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

Findings:  The physician reviewer found that the patient has requested reimbursement for bone density testing services. According to the National Osteoporosis Foundation guidelines, serial central DEXA testing is an important component of osteoporosis management (Cosman, et al.). More frequent testing may be warranted in certain clinical situations. The International Society of Clinical Densitometry (ISCD) guidelines indicate that intervals between bone mineral density testing should be determined according to each patients clinical status. Repeat testing is indicated one year after initiation or change of therapy, with longer intervals once therapeutic effect is established. In this case, the patient has history of osteopenia since age 24 and her vitamin D is low. There is no documentation of new or changed osteoporosis therapy to support annual bone mineral density scans. All told, the bone density testing services were not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Final Result: Two of the three reviewers determined that the services at issue were 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:  One reviewer is board certified in internal medicine with subspecialty certification in diabetes, endocrinology and metabolism and is actively practicing. One Reviewer is board certified in internal medicine with subspecialty certification in diabetes, endocrinology and metabolism and is actively practicing.  One Reviewer is board certified in internal medicine with subspecialty certification in diabetes, endocrinology and metabolism and is actively practicing.  All three reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

A 31-year-old male has requested a Livingskin custom made silicone prosthesis for his medical condition status post left arm amputation.  Findings:  The physician reviewer found that upper extremity prostheses need to be tailored to the specific needs of the individual to achieve successful use of the device (Kejlaa). Some individuals benefit from an active prosthesis but others prefer a passive design. According to Ritchie and colleagues, both function and cosmesis are important factors that impact on use of the device (Ritchie, et al.). This patient has used a Livingskin prosthesis for several years and relies on this passive prosthesis as his primary prosthesis for functional tasks. The submitted documentation demonstrates the Livingskin prosthesis helps the patient maintain a high functional level. At the time a new Livingskin prosthesis was recommended, the patients existing Livingskin prosthesis was five years old and in disrepair. Therefore, a replacement Livingskin custom prosthesis was medically appropriate and necessary for treatment of the patients condition.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary:   The parent of an enrollee has requested removal of tissue at the base of the tongue (coblation or radiofrequency volume reduction) for treatment of the enrollees sleep apnea. Findings:  Three physician reviewers found that studies support adenotonsillectomy (AT) as the recommended first-line treatment for pediatric obstructive sleep apnea (OSA) in children with adenotonsillar hypertrophy. The majority of studies establish that AT results in improvement for patients with severe OSA in most cases. In this patient, tonsillar hypertrophy was not documented. There is limited literature evaluating radiofrequency tongue ablation in pediatric patients. As such, there is inadequate data to establish that the tongue base reduction procedure was likely to result in a superior clinical outcome in this setting.  All told, radiofrequency tongue ablation was not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.   Final Result: Three reviewers determined that the procedure at issue was not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld.   Credentials/Qualifications:   All three reviewers are board certified in otolaryngology and are actively practicing. All three reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

A 35-year-old female enrollee has requested a magnetic resonance imaging (MRI) of the left eye, upper eyelid, soft tissue area, and tear duct for an evaluation of her left eyelid condition. Findings:  The physician reviewer found that the submitted clinical evidence does not establish the medical necessity of the disputed MRI. There was no indication by history or examination that suggested soft tissue pathology in or around the orbits. The patients symptoms were vague, but more consistent with an external ocular issue. It is not likely that the foreign object could penetrate tissue and move around to different areas. It would have been possible for the object, if it was still present, to become embedded and have a granulomatous reaction around it, but that would have been seen on examination. In addition, a computed tomography (CT) scan had already been performed which did not suggest any pathology in or around the area of concern. An MRI of the deep tissues around the orbit was not likely to be clinically useful in this setting, and as such, was not indicated.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement and prospective authorization and coverage for 30-day residential treatment 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 services at issue. The patient did not have any suicidal or homicidal ideation.  She did not have any agitation, mania, or psychotic symptoms.  The records do not document a history of suicide attempts.  The patient was compliant with treatment, and there were no reports of dangerous or disruptive behaviors.  She was able to perform her activities of daily living. She lives with a supportive family and was medically stable.  Although the patient continued to require treatment, this could have been provided in a less restrictive environment such as an intensive outpatient program level of care.  All told, 30-day residential treatment was not and is not medically indicated for the treatment of this patient. Final Result: The reviewer determined that the services at issue were not and 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 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

