Persius/imr-appeals huggingface dataset:
Diagnosis:  Neck pain and migraines.
Treatment:  Surgery - 64633-RT and 64634-RT (cooled radiofrequency neuroablation), Pre-service.

The insurer denied the Surgery - 64633-RT and 64634-RT (cooled radiofrequency neuroablation), Pre-service.  The denial is overturned. 

The patient is a female with neck pain and migraine headaches that has previously
had cooled radiofrequency ablation (c-RFA) with near 100% relief for almost one
year.

Yes, the proposed cooled radiofrequency neuroablation (64633-RT and 64634-RT) is medically necessary.

The requested cooled radiofrequency ablation (c-RFA) is medically necessary.  The procedure uses the same code as thermal radiofrequency ablation (t-RFA), often referred to as conventional radiofrequency ablation (RFA).  The temperature for cooled radiofrequency ablation (c-RFA) is above 60 degrees Celsius, which is often the temperature used in a thermal radiofrequency ablation (t-RFA).  Many of
the original articles on radiofrequency ablation (RFA) cite 60 degrees for ablation.  In addition, the tissue temperature has been shown to be 80 degrees.  Cooled radiofrequency ablation (c-RFA) is not to be confused with pulsed radiofrequency
ablation (RFA), where the temperature is below 42 degrees.  Neural ablation has
been shown to occur at 42 degrees Celsius.  Therefore, any temperature about 42 is
a thermal lesion.  Studies have shown conventional radiofrequency ablation (c-RFA) to be as effective as thermal radiofrequency ablation (t-RFA).

Studies have shown conventional radiofrequency ablation (c-RFA) to as effective as t-RFA.  It poses no increased risk and is an alternative to thermal radiofrequency ablation (t-RFA).  The distinction between the two is primarily due to proprietary technology.  No study has shown it to be inferior to  thermal radiofrequency ablation (t-RFA), and its
indications are same for thermal radiofrequency ablation (t-RFA).  In essence, there is no distinction, and it can be used in all settings that  thermal radiofrequency ablation (t-RFA) can be used. 

This patient has chronic low back pain with facet arthropathy.  The patient has had
two diagnostic medial branch blocks and previously had radiofrequency ablation (RFA) with excellent results.  Therefore, the criteria according to the Spine Intervention Society has been met, and this is medically necessary and standard of care.  In essence, there is no distinction, and it can be used in all settings that  thermal radiofrequency ablation (t-RFA) can be used.  In addition, the patient has previously undergone this procedure with near 100% relief for about a year.  Given the above, the requested conventional radiofrequency ablation (c-RFA) is medically necessary.
Diagnosis: Neuropathic pain
Treatment: Lidocaine Patch
The insurer denied the Lidocaine Patch.
The denial is overturned. 

The patient is a female with neuropathic pain who has been prescribed Lidocaine 5% patch.

Yes, the treatment with Lidocaine 5% patch is medically necessary.

The patient is a female with low back pain and lumbar radiculopathy, a neuropathic type pain, who has been prescribed lidocaine patches. This is a continuation of therapy. The patient has been on this in the past. She has tried and failed multiple options. She cannot take NSAIDs (nonsteroidal antiinflammatory drugs) due to anti-coagulation. She has failed Gabapentin and Cymbalta. She cannot take Tylenol due to liver issues. Chronic opiates are generally not recommended. She has used this medication in the past with good results. Lidocaine patches have been shown to be effective in the treatment of chronic low back pain in the literature. It is the least invasive option, and it tends to have low side effects.  She has tried lidocaine jelly, but she develops a rash. The options are limited. Given the above, the requested lidocaine patches are medically necessary,  

The risks of the alternatives far outweigh the benefits. The patient has failed most conventional and common modalities. 

Lidocaine patches have been used for numerous pain complaints outside of PHN (postherpetic neuralgia), including low back pain. This has been shown in the literature, and is considered standard of care in the treatment of many pain complaints aside from PHN.
Diagnosis:  Iritis.
Treatment:  BromSite 0.075% Ophthalmic Solution.

