strategies. For dimension 5, the patient has a history of multiple brief periods of abstinence followed by relapses. His history of multiple relapses in an uncontrolled environment is a strong risk factor for recurrent relapses in the absence of adequate supervision and appropriate direction. For dimension 6, the patient reports difficulty with trusting in interpersonal relationships leading to potential lapses in support in his recovery environment. He continues to be unemployed without a path to reemployment. The patient requires a safe and stable living environment in order to develop his recovery skills. Thus, the patient qualifies for ASAM Level III treatment similar to what the patient has received at the current RTC. Given the severity of the patients illness, RTC services were and are medically necessary for 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 psychiatry with expertise in addiction psychiatry and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement and prospective authorization and coverage for Botox (botulinum toxin) treatmentsto be provided every four to six months. Findings:  The physician reviewer found that The patient who has been diagnosed with temporomandibular joint disorder and sleep related bruxism. The patient has reported mouth clenching and ear pain. the patient has  described the pain as severe and throbbing. The patient  has been treated with masseteric botulinum toxin injections. The patient requested reimbursement and prospective authorization and coverage for Botox (botulinum toxin) treatments  to be provided every four to six months. The Health Plan denied the services at issue. The Health Plan noted that the services at issue were and are investigational for treatment of this patients medical condition. There is clinical support in the efficacy of the services at issue in this clinical setting. Botulinum toxin has been shown to be effective for a variety of disorders in several medical conditions, when used therapeutically. In recent years, there has been a rising trend in the use of this pharmacological agent to control bruxing activity.  The medical literature supports the use of botulinum toxin to reduce the frequency of bruxism events and myofascial pain. Current clinical data reflect that botulinum toxin has been an effective treatment option for reducing nocturnal bruxism and myofascial pain in patients with bruxism such as in this patients case.  For these reasons, Botox (botulinum toxin) treatments  retrospectively and forward, to be provided every four to six months were and are more likely to be effective than the standard options for treatment of this patients medical condition.  Final Result: The reviewers determined that the services at issue were and 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:  Physician reviewer number 1 & 3 are board certified in otolaryngology and physician 2 is   is board certified in oral facial and maxillary surgery and all are  actively practicing. The reviewers are 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 patient has requested authorization and coverage for oxycodone HCL in three various dosages. The Centers for Disease Control and Prevention (CDC) guidelines on opioid prescribing suggest comprehensive steps at all stages of opioid initiation, monitoring, continuation, and discontinuation. The CDC specifically suggests that every three months if the benefits do not outweigh harms of continued opioid therapy, clinicians should optimize other therapies and work with patients to taper opioids to lower dosages or to taper and discontinue opioids. Within the documentation available for review, the records support the medical necessity of the oxycodone HCL tablets. This medication was a quantity consistent with the providers documented treatment plan. The provider evaluated the patient and determined that the patient could be switched to oral oxycodone tablets in conjunction with a trial of Hysingla. Therefore, the oxycodone HCL tablets were medically necessary for treatment of this patient. However, there is a lack of documentation to support use of oxycodone liquid. The patient had documentation of previous and upcoming dental work, but an update on her status with regard to the ability to swallow pills was not provided for review. In addition, the provider indicated in the progress notes that the plan was to change from liquid oxycodone to the tablet formulation. Thus, the oxycodone HCL liquid was not medically necessary. Further, there is a lack of support in the records for oxycodone HCL in higher dose. The records include a pharmacy benefit prescription history that the patient has been on oxycodone, and the quantity dispensed each month is slowly reduced. However, the records do not include urine drug testing results, functional improvement, and pain reduction to warrant this medication. In addition, opioid risk stratification is not evident in the records. Moreover, querying of the CURES database was not reported beyond the initial timeframe. This monitoring is required in an ongoing basis. Therefore, the oxycodone HCL tablets were not medically necessary for treatment of this patient. Final Result: The reviewer determined that a portion of the medication at issue was medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be partially overturned. Credentials/Qualifications: The reviewer is board certified in physical medicine and rehabilitation with subspecialty certification in pain management 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

