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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for radiofrequency ablation (RFA) of the nerves innervating the sacroiliac (SI) joint with image guidance. The records provided for review document that this patient has a history of chronic low back pain secondary to right-sided sacroiliitis. Treatment has included a successful SI joint injection followed SI joint RFA with improvement in pain from 8/10 to 2/10. The patients provider has recommended repeat RFA of the SI joint. As noted in the medical literature, RFA of the sacral lateral branches affects the nerves that supply the posterior SI ligaments and posterior portion of the SI joint, also referred to as the posterior SI joint complex. Yang and colleagues evaluated the use of the local anesthetic blocks for the diagnosis of posterior SI joint complex pain and the efficacy of RFA on the sacral lateral branches. The authors concluded that RFA is effective in relieving pain that originates from the posterior SI joint complex. Chen and colleagues reported that patients who received RFA had a significantly greater improvement in Oswestry disability scores compared with patients who received sham treatment. The records document that this patient has responded well to the SI block and previous RFA that lasted eight months. The records also support that the patients pain generator is the right SI joint. Given these findings, the requested RFA of the nerves innervating the SI joint with image guidance is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Findings:  Three of the three physician reviewers found the requested RFA of the nerves innervating the SI joint with image guidance is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the requested services 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 reviewers 1, 2, and 3 are board certified in orthopedic surgery and are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

A 51-year-old female has requested surgical buttocks lift for treatment of an excess skin condition.  Findings:  The physician reviewer found that there is no medical documentation of on-going infections in the buttocks fold and the photographs do not suggest cellulitis, ulcerations or severe rashes. There is no evidence of frequent office visits to a primary care provider or dermatologist for the management of clinically significant dermatologic problems that have either not responded to topical therapy or despite an initial response, have recurred and caused significant functional impairment. A reasonable standard when evaluating the medical necessity of potentially cosmetic surgery is to require convincing and confirmatory evidence of a chronic functional problem that has failed reasonable attempts at conservative therapy. While the patients history of complaints may be correct, the records fail to document significant complications due to these infections or failed medical attempts to control her symptoms.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for left knee replacement surgery. This patients evaluation revealed chondromalacia of patella but no degenerative changes in the medial or lateral compartments. The menisci are also intact. The requested surgical procedure of a total knee replacement surgery necessitates presence of severe degenerative arthritis in at least one compartment, and lesser grade arthritis in at least one additional compartment. In the absence of osteoarthritis on the imaging studies, the pain generator has not been established, and the expectations of complete pain relief will not be consistent with the outcome. Furthermore, the records document radiation of the pain to the hip and lower back which has not been thoroughly evaluated. In the absence of significant degenerative joint disease on the imaging studies, a total knee replacement surgery is not supported by the medical literature. In light of the foregoing, the requested left knee replacement surgery is not medically necessary for treatment of this patients medical condition. Final Result: The reviewer determined that the requested surgery 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: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for (1) facet joint injection to the right cervical thoracic region and (2) facet joint injections to the lumbar region. In a systematic review of lumbar facet joint injections and medial branch blocks for chronic low back pain, medical literatures reported that steroids promoted a reduction of numeric rating scale (NRS) by 28% and an improvement of the Oswestry Disability Index (ODI) by 13.2%. The authors further reported that local anesthetics produced an improvement of the ODI by 9.8%, concluding,  Injections for chronic low back pain deriving from facet joints osteoarthritis are encouraging, especially when considering medial branch blocks. Researchers report state, The level of evidence is II in selecting patients for facet joint nerve blocks at least three months after onset and failure of conservative management, with strong strength of recommendation for physical examination and clinical assessment. The authors further state, The level of evidence is II with moderate strength of recommendation for therapeutic lumbar facet joint nerve blocks with inclusion of three relevant randomized controlled trials, with long-term improvement. In this case, the patient has axial mechanical back pain, without signs or symptoms or radicular pain, such as shooting electrical pain in the abdomen or legs, paresthesias, or deep tendon reflex abnormalities. Magnetic resonance imaging (MRI) of the lumbar spine did not reveal signs of high grade canal stenosis. The patient was diagnosed with suspected facet joint related back pain and had attempted physical therapy and medication management for six weeks without relief. In this clinical setting, given the evidence in current medical literature that medial branch blocks can effectively diagnose and treat low back pain related to facet joint disease, the services at issue were medically indicated. Therefore, (1) facet joint injection to the right cervical thoracic region and (2) facet joint injections to the lumbar region were medically necessary for the treatment of this patient.Final Result: The reviewer determined that the services at issue were 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 anesthesiology with sub-specialty certification in pain medicine and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