The insurer denied coverage for BromSite 0.075% Ophthalmic Solution.  The denial is upheld. 

This is a male patient with a history of chronic iritis in the right eye.  The patient's visual acuities are 20/40 in the right eye (OD) and 20/20 in the left eye (OS).  The patient has diagnoses of posterior capsular opacification OD, dry eye and status post retinal detachment repair OD.  The patient's treating physician noted that BromSite is used to treat chronic iritis in the right eye, and BromSite will be used to stabilize and alleviate the patient's symptoms due to iritis.  The physician also noted that the patient has used Ketorolac 0.5% in the past with no success and is currently using Bromfenac, but the patient states this does not seem to be as effective as BromSite.  It was noted that the patient has used BromSite in the past with great success.

Based on the review of the patient's medical record and literature, the requested medication, BromSite (bromfenac) 0.075% ophthalmic solution is not considered medically necessary for this patient.  The patient has not tried available formulary alternatives (i.e., flurbiprofen), or has not demonstrated contraindications to use of alternatives.  The literature does not support that BromSite is superior in efficacy or tolerability compared to other topical nonsteroidal anti-inflammatory drug (NSAID)-based ophthalmic drops.

The health plan acted reasonably with sound medical judgment, and in the best interest of the patient.

Based on the above, the medical necessity for BromSite 0.075% Ophthalmic Solution is not substantiated.  The insurer's denial should be upheld.
Diagnosis: Hypertensive emergency.

Treatment: Full hospital admission.

The insurer denied coverage for the full hospital admission.

The denial is overturned.

This is a male patient who was admitted with hypertensive emergency which is indicated by a systolic blood pressure (SBP) greater than 180 or diastolic blood pressure (DBP) greater than 120 with evidence of acute or worsening target organ damage. The patient's blood pressure was 261/147, and he presented with signs of myocardial infarction including elevated troponin and electrocardiogram (EKG) changes. The patient also had acute kidney injury (AKI) noted with elevated creatinine from a baseline of 2.2 up to 4.7. The patient's condition required close cardiac monitoring in the Coronary Care Unit (CCU) and required intravenous (IV) Cardene drip and adjustment of multiple blood pressure medications to stabilize his condition and control his blood pressure.

Based on the review of the medical record and literature, the full hospital admission was medically necessary for this patient. The patient's medical condition required an extended stay after blood pressure control due to his worsening kidney function and possible need for renal replacement therapy. Thus, the inpatient admission was appropriate and consistent with the standard of care.

The health plan did not act reasonably with sound medical judgment, and in the best interest of the patient.

Based on the above, the medical necessity for the full hospital admission is substantiated. The insurer's denial should be overturned.
Diagnosis:  Spastic quadriplegic cerebral palsy.
Treatment:  Gait Trainer.

The health plan denied the Gait Trainer.  The determination is upheld.

The patient has a diagnosis of spastic quadriplegic cerebral palsy, hypertonia, seizure disorder, kyphosis of spine, spasticity and weakness of all four limbs, who cannot walk independently.  Available records include a letter of medical necessity a letter from her physical therapist (PT), a fax, a letter detailing accessories, Durable Medical Equipment Order, progress note (telehealth office visit), and appeal from physical therapy for Rifton Dynamic Pacer.  At issue is the medical necessity of the requested gait trainer.