The patient has requested authorization and coverage for a power pressure-reducing air mattress. The patient has been diagnosed with spina bifida. The Health Plan denied the request and reported the requested device is not medically necessary for the treatment of this patient. At issue in this case is whether a power pressure-reducing air mattress is medically necessary for the treatment of the patients medical condition. Medical literature states that treatment of pressure ulcers is necessary for patient comfort and to decrease risk of systemic infection. The mainstays of treatmentinclude debridement of devitalized tissue, control of remaining infection with antibiotics, medical and nutritional patient optimization, appropriate dressing selection, and frequent monitoring of progression of wound evolution. In this case, the records do not document that the patient currently has a pressure ulcer. The record indicates that patient had a sacral decubitus ulcer in 2008, but the recent documentation does not reveal skin rashes or lesions.  There is no indication that this patient has had a recent myocutaneous flap or skin graft for a pressure ulcer on the trunk or pelvis or that the patient has failed recent appropriate skin care management, including management of moisture/incontinence, appropriate turning and positioning, education on the prevention and/or management of pressure ulcers, nutritional assessment, or regular monitoring of the skin by a medical practitioner. The medical evidence does not support the requested device in this clinical setting. Therefore, a power pressure-reducing air mattress is not medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested device 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 physical medicine and rehabilitation with sub-specialty certification in neuromuscular 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: Medical Necessity
Decision: Overturned

A 20-year-old male enrollee has requested removal of breast tissue (surgery and biopsy) for treatment of his gynecomastia. Findings:  The physician reviewer found that surgical removal of the patients excess breast tissue meets the definition of reconstructive surgery as defined by California law. The patients condition, asymmetric gynecomastia with enlarged left areola, is an abnormal structure of the body. The abnormal structure is caused by a developmental abnormality. While the requested surgery will not have an effect on function, it is being performed to create a normal appearance to the extent possible. Furthermore, based upon the photographic evidence provided, surgical excision of the breast tissue will offer more than a minimal improvement in appearance. As such, this patients condition meets the definition of medically necessary reconstructive surgery as defined by California law.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: A patient has requested authorization and coverage for prescribed Otezla. The Health Plan has denied this request indicating that the requested medication is not medically necessary for treatment of the enrollees medical condition. The submitted documentation supports the medical necessity of the requested medication. This patient has chronic severe widespread plaque psoriasis that requires systemic treatment to prevent further dissemination. Given this support, the requested Otezla is medically necessary for treatment of this patients psoriasis. Final Result: The reviewer determined that the requested medication is 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 dermatology and 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

Nature of Statutory Criteria/Case Summary: An enrollee has requested  authorization and coverage for a Group 4 motorized wheelchair for treatment of her rheumatoid arthritis.  Findings: The physician reviewer found that the requested Group 4 motorized wheelchair is medically necessary for treatment of the patients medical condition. Edwards and colleagues state that The benefits of power-mobility devices are reported to include improved quality of life, an increased sense of freedom and improved self-esteem. According to the Centers for Medicare and Medicaid Services (CMS), the criteria for a Group 3 PWC include a minimum top end speed of 4.5 miles per hour (mph), minimum range of 12 miles, a minimum obstacle climb of 60 mm and dynamic stability incline of 7.5 degrees. Per CMS, the criteria for a Group 4 PWC includes a minimum top end speed of 6 mph, minimum range of 16 miles, minimum obstacle climb of 75 mm and a dynamic stability incline of 9 degrees. These devices differ in that the Group 4 device has parameters more conducive to community use. In this case, the patient has a high level of independence and a Group 4 power wheelchair is medically necessary for treatment of the patients medical condition.Final Result: The reviewer determined that the requested equipment is 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 physical medicine and rehabilitation with sub-specialty certification in neuromuscular 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: Medical Necessity
Decision: Overturned

The parent of a 14-year-old female enrollee has requested use of a continuous passive motion (CPM) machine for the treatment of the enrollees medical condition status post anterior cruciate ligament replacement surgery. Findings:  The physician reviewer found that ACL repair surgeries have been performed in the hospital but with shorter hospital stays. The use of a CPM device in the hospital after surgery has become a standard of care. The shorter hospital stays have resulted in utilization of the CPM device in the home in the post-operative period. All of the references suggest that the standard of care post ACL repair for both young and older patients is to use a CPM machine daily for at least two weeks. Thus, the use of the CPM equipment for two weeks following surgery is consistent with the recommendations in the studies.
Appeal type: Experimental/Investigational
Decision: Overturned