A 63-year-old female enrollee has requested vaginal prolapse repair for treatment of her female cystocele and prolapse of vaginal vault after hysterectomy. Findings:  The physician reviewer found that the submitted documentation and relevant literature fails to demonstrate the medical necessity of the requested procedure. The patient has been found to have atrophic changes of the vaginal vault, but no evidence of residual urine, infection and no evidence of vaginal prolapsed. The current medical evidence does not support the requested procedure in this clinical setting. The proposed conservative approach to this patients symptomatology does not preclude reassessment in the future should the recommended clinical approach fail to alleviate her symptoms. Moreover, surgery for this patients condition does not always alleviate all issues and can sometimes lead to further concerns. For the reasons set forth above, vaginal prolapse repair is not medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has been treated for chronic pain for several years. She has been treated with physical therapy, nerve blocks, acupuncture, and medication therapy. The patient has undergone multiple surgical interventions. The records noted that she is status post lysis of adhesions. She has had some response to hormone replacement and requires chronic narcotic use for pain control. The patient has requested authorization and coverage for deep excision laparoscopic surgery. The Health Plan has denied this request and reported that the requested services are not medically necessary for the treatment of this patient.The submitted documentation fails to demonstrate the medical necessity of the requested services.  This patient has undergone multiple prior surgeries without benefit. There is no indication that a repeat surgery will provide benefit for the patients pain. There is literature describing the use of excision in areas categorized as deep excision as well as the lateral pelvis.  The role of laparoscopy for diagnosis is well substantiated, as is the role of excision for endometriosis. There is a lack of literature to support the use of repeated laparoscopy or surgical intervention in the setting of chronic pelvic pain. In this case, the records do not demonstrate that further surgical exploration is warranted. Pathology from surgery did not document endometriosis. The records noted microscopic endometriosis. Therefore, the requested deep excision laparoscopic surgery is not medically necessary 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 board certified in obstetrics and gynecology 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

The parent of a nine-year-old male enrollee has requested single photon emission computed tomography (SPECT) scans for evaluation of the enrollees attention deficit/hyperactivity disorder. Findings:  Three physician reviewers found that in this patients case, the services at issue were not likely to have been more effective than other available modalities.  This patients presentation and symptoms were consistent with attention deficit/hyperactive disorder.  The family history also strongly supports this diagnosis.  The evidence base and case presentation indicate that this diagnosis can be made through a clinical interview without the need for further evaluation procedure.  Current American Academy of Child and Adolescent Psychiatry (AACAP) practice parameters do not support the use of SPECT scans to diagnosis or treat attention deficit/hyperactivity disorder in children or adolescents.  The AACAP practice parameters detail the method of diagnosis of attention deficit/hyperactivity disorder as a clinical interview involving the family, patient and school as the standard for diagnosis.  The records indicate that the patient has tried three different stimulant medications.  However, there are no records that indicate the duration or dose for two of the medications, Adderall and Ritalin SR.  Thus, SPECT scans provided were not likely to be more efficacious than other methods of evaluation.
Appeal type: Medical Necessity
Decision: Upheld

The parent of a minor enrollee has requested authorization and coverage for removal of teeth numbers 1 and 16. Findings:  The physician reviewer found that the radiograph provided does not demonstrate any pathology associated with teeth numbers 1 or 16, and appears to show adequate space present to allow normal passive eruption of these teeth.  The radiograph does not demonstrate etiological factors for pain caused by the presence of teeth numbers 1 and 16 other than the potential for the discomfort normally associated with tooth eruption.  The morbidity risk associated with prophylactic extraction of third molars when not dentally necessary has led to a need to assess risk versus benefit of extractions where no pathology is demonstrated.  The submitted surgical notes indicate that extraction of tooth number 1 was performed due to perforation of the tissue and inflammation, and extraction of tooth number 16 was performed due to complete bony impaction.  However, the radiograph provided does not demonstrate pathology associated with either of these teeth which would necessitate their extraction.  All told, removal of teeth numbers 1 and 16 was not dentally necessary for the treatment of this patient.  Final Result: The reviewer determined that the services at issue were not dentally necessary for treatment of the patients dental condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in dentistry 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 63-year-old male enrollee has requested authorization a 12-week course of Sovaldi 400mg and Olysio 150mgfor treatment of his hepatitis C. Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested medication combination in this patients case.  This patient has been diagnosed with hepatitis C, genotype 1a.  On the date incdicated, ultrasound of the abdomen showed normal liver morphology.  In this patients case, there is no demonstration either through liver biopsy, liver fibrosis panel or elastography that the patient has significant fibrosis.  There is a lack of support for the requested medication combination in this clinical setting.  The advantage of treatment in patients with minimal to no fibrosis has not been established.  All told, the requested 12-week course of Sovaldi 400mg and Olysio 150mg is not medically indicated that the treatment of this patient.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested reimbursement for D7240, removal of tooth #58 and #59 for treatment of her maxillary incisor supernumerary teeth. Findings:  The physician reviewer found that the medical literature and the documentation provided support the dental necessity for the services at issue in this clinical setting. The Health Plan denied the services at issue due to the patients age. The Health Plan requires patients undergoing these procedures must be 14 years old. However, removal of the supernumerary teeth is indicated prior to closure of the apex of the central incisors which usually occurs between the ages of eight and nine. The literature demonstrates that supernumerary teeth are common causes for delayed eruption of maxillary incisors. Well accepted approaches to the management of these teeth include removal when it is clear that the eruption of the central incisors will be blocked and before the apex of the permanent incisor is complete. The records provided demonstrate that the supernumerary teeth in this patients case were impeding the eruption of teeth #8 and #9. Given this information, the removal of this patients supernumerary teeth was reasonable and necessary. Final Result: The reviewer determined that the services at issue were dentally necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in oral facial and maxillary 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