The requested gait trainer is not medically necessary for this patient.  The patient has diagnoses of spastic quadriplegic cerebral palsy, hypertonia, seizure disorder, kyphosis of spine, spasticity and weakness of all four limbs, who cannot walk independently.  There are not sufficient benefits of the use of a gait trainer in patients with cerebral palsy supported by medical literature to warrant it as a medically necessary device.  A Cochrane Review of Mechanically assisted walking training for walking, participation, and quality of life in children with cerebral palsy found that there was a lack of evidence to support significant benefits.  In this review, comparison with no walking, mechanically assisted walking training probably results in small increases in walking speed (with or without body weight support) and may improve gross motor function (with body weight support).  However this was not definite.  Compared with the same dose of overground walking, mechanically assisted walking training with body weight support may result in little to no difference in walking speed and gross motor function, although two studies found that mechanically assisted walking training without body weight support is probably more effective than the same dose of overground walking training for walking speed and gross motor function.  The lack of supportive medical evidence of significant benefit and outcomes for gait trainer in patients with cerebral palsy means this device cannot be considered medically necessary, even if it is useful for the patient.  The PT Letter documents that patient had a Kid Walk Gait trainer but has grown out of the device.  The patient was stable with the dynamic pacer and was able to perform assisted stepping approximately 30 feet at a time.  Gait trainer devices can be usable by patients and yet not be medically necessary.  The patient's possession of and ability to use a gait trainer in the past does not alter the lack of evidence that such a device is medically necessary
Orthopedic/Musculoskeletal
Nursing Services (including Private Duty Nursing)

Diagnosis: osteoarthritis
Treatment: Personal Care Worker (PCW) Service 
The insurer denied Personal Care Worker (PCW) Service Increase to 7 Days per Week, 8 Hours per Day. The health plan's determination is overturned.

The patient is a female with past medical history of hypertension, hypothyroidism, osteoarthritis, urinary incontinence, chronic kidney disease, and chronic constipation who had been assigned 4 hours of PCA (personal care assistant) services per day, 7 days/week. There was a request to increase PCA service hours and the patient had an assessment tool performed telephonically and was assessed at maximal assistance with tasks of meal preparation, ordinary housework, managing finances, and shopping while extensive assistance with tasks of managing medication, phone use, stairs, transportation, equipment management, bathing, dressing lower body, transfer toilet and toilet use. The patient was assessed at limited assistance with tasks of personal hygiene, dressing upper body, walking, locomotion, bed mobility, and eating.

The Personal Care Worker (PCW) Service Increase to 7 Days per Week, 8 Hours per Day is medically necessary for this patient. 
The patient's previous informal caregiver moved out of state leaving the patient with no informal caregiver, although the insurer incorrectly assumed the patient continued to have informal caregiver. The patient has activities of daily living (ADL) and Instrumental activities of daily living (IADL) care needs outside of the PCA service hours currently provided, specifically with needed help with meal preparation, eating, dressing, toileting, toilet transfer, walking, and locomotion. The assessment tool performed over the phone also underestimated the patient's ADL and IADL assistance needs for tasks of meal preparation, personal hygiene, dressing upper/lower body, walking, locomotion, toileting, transfer toilet, and eating. The PCA service hours are not solely for safety and supervision but to assist the patient with successful completion of ADL and IADL tasks. Personal care services are medically necessary when assistance with nutritional and environmental support function is essential to the maintenance of the patient's health and safety in her own home. The requested PCA services 8 hours/day, 7 days/week are medically necessary for this patient.
Diagnosis:  Dental Disorder.
Treatment:  Braces and Monthly Visits.

The insurer denied Braces and Monthly Visits.  The determination is upheld.

The patient has maxillary and mandibular crowding and many unerupted permanent teeth.  The orthodontist noted in the diagnosis that tooth number (#) 22 is impacted.  The patient is treatment planned for 36-42 months of comprehensive orthodontics with canine exposure and ligation.  At issue is the medical necessity of braces and monthly visits.

Orthodontic treatment is not medically necessary for the patient at this time.  He is in the process of losing his remaining primary teeth, as they are replaced with permanent teeth.  Research indicates the following risk factors for impacted canines in patients over 10 years of age (2):  1) If there is asymmetry in palpation or a pronounced difference in eruption of canines between the left and right side (The patient does not have this, as shown in the panoramic radiograph), 2) The canines cannot be palpated, and occlusal development is advanced (occlusal development is not advanced - there are many primary teeth remaining and the second molars are far from eruption), 3) The lateral incisor is proclined and tipped distally (Photographic evidence does not indicate proclined lateral incisors), and 4) On a panoramic radiograph of the late mixed dentition if the incisal tip of the canine overlaps the root of the lateral incisor (Neither canine overlaps the root of a lateral incisor on the panoramic radiograph provided).

