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

The patient is a 46-year-old woman with a history of uretal stones involving both kidneys. The submitted records indicate the patient has undergone four extracorporeal shockwave lithotripsy (ESWL) procedures. In the past the patient has had multiple large stones measuring up to 9 mm particularly on the left. There is no documentation of any procedures from the first radiography on 2/14/03 until 1/23/04 when the patient underwent ESWL. A follow-up x-ray ordered on 1/29/04, showed no ureteral stones. On 2/27/04, the patient was scheduled for another ESWL procedure; however, the procedure was not performed because the stones could not be visualized. The patient has requested authorization for percutaneous nephrolithotomy. The Health Plan has denied the request.The submitted clinical information does not describe the patients symptoms. In addition, there are no reports of stone composition. Although it appears the patient has had some calcium containing stones, it is not known if less radiopaque stones are present. There is also no documentation of the other procedures the patient has undergone including ureteroscopy. The stone size documented on the ESWL report is 2 x 5 mm in the left pelvis and 2 x 4 mm in proximal ureter. However, at the time of the patients last scheduled ESWL treatment the stones could not be visualized. Given the lack of sustained success of the patients previous ESWL procedures a nephrolithotomy is appropriate as the next treatment option if the stones are still present. However, in the absence of evidence of the stones, the requested procedure is not medically necessary. Therefore, the Health Plans denial should be upheld at this time. If the presence of a stone in the left ureter is confirmed, percutaneous nephrolithotomy should be authorized.
Appeal type: Medical Necessity
Decision: Upheld

The patient is a 37-year-old female who recently experienced a massive weight loss. She has requested authorization and coverage for removal of excess abdominal wall skin. The Health Plan has denied this request on the basis that a panniculectomy is not medically necessary for treatment of the patients medical condition.The medical records provided do not demonstrate the patient meets medical necessity criteria for coverage of a panniculectomy. No photographic evidence has been provided to demonstrate the defect or intertrigo. Though the patient reports experiencing skin irritation under the pannus, there is no clinical evidence that the patient has a severe skin infection or ulceration that has been refractory to medical management. Therefore, I have determined that the requested procedure is not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld

A 51-year-old female enrollee has requested continued acupuncture for treatment of her Myofascial Pain Syndrome of the scapular region.  Findings:  The physician reviewer found that this patient underwent approximately 46 acupuncture sessions between 2010 through 2012 and recently additional acupuncture was rendered in January and February 2013, due to the patients myofascial pain syndrome of the scapular region. The acupuncture was reportedly beneficial with pain reduction and improvement in the patients ability to perform activities of daily living (ADLs), but no specifics were documented. Although the patient reports that previous acupuncture treatment was beneficial, no evidence of significant, objective functional improvement to establish the reasonableness of additional care beyond an initial trial was provided for review. Specifically, there is no documentation indicating that the patient obtained any significant objective benefits, such as decrease of pain on the Visual Analog Scale, increased endurance, increased body mechanics and ability to perform ADLs, increased ability to perform job-related duties, reduction of pain medication, improved sleep or reduced pain behaviors. Therefore, the records suggest the acupuncture services have been maintenance in nature. In addition, it is not known if the patient is participating in a home exercise program which is recommended given her chronic pain to stimulate self reliance and avoid dependency on passive care. Self-care with rest, ice/heat, and an independent exercise program as well as coping mechanisms, should be in place to avoid co-dependency with prolonged medical interventions. The peer-reviewed medical literature indicates that after a trial of acupuncture is completed, further care is based on the presence of significant functional symptom improvements, which were not documented in this patients case. Consistent with these findings, the continuation of passive care in the form of acupuncture is not supported as medically necessary for treatment of this patients medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld

A 40-year-old male has requested coverage for a past CT angiogram of the heart for evaluation of his medical condition after being diagnosed with ascending aortic aneurysm and bicuspid aortic valve.  Findings:  Two physician reviewers found that the patient presents with a history of bicuspid aortic valve, ascending aortic aneurysm, hypertension, gastroesophageal reflux disease, and migraine.  On a date at issue, a CT of the chest reportedly showed a 5 cm ascending aortic aneurysm.  The following month, an echocardiogram reportedly showed left ventricular hypertrophy with normal ejection fraction, a bicuspid aortic valve with mild regurgitation, and an ascending aortic aneurysm.  The patient then had a CT angiogram of the heart one month after the echocardiogram.  In this clinical setting, the services at issue were not likely to be of greater benefit than other modalities for evaluating this patient.  If an assessment of coronary anatomy were thought to be indicated, conventional coronary angiography would have been the preferred method of evaluation.   Conventional coronary angiography provides the ability to intervene with coronary revascularization during the same procedure, if clinically indicated.  Current guidelines that are endorsed by several national organizations do not support the services at issue in this case.
Appeal type: Experimental/Investigational
Decision: Upheld