A 45-year-old male enrollee has requested a transforaminal epidural block with instillation of hyaluronidase (lysis of adhesions), a ramus communicans block and a pulsed radiofrequency procedure of the ramus communicans of the sympathetic nerves for treatment of back and groin pain.Findings:  Two physician reviewers found that these procedures have been chronicled in the literature and are used for treatment of pain that is refractory to standard therapeutic regimens. Pulsed radiofrequency is FDA approved and is considered a useful tool in the treatment of pain that occurs in a well defined and fairly limited anatomic location. The most appropriate patients for pulsed radiofrequency and lysis of adhesions are those in whom reasonable conservative treatment has failed to provide adequate analgesia.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Synvisc injections. Findings:  The physician reviewer found that evidence based medical peer-reviewed literature supports the use of repeat series of viscosupplementation injections for the treatment of pain in patients with osteoarthritis of the knee. Treatment with viscosupplementation injections have been found to be safe and effective and allow for delay of total knee replacement . In this case, the patient has been diagnosed with advanced bilateral knee osteoarthritis. He has undergone previous viscosupplementation series with Synvisc with positive results documented in terms of pain reduction and improved function. The patient reports progressively worsening of his knee pain and difficulty maintain an active lifestyle. Therefore, the requested Synvisc injections are medically necessary for treatment of the patients medical condition. Final Result: The reviewers 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: Physician reviewer is board certified in orthopedic surgery and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for left knee ACL repair surgery. Regarding the management of ACL injuries in adults over age 40 years, Salzler and colleagues noted that multiple structural and biomechanical age-dependent changes exist in the ACL, including fewer mesenchymal stem cells, decreased healing potential, decreased structural organization, decreased stiffness, and a decreased load to failure with age. The authors further noted that ACL insufficiency can predispose an older patient to recurrent instability, meniscal and chondral injury, and osteoarthritis. The authors concluded that role of nonsurgical versus surgical management in these patients remained controversial, and that lower-demand patients may be able to cope with ACL deficiency, while limited studies suggested good functional outcomes with surgical ACL reconstruction in higher-demand patients. Regarding the management of ACL rupture in patients aged 40 and older, Legnani and colleagues noted that while surgery is often the best therapeutic option after an ACL tear in the young and active population, ACL reconstruction in the middle-aged population is more controversial due to concerns about a higher complication rate. The authors noted that high-level studies were limited, and deciding factors included occupation, sex, activity level of the subject, amount of time spent performing highly demanding activities, the presence of associated knee lesions, and physiological age and activity level. Current medical literature indicates that the role of surgical management in patients over the age of 40 with ACL instability remains controversial. At this time, it appears that the patient has not exhausted recommended conservative treatment prior to proceeding with surgery. Therefore, left knee ACL repair surgery is not medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested service 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 orthopedic surgery and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

The parent of a 14-year-old male enrollee has requested authorization and coverage for Humatrope 24mg cartridge for treatment of the enrollees short stature.  Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested therapy in this patients case.  This patient does not meet standard criteria for growth hormone deficiency, as his pre-treatment height was not more than 2.25 standard deviations below normal for age and sex, pre-treatment growth velocity was normal, bone age was normal, growth factors were normal, and he has no known morphological abnormalities of his pituitary gland.  Based on the patients bone age radiograph and height measurement, the estimated final adult height prediction was 65 inches, using the Bayley-Pinneau method.  This is an adult height that is within normal range.  The fact that the patients peak growth hormone response on provocative growth hormone testing was less than 10ng/mL does not prove that he was growth hormone-deficient, as the false positive rate of such testing is high in this setting.  Although the patient demonstrated improved growth velocity while receiving growth hormone treatment, this does not indicate that growth hormone therapy is medically necessary, as treatment was initiated during mid-puberty when endogenous sex steroid secretion is expected to boost the growth rate.  All told, the requested Humatrope 24mg cartridge is not medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld

The parent of a 16-year-old male enrollee has requested for use of a continuous passive motion (CPM) machine for treatment of the enrollees medical condition following right knee arthroscopic debridement and microfracture chondroplasty surgery. Findings:  The physician reviewer found that Steadman and colleagues recommend that for patients who had lesions on their femoral condyle and subsequently underwent microfracture surgery, they should be treated with a CPM machine commencing immediately in the recovery room, with the initial range of motion (ROM) at 30 to 70 degrees which is increased as tolerated by 10 to 20 degrees until full passive ROM is achieved. There is inadequate documentation in the form of physical therapy notes or follow-up office visits which validates the need for the use of a CPM machine past the three weeks.
Appeal type: Medical Necessity
Decision: Upheld

The patient has requested authorization and coverage for an ultrasound of the carotid arteries. Based on the records provided for review, the patient has coronary artery disease and a family history of carotid stenosis. The patient does not have a personal history of carotid stenosis or bruit, or symptoms concerning for transient ischemic attack such as focal neurologic deficits. In the absence of these conditions, the documentation does not support an indication for an ultrasound of the carotid arteries. Screening ultrasounds of the carotid arteries are not recommended by any guidelines for use in this clinical setting. Therefore, the requested ultrasound of the carotid arteries is not medically necessary for 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 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.