While that study shows risk factors for impacted maxillary canines, there is nothing in this panoramic radiograph to suggest that tooth #22 will be unable to erupt.  Studies show that impacted mandibular canines are rare (3), and none of the records support a diagnosis requiring treatment at this time.  The patient does have maxillary and mandibular crowding; however, the patient does not exhibit any of the criteria to suspect that the canine is impacted.  Therefore, orthodontic treatment is not medically necessary.
Diagnosis: Spinal Muscular Atrophy
Treatment: Evrysdi SGM
The health plan denied the requested prescription drug. 
The health plan's determination is upheld.

A review of the prior authorization request indicated a diagnosis of spinal muscular atrophy type 2. The patient was not dependent on any invasive ventilation or noninvasive ventilation (though other notes indicate that he was using bi-level positive airway pressure (BiPAP)). The medication was prescribed by or in consultation with a physician specializing in the treatment of spinal muscular atrophy. The patient is not currently undergoing treatment with Evrysdi. The diagnosis of spinal muscular atrophy was confirmed with genetic testing. The patient has three copies of (genetic proteins= survival motor neuron (SMN) SMN2 and 0 copies of SMN1.
The patient did not undergo a Hammersmith Infant Neurological Exam, Part 2, Hammersmith Functional Motor Scale Expanded (HFMSE), Children's Hospital of Philadelphia infant test of neuromuscular disorders or Motor Function Measure - 32 items (MFM-32). The patient's age and initiation of the request is not documented.
An office note indicates that the patient did have BiPAP dependence. He is using BiPAP at night with classicist daily. He was undergoing a home physical and occupational therapy. He required a G-tube (gastrostomy tube) for feeding. He was receiving Spinraza. It was noted that the patient had spinal muscular atrophy type 2 and had a stable motor assessment despite complaints of weakness in the arm that was attributed to a delay in Spinraza dosing. A change to Evrysdi was planned.
The reason for denial on prior review as per communications from CVS Caremark is that the patient did not undergo a Hammersmith infant neurologic exam, part two (HIN2), Hammersmith functional motor scale expanded, Children's Hospital of Philadelphia infant test of neuromuscular disorders (CHOP-INTEND or MFM32).
A letter of medical necessity dated indicated that he had been treated with Spinraza but had a decline in function. His physician recommended Evrysdi. He indicated that the HIN2 and CHOP-INTEND would not be appropriate, that HFMSC could not be performed, and that the MFM 32 was not routinely used in clinical practice.

The health plan's determination of medical necessity is upheld, in whole.

No. Evrysdi SGM is an oral medication used to treat spinal muscular atrophy type I. Evrysdi is not medically necessary. In order to determine whether accuracy is effective for the patient, there must be a reproducible documentation of examination findings. It is possible that the physician may not see the patient at every visit. The HFMSC and MFM 32 would be appropriate for these patients. The risk of physical injury with the HFMSC is low. There is no rationale why the physician cannot perform these simple tests or derive a score from his existing examination. The patient would be most properly monitored with the use of these of one of the scales, and, in its absence, response or lack of response cannot be monitored and the requested medication would therefore not be considered medically necessary.
Diagnosis: Seizures
Treatment: Inpatient Hospital
The health plan denied the inpatient stay. 
The health plan's determination is overturned.

The patient is a male who presented to the emergency department after a staring episode.
He was well until approximately a month prior to presentation when he had his first episode of staring. The episodes occurred twice a day and lasted for a few seconds. He did not have any shaking or involuntary movements. He was seen by his primary doctor for his health supervision visit and had an episode of staring during the visit. He was subsequently referred to the emergency department for evaluation of these episodes. His past history was significant for premature birth. Upon presentation he had a temperature of 100 F. His physical examination was normal. Laboratory values were obtained, and he was admitted for evaluation of possible seizures.
He was admitted with seizure precautions and monitoring, with Ativan ordered as needed. A video electroencephalogram (EEG) was obtained as well as a consultation from the neurology team. He did not have staring episodes during the admission, and the video EEG did not show seizure activity. The neurology team also recommended a head magnetic resonance imaging (MRI), and he was given intravenous fluids in preparation for the study. The MRI was normal. He remained stable,  he was felt to be stable for discharge to home with follow up as an outpatient.
The hospitalization is under review for medical necessity.