This patient is a 28-year-old female who has requested bilateral breast reduction surgery. The submitted records indicate the patient is 411 and weighs 126 pounds. Her bra size is 36DD. The notes of the patients provider note shoulder, back, and neck pain. The patients provider has recommended bilateral breast reduction surgery to alleviate the patients pain. The Health Plan has denied authorization for the procedure on the basis that it is cosmetic in nature and is not medically necessary.Based upon the submitted clinical information, which includes photographs, the requested procedure is not medically indicated. The submitted photographs do not show evidence of intertrigo, shoulder grooving, ulceration, or hyperpigmentation. While there is documentation of back and neck pain, the various reports allude to other possible causes of the pain. The procedure of bilateral breast reduction is not medically indicated and is cosmetic in nature. Therefore, I have determined that the requested procedure is not medically necessary for the treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Experimental/Investigational
Decision: Upheld

A 57-year-old male enrollee has requested a PET scan for evaluation of his history of melanoma. Findings:  Two physician reviewers found that he was diagnosed with melanoma. The patient was treated with both radiation and adjuvant treatment.  Per the submitted documentation, there are no current complaints and no evidence of recurrent disease since his initial treatment.  Therefore, he has been disease-free for five years. The National Comprehensive Cancer Network issues guidelines for the treatment of melanoma, and these guidelines do not support PET scanning in this patients case.  The requested diagnostic procedure is considered a low yield procedure, and there is a cumulative risk of radiation exposure.  Since most recurrences manifest within five years, routine laboratory testing and imaging is not recommended beyond this period.  The medical literature does not show that routine PET scans in asymptomatic patients is likely to be of benefit.
Appeal type: Medical Necessity
Decision: Upheld

A 47-year-old female enrollee has requested for an MRI study of the thoracic and lumbar spine for evaluation of her back pain. Findings:  The physician reviewer found that there is no documentation of a trial of adequate conservative measures including physical therapy and NSAIDS. Further attempts at standard therapy should be initiated prior to consideration of imaging studies.
Appeal type: Experimental/Investigational
Decision: Upheld

A 52-year-old female enrollee  requested 3D x-ray picture of the breast (breast tomosynthesis) for medical evaluation of her medical condition.  Findings:  Three physician reviewers found that the services were not likely to be more beneficial for evaluation of the patients medical condition than available standard modalities. There is no documentation provided that shows a family history of breast cancer. The patient is asymptomatic with no reports of dense breast tissue. Although, breast tomosynthesis has a role in screening as an adjunct in a select group of patients, this is not the case in this clinical setting. Therefore, the services at issue were not likely to be more beneficial for evaluation of the patients medical condition than any available standard.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a three-year-old male enrollee has requested authorization and coverage for at-home applied behavioral analysis (ABA) therapy for treatment of the enrollees autism.  Findings:  The physician reviewer found that although review of the literature reveals no citations evaluating the differences between in-home ABA and clinically based ABA, most ABA programs provided today have at least some component of in-home treatment. The ultimate goal of any ABA program is to have the patient functioning independently in the community.  Independent functioning must begin in the home with self-help skills and family communications.  All the social/play and perspective taking skills as well as the self-help skills (especially continence) should take place in the home. The patient will have a need for future self-help skill goals as he becomes developmentally age-appropriate. It is often difficult to have these skills carry over into the home if taught in an outside environment. All behavioral programs should involve training of the parents/caregivers to allow for carry-over from the behavioral sessions.
Appeal type: Medical Necessity
Decision: Upheld

The patient is a 42-year-old female who lost 100 pounds following gastric bypass in 2000. She previously underwent a medial thigh lift and abdominoplasty. She and her plastic surgeon are now seeking authorization for excision of excess skin and soft tissue of the arms and liposuction of the trunk and lower extremities. The patient has had scar revisions of these areas for hypertrophic scar. The Health Plan has denied the proposed brachioplasties and liposuction of the trunk and lower extremities on the basis the requested procedures are not medically necessary. There is no documented objective evidence that the patient meets accepted criteria for consideration of brachioplasties and liposuction of the trunk and lower extremities. There is no indication that the requested procedures are medically warranted in order to treat clinical symptoms or functional complaints. As such, I have determined the requested procedures are cosmetic in nature and therefore, not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Experimental/Investigational
Decision: Upheld