The parent of a 7-year-old female enrollee has requested 2 dorsiflexion Dynasplints for treatment of the enrollees idiopathic toe walking with mild heel corcontractures. Findings:  Three physician reviewers found that the provider notes the patient was born at 35 weeks gestation and was diagnosed before birth with intrauterine growth retardation. Her provider documented that her toe walking has resulted in mild heel cord contracture that required treatment with bilateral Dynasplints. The patient was also treated with physical therapy (PT) and provided the Dynasplints to promote dorsiflexion at night. To date, medical studies have not shown ankle dorsiflexion Dynasplints to be effective in treating persistent joint stiffness. Although some research shows that patient outcomes are improved with splinting, the majority of the literature does not support these findings. Most of the current data indicates that night splinting does not increase ankle range of motion or stretch the plantar flexors. Moreover, most of the articles suggest that conservative splinting does not improve equinus type gait. Consequently, the equipment at issue was not likely to be more beneficial for management of this patients condition than standard, proven alternative modalities.
Appeal type: Medical Necessity
Decision: Upheld

A 62-year-old male enrollee has requested an MRI of the right arm for evaluation of his arm pain and numbness.  Findings:  The physician reviewer found that the submitted documentation fails to establish the medical necessity of the services requested. The patient has an injury that could cause neuropathic pain due to nerve trauma. The diagnosis of the site and severity of a nerve injury has implications for prognosis and treatment. Electromyogram (EMG) is considered the first line as part of an evaluation for possible nerve injury and is considered an extension of the neurologic examination. If surgery were to be considered in the future, diagnostic imaging might be warranted. However, at present, there is no clinical information to be gained from an MRI that would help decision-making or facilitate clarification of prognosis. All told, the medical necessity of the requested MRI study has not been established.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for corneal collagen crosslinking with riboflavin procedure for treatment of the enrollees keratoconus. Findings:  Two physician reviewers found that there is sufficient support for the services at issue in this clinical setting. Based on the patients vision loss and progression, corneal collagen crosslinking was the most appropriate and effective treatment available.  Per the medical evidence, corneal collagen crosslinking is a safe and effective procedure for stabilizing corneal ectasia and potentially delaying or preventing the need for full-thickness corneal transplant. There are a lack of other treatment options available to slow or halt disease progression. Therefore, corneal collagen crosslinking with riboflavin procedure was likely to have been of greater benefit than other treatment options. Final Result: The reviewers determined that the services at issue were 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: Reviewers 1, 2 and 3 are board certified in ophthalmology 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

Nature of Statutory Criteria/Case Summary: The enrollee has requested authorization and coverage for a third opinion consultation with a plastic surgeon. The Health Plan has denied this request indicating that the requested services are not medically necessary for evaluation of the enrollees medical condition. Findings: There is support in the documentation provided for the medical necessity of the requested services in this clinical setting. The initial consultation with a plastic surgeon proposed a different treatment plan from the second plastic surgeon. The first surgeon suggested a staged approach with mastopexy followed by augmentation mammaplasty. The second plastic surgeon recommended an apparent single stage procedure, as well as other surgical options. The patient was not comfortable with the recommendation proposed by the second plastic surgeon who suggested a possible liposuction. The second consultation occurred after the patient had significant weight loss. Accordingly, the patients current request should be considered a second opinion following the 2017 plastic surgeon consultation. Moreover, the patients medical condition is a complex condition that requires possible complex breast reconstruction. Thus, an additional plastic surgery consultation should be considered medically necessary to re-evaluate the patient and provide an expert opinion. For these reasons, the request for a third opinion consultation with a plastic surgeon has been demonstrated as medically necessary in evaluating this patients medical condition.Final Result: The reviewer determined that the requested services are medically necessary for evaluation of the patients medical condition. Therefore, the Health Plans denial should be overturned.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: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: A male enrollee has requested authorization and coverage for a supervised polysomnography in a sleep laboratory for evaluation of the enrollees obstructive sleep apnea. Findings:  The physician reviewer found that in this patients case, the medical records fail to demonstrate the medical necessity of the requested services. This patient already has a diagnosis of sleep apnea. The records document that he is clinically improved on CPAP at the setting of 10 cm of water. The denial documentation noted that a home sleep study was available to the patient. There is no objective documentation that would preclude this patient from having a home sleep study.  A facility-based sleep study is not medically indicated in this clinical setting. 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: Medical Necessity
Decision: Overturned

A 51-year-old female enrollee requested authorization and coverage of the medication Provigil. The Health Plan denied the request indicating that the requested medication is not medically necessary for the treatment of the enrollees systemic lupus erythematosus (SLE) associated fatigue.One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer overturned the Health Plans denial on the basis that the requested medication is medically necessary.
Appeal type: Experimental/Investigational
Decision: Overturned