I overturn, in whole, the health plan's determination of medical necessity.

Yes, the requested health service of the inpatient stay was medically necessary for this patient. This is a patient who presented with unexplained staring spells. He was referred to the emergency department after one of the events was observed in the primary care physician's office. He required prompt evaluation for possible seizures or other causes of paroxysmal behavior. His evaluation included video EEG monitoring, which needs to be done in an inpatient setting, as well as an MRI study, while monitoring for other possible etiologies and with administration of intravenous fluids in preparation for the study. While typical absence seizures cause staring episodes and are often benign, they typically present at an older age (mean age 6 years). Staring episodes in a can be a sign of a much more serious disorder, including seizures or sepsis, and require prompt evaluation with close monitoring for potential deterioration of clinical status.
Diagnosis: Cardiac/Circulatory. 
Treatment: Inpatient Hospital. 
The insurer denied inpatient stay. 
The denial is overturned.

The patient is a male with a history of non-ischemic cardiomyopathy, atrial fibrillation, chronic kidney disease and morbid obesity presented to the emergency department complaining of dyspnea, edema and a 50 pound weight gain over the prior two weeks. He had a left ventricular ejection fraction of 20% and an implanted left ventricular assist device (LVAD). He was on chronic antibiotics for a driveline infection. 

In the emergency department, his mean arterial blood pressure (MAP) was 80 millimeters of mercury (mmHg). His heart rate was 70 beats/minute. His respiratory rate was 22/minute with a room air oxygen saturation of 98%. His physical exam was remarkable for abdominal distension and lower extremity edema. The cardiology consultant later noted bibasilar pulmonary rales. Chest x-ray showed mild vascular congestion. The patient was admitted to the hospital with decompensated heart failure. He noted persistent dyspnea. His physical exam showed bibasilar rales and edema. He was treated with high dose intravenous furosemide twice daily. The next day, his dyspnea had improved but he had persistent rales, jugular venous distension and peripheral edema. High dose twice daily intravenous furosemide was continued until it was held after hypotension the night prior; the patient's MAP had fallen to 40 mmHg. His blood pressure was improved and oral diuretics were started. He was discharged. His discharge weight was 50 pounds less than his admission weight. Medical necessity for an inpatient admission is the subject under review.

An inpatient stay was medically necessary for this patient. This patient, with severe left ventricular systolic dysfunction and a left ventricular assist device, presented to the hospital with massive volume overload due to acute decompensated heart failure. He remained volume overloaded despite six days of aggressive intravenous diuresis, which was then complicated by hypotension. He required careful and continuous monitoring of his clinical status, LVAD parameters and laboratory values, along with adjustment of his pharmacologic regimen. This warranted an inpatient level of care.
Diagnosis: Class I malocclusion.
Treatment: Braces/monthly visits.
The insurer denied braces/monthly visits.
The health plan's determination is upheld. 

The patient in question is a female with a diagnosis of Class I malocclusion, appropriate overjet and overbite. The upper and lower arches are both mildly crowded. She is treatment planned for 24-30 months of orthodontics to correct her malocclusion. Braces and monthly visit (x 12) were denied as not medically necessary. 

Braces and monthly visit (x 12) are not medically necessary at this time.

The patient has an appropriate overbite and overjet. Yes, there is mild crowding, but that alone does not rise to the threshold of medically necessary. The photos do not support a diagnosis of a crossbite of tooth 27 with tooth 6, and the gingival margin of 27 appears to be the same as tooth 22. There does not appear to be attachment loss. There is no indication of functional problems on the diagnostic records or the orthodontic treatment plan. The diagnosis states the patient has a skeletal Class I relationship which is the most efficient jaw relationship for mastication. If her teeth were aligned, it would provide an esthetic improvement, but it would not create a medically significant improvement to the patient's health. For these reasons, treatment is not medically necessary.