A 46-year-old male enrollee has requested total disc replacement (TDR) utilizing the ProDisc-C artificial disc for treatment of his left sided cervical radiculopathy. Findings:  Three physician reviewers found that in regards to this particular patient, the manufacturer specifically states that the ProDisc-C device is contraindicated in patients with symptomatic cervical disc disease at more than one level. The patients provider reports cervical disc disease at both C5-6 and C-7. Given the guidelines for usage of this device and the clinical data, the prosthesis is intended for use at a single-level in patients with only one level symptomatic cervical disc disease. For these reasons, the requested surgery would not be expected to be more beneficial than conservative therapy for management of this patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld

The patient is a 35-year-old female with an approximate eight-year history of alcohol dependence, consisting of drinking a bottle of wine per night and apparently significantly more on the weekends. This resulted in verbally abusive (and what had been deemed manic) behavior. Her boyfriend who lives with her had noted dreading the weekends due to the extent of her drinking and subsequent unruliness. The patient also has a past history of anorexia and bulimia, though she reported this as in good control with Zoloft 200mg. She has not been formally diagnosed with bipolar disorder despite the history of becoming manic when drinking.The patient initially entered residential treatment on 12/30/04 with the request to learn how to cut down on her drinking, but still be able to drink socially. However, she was receptive to being told that this was a frequent folly of alcohol dependent individuals, noted by the clinician as she accepted this option without further question or argument. The patient did not have a history of withdrawal symptoms and none are documented in the information provided. Treatment notes from 1/2/05 indicate the patient was very congenial and friendly, seems open-minded to treatment. Maybe ambivalence, not sure. On 1/3/05, she was noted as more comfortable with residents and peers. Client utilized group process more willingly and openly today by sharing self and feelings. On 1/7/05, it was noted the patient was distraught, wanting to leave program and go ahead and relapse since hearing that insurance will not support her level of care. However, by 1/9/05, she was noted as cheerful and bouyant all morning as well as grateful for her sobriety. The submitted notes indicate the patient did sneak alcohol into residential care on two occasions, though she drank a lesser amount at those times.The patient has requested coverage for residential treatment services from 1/6/05 onward. The Health Plan has denied the patients request indicating the patient could have been treated at a less intensive level of care as of 1/6/05.All told, there appears little evidence in the submitted documentation to indicate the patient was not appropriate for transfer to a less intensive level of care by 1/6/05. Though the fact that the patient snuck alcohol into residential treatment on two occasions does indicate the patients ambivalence about sobriety, this no more argues for the need for residential treatment that it does for intensive outpatient treatment. If anything, if a patient is really that intent on drinking, neither residential treatment nor intensive outpatient treatment is likely to be successful. As such, residential treatment services were no longer medically indicated as of 1/6/05. Based upon the information set forth above, I have determined that the services at issue were not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld

An enrollee has requested authorization and coverage for liposuction and excess skin removal of the upper arms, and excess skin removal of the legs. Tthe submitted documentation includes photographs of the patients upper arms and legs, and they do not have the appearance of abnormal structures of the body, particularly given the patients history of weight loss. Furthermore, the condition of the patients upper arms and her legs is not caused by congenital defects, developmental abnormalities, trauma, infection, tumors or disease. While lipedema is a diagnosis seen in the medical literature, it is not supported by well-designed, controlled, high level of evidence, peer reviewed literature, and there is no objective testing for the disease. Consequently, while the performance of liposuction is proposed to improve function, there are no well controlled, peer reviewed, high level of evidence studies that support the efficacy of the procedure either in the short or long term. Additionally, there is limited evidence if any in the peer reviewed literature to support skin excision as a treatment for lipedema. Accordingly, under these circumstances, the requested services are not reconstructive in nature.Final Result: The reviewer determined that the requested services are not medically necessary for treatment of the patients medical condition and not reconstructive in nature. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is board certified in plastic 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 authorization and coverage for laparoscopic hiatal hernia repair with LINX placement surgery.  Findings:  The physician reviewer found that there is a lack of randomized controlled trials comparing LINX with Nissen fundoplication or other surgical anti-reflux procedures.  Adverse events, such as erosion through the esophagus, have been reported in the period after U.S. Food and Drug Administration (FDA) approval.  Additionally, LINX (more than surgical fundoplication) is associated with severe dysphagia requiring endoscopic intervention. The currently available peer-reviewed literature does not definitively support the conclusion that LINX is more likely to be beneficial in this case than standard treatment, surgical fundoplication. Thus, the requested laparoscopic hiatal hernia repair with LINX placement surgery 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 gastroenterology and are actively practicing. The reviewers are 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.