A 62-year-old male enrollee has requested radiofrequency bipolar ablation  right, sacral S1, S2, S3, and L5 for treatment of his back pain.  Findings:  Two physician reviewers found that in a study authored by Cohen and colleagues evaluating lateral branch radiofrequency denervation for SI joint pain, the authors indicate that, larger studies are needed to confirm these results and to determine the optimal candidates and treatment parameters for this poorly understood disorder. Further, Rupert and colleagues concluded that, the evidence for radiofrequency neurotomy is also limited (level II-III). All told, this request is not supported by long-term studies documented in the peer-reviewed medical literature and is not likely to provide this patient with a superior outcome when compared to standard therapies.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested authorization and coverage for 20 hours per week of direct applied behavioral analysis (ABA) therapy, six hours per month of supervision and one hour per month of parent training for treatment of the enrollees autism spectrum disorder.Findings:  The physician reviewer found that a study found that children with autism who started ABA therapy at an earlier age and had intensive ABA were more likely to have an optimal outcome. The study also found intensive behavioral treatment for children with ASD was effective. Another study found that ABA was effective for disruptive behaviors in children in public school. In this case, 20 hours per week of direct ABA therapy is medically necessary due to the patients maladaptive behaviors that include aggression, non-compliance and vocal protest. In addition, he has trialed multiple medications for treatment of his maladaptive behaviors with only some improvement. 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 pediatrics with sub-specialty certification in developmental-behavioral pediatrics 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 patient is a 44-year-old woman first diagnosed with breast cancer in 2002. She was initially treated with surgery, radiation therapy and chemotherapy with doxorubicin and Cytoxan, followed by Taxotere. In June 2005 the patient was found to have rising markers, indicative of recurrent breast cancer. Treatment with Herceptin and Avastin was not effective, and she was begun on Abraxane in November 2005. This did produce a lowering of her tumor markers, though they have been rising since discontinuation of the Abraxane. At issue is whether Abraxane was medically necessary for treatment of the patients medical condition.Abraxane is a form of Taxol and has been approved for use in cases involving women with metastatic breast cancer after a failure of combination chemotherapy for metastatic disease and/or relapse after adjuvant chemotherapy including an anthracycline. This patient had progression of metastatic disease after combination chemotherapy. Furthermore, she had adjuvant therapy including an anthracycline (doxorubicin). Therefore, her treatment with Abraxane was medically necessary and within current approved guidelines for metastatic breast cancer.For the reasons set forth above, I have determined the therapy at issue was medically necessary for treatment of the patients medical condition. The Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Synvisc-One (hyaluronic acid) injection. Findings:  The physician reviewer found that while there is medical literature to support hyaluronic acid as a pharmacologic intervention for knee osteoarthritis, there is insufficient evidence for its use for the treatment of other conditions, including osteochondritis dissecans. This patient presents with persistent and worsening left knee pain, following a left knee arthroscopy and partial medial meniscectomy. Clinical examination findings are consistent with imaging evidence of osteochondritis dissecans over the medial femoral condyle and x-ray evidence of mild left medial compartment osteoarthritis. Current peer reviewed literature supports the use of hyaluronic acid as a better option than corticosteroid injections for the treatment plan knee osteoarthritis. However, current evidence based medical guidelines recommend the use of hyaluronic acid injections for severe osteoarthritis and not for osteochondritis dissecans. There is no compelling rationale presented to support the medical necessity of this request for treatment of her left knee pain, which is primarily associated with osteochondritis dissecans and in the setting of mild osteoarthritis. Therefore, the request for Synvisc-One (hyaluronic acid) injection is not medically necessary for the treatment of this patients medical condition. 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 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.