A 55-year-old male enrollee has requested for Transcatheter Arterial Chemoembolization (TACE) for treatment of his end-stage liver disease. Findings:  Three physician reviewers found that transcatheter arterial chemoembolization is a standard treatment for unresectable hepatocellular carcinoma. It is endorsed by the National Comprehensive Cancer Network (NCCN) guidelines. The presence of a portocaval shunt is not a contraindication to this procedure.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for a breast tomosynthesis for evaluation of the enrollees medical condition. Findings:  The physician reviewers found that breast tomosynthesis is a technique that was developed several years ago as a problem solving adjunct to routine mammography.  Applying the same basic concept as computed tomography (CT) scanning, the logic is that by separating the various layers of breast tissue, one can better detect abnormalities.  This has been shown to be most useful in the evaluation of dense breasts.  In this patients case, breasts have been described as dense.  It is specifically those patients who have dense breasts that can benefit most from breast tomosynthesis. The ability to separate out the overlapping structures enables the possibility of demonstrating an otherwise occult tumor. Final Result: All 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: Physician reviewers number one, two, and three are board certified in diagnostic radiology and 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

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for endocrinology services at a tertiary level of care. Polycystic ovarian syndrome (PCOS) is an endocrine disorder that has been associated with infertility, menstrual disorders, insulin resistance, obesity, and cardiovascular problems (Patel). Although data gained in recent years has improved understanding of the pathogenesis, diagnosis, and clinical manifestations, there are limited data directing therapeutic interventions (Aversa, et al.). Recent studies have demonstrated that due to the complexity of the condition, a multidisciplinary treatment approach to PCOS is an effective strategy that enables the coordination of care and serves as an innovative platform for research (Wolf, et al.). For these reasons, the requested endocrinology services at a tertiary level of care are medically necessary for 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 internal medicine with subspecialty certification in diabetes, endocrinology, 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: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested 90-day residential drug rehabilitation for treatment of the enrollees behavioral health conditions.  Findings: The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested services.  Per the medical records, this patient did not have suicidal or homicidal thoughts.  This patient has been unable to maintain abstinence and recovery.  However, he does not appear to be residing in a dysfunctional living environment.  Based on the medical records, this patient does not meet the severity of need for residential drug rehabilitation facility treatment and could be treated in a lesser restrictive setting.  Therefore, the requested 90-day residential drug rehabilitation treatment is not medically indicated for the treatment of this patient.Final Result: The reviewer determined that the requested services are not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is board certified in 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.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for routine intravenous (IV) saline infusions every two to three weeks.Findings:  The physician reviewer found that based on the records provided, the patient has POTS and presyncope symptoms refractory to several medication trials. The patients condition has transiently improved after saline infusions. Hydration may be an effective treatment for POTS. However, there is no documentation in the records provided for review that this patient cannot tolerate oral hydration. In addition, there is increased risk of infection with IV saline hydration as opposed to oral hydration. There is a lack of scientific literature supporting the routine use of IV saline in the management of POTS. Therefore, the requested routine IV saline infusions every two to three weeks are not medically necessary for treatment of this patient. Final Result: The reviewer determined that the requested services are not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in internal medicine with subspecialty certification in cardiovascular 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: Medical Necessity
Decision: Upheld

A 16-year-old female enrollee requested authorization and coverage of occupational therapy.  The enrollee suffered a drowning, cardiac arrest, head injury, and resultant hemiparesis in 1996 at 10 years of age .  The Health Plan denied the enrollees request indicating that the requested treatment is not medically necessary.One physician reviewer performed a medical necessity Independent Medical Review.  The physician reviewer upheld the health plans denial on the basis that the requested services are not medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld

A 42-year-old female enrollee has requested continued physical therapy for treatment of her cervicalgia and myofascial pain syndrome. Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested therapy.  This patient has undergone extensive physical therapy and should be independent with a home exercise program.  The records do not document any significant impairment that would preclude her from performing an independent program.  Further, there are no documented exercises that she has been performing in the formal therapy setting that she cannot perform independently, or substitute with independent exercise.  There is no proven benefit of passive modalities provided in a formal setting on a prolonged basis on health or functional outcomes in this clinical setting.  Palliative modalities, such as topical heat, can be applied independently by the patient without anticipation of a marginally significant difference in health or functional outcomes compared to modalities provided on a prolonged basis in the formal physical therapy setting.  While the patient continues to be symptomatic, no marginally significant benefit would be expected from ongoing formal treatment over an independent program.  All told, continued physical therapy is not medically necessary for the treatment of this patient.