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

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for physical therapy. Findings:  The physician reviewer found that there is no one surgical technique or protocol that has been established to address each combination of prognostic factors for recovery following rotator cuff repair surgery. Coda and colleagues found that although certain rehabilitation components are common, such as duration of passive range of motion and sling or immobilizer use, a large degree of variation remains among published rehabilitation protocols after rotator cuff repair. Post-operative physical therapy can be beneficial. The goal of physical therapy is to transition to an independent home exercise program without continued dependence on supervised therapy. The records provided for review document that this patient has undergone prior extensive physical therapy. The patient has been educated in a home exercise program and has requested additional physical therapy. However, the patients expected rehabilitation potential is not significant in relation to the extent and duration of the physical therapy services requested. The specialized skill of a qualified therapist is not required to establish, design or deliver a maintenance program to maintain the patients current condition or to prevent or slow further deterioration. The patient can continue her home exercise program and follow up with her provider for further evaluation and management of her symptoms. All told, the requested physical therapy is 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 physical medicine and rehabilitation with subspecialty 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 patient is a 66-year-old man with cirrhosis and a single hepatocellular carcinoma of the left lobe of the liver. He has a history of severe portal hypertension secondary to his cirrhosis and has had esophageal variceal bleeding. The patient underwent two banding procedures for his esophageal varices without recurrent upper gastrointestinal bleeding. In November 2003, the patient was found to have two hepatic masses on CT scan. By report, a biopsy was performed that documented hepatocellular carcinoma. An MRI was performed on 2/4/04 that revealed only a single lesion in the left lateral segment, cirrhosis, and evidence of portal hypertension. There was no ascites noted.In March 2004, the patients surgeon recommended a transjugular intrahepatic portosystemic shunt (TIPS) procedure prior to surgical resection of the isolated hepatoma. Based upon the information provided, it appears the TIPS procedure has been requested as a preoperative measure to control the patients portal hypertension and is not directed at management of the esophageal varices or any potential ascites. The Health Plan had denied authorization and coverage for the requested TIPS procedure.Hepatic resection in patients with portal hypertension can be quite difficult with complications related to bleeding from the liver surface. It has been clearly demonstrated that combined portal decompression procedures (i.e., portosystemic shunts) with hepatic resections reduce operative complications. However, these reports primarily used operative shunts. There are case reports that have been published using TIPS preoperatively rather than surgical decompressive shunts in patients undergoing major upper abdominal surgery or liver resection. The ability of TIPS to decompress the portal system in patients with portal hypertension from cirrhosis has clearly been established. Therefore, it is medically appropriate to use the TIPS procedure preoperatively in those patients who have portal hypertension and are to undergo major hepatic or upper abdominal surgery. This preoperative maneuver is expected to decompress the portal venous system and therefore, reduce intraoperative and postoperative bleeding complications.Based upon the information set forth above, I have determined that the requested procedure is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested a positron emission tomography (PET) scan of the brain. Functional neuroimaging such as PET scanning is used in several disease processes including frontotemporal dementia but are not alone diagnostic. In the setting of corticobasilar degeneration diagnosis is achieved through clinical measures and tissue analysis. There is evidence to support that PET imaging can provide additional insight into the evaluation of certain neurocognitive disorders. However, the records do not support that PET imaging was indicated in lieu of standard testing for evaluation of this patients medical condition. All told, the PET scan of the brain performed was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Findings:  Two of the three physician reviewers found the PET scan of the brain was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the services at issue were not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: Physician reviewer 1 is board certified in neurology with subspecialty certification in neuromuscular medicine and is actively practicing. Physician reviewer 2 is board certified in neurology with subspecialty certification in vascular neurology and is actively practicing. Physician reviewer 3 is board certified in neurology and is 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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for topical compound cream Keto/Keta/Cyclo/Lido/Gaba. In the documentation available for review, not all the standard treatment options for fibromyalgia have reportedly been tried and failed. In addition, topical anti-inflammatory agents have not been demonstrated to be more efficacious than oral anti anti-inflammatory agents in the treatment of fibromyalgia. Researchers concluded that more studies are needed for elucidation of the role of topical analgesics and their effects, especially when combined with other treatments. Finally, not all of the components of the requested compound medication have significantly better concentrations in topical form when compared with oral alternatives. For these reasons, the requested topical compound cream Keto/Keta/Cyclo/Lido/Gaba is not medically necessary for treatment of the patients medical condition. Final Result: The reviewer determined that the requested medication 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 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: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for advanced lipoprotein testing for evaluation of the enrollees medical condition.   Findings:  The physician reviewer found that in this circumstance, primary prevention guidelines for the management of cardiac risk and dyslipidemia have been established, are periodically updated by expert committees, and are endorsed by several national organizations.  These guidelines currently do not recommend routine performance of specialized tests in the context of assessing coronary risk including lipoprotein-associated phospholipase A2 (Lp-PLA2), sub-classifications of low-density lipoprotein (LDL), high-density lipoprotein (HDL) subclasses, lipoprotein (a), C-reactive protein, insulin, insulin resistance testing, fibrinogen, genetic testing and homocysteine.  Treatment change or addition based on the results of screening with these specialized tests has not been shown to improve cardiac outcome incremental to that achievable by treatment based on standard risk factor profiling and basic lipid analysis.  Although results of some of these specialized tests may be abnormal and considered independent risk markers for coronary disease, there is a lack of controlled trials that demonstrate outcome benefits by treating routinely obtained abnormal results.  Final Result: All 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: Physician reviewers number one, two, and three are board certified in internal medicine with sub-specialty certification in cardiovascular disease and are actively practicing. The reviewer 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: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the bilateral digital breast tomosynthesis for evaluation of the enrollees breast exam. Findings:  2/3 of the physician reviewers found that there is sufficient support in the peer-reviewed literature for the diagnostic procedure at issue in the routine screening population. According to the study by colleagues, the addition of breast tomosynthesis reduces false positives and increases cancer detection when compared to two-dimensional mammography alone. In addition, Detection rates, including those for invasive and in situ cancers, were 6.1 per 1000 examinations for mammography alone and 8.0 per 1000 examinations for mammography plus tomosynthesis. Given the support above, the bilateral digital breast tomosynthesis performed was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Final Result: 2/3 of the reviewers determined that the diagnostic procedure at issue was 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 reviewer number one is board certified in diagnostic radiology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.Physician reviewer number two is board certified in diagnostic radiology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.Physician reviewer number three is board certified in diagnostic radiology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for digital breast tomosynthesis for evaluation of enrollee, who was breastfeeding.  Findings:  Three 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, her breasts were described as heterogeneously dense.  This is common when breastfeeding, but if there is a question of an underlying breast abnormality (which could include an abscess), it is specifically those patients who have dense breasts that can benefit most from tomosynthesis.   The ability to separate out the overlapping structures enables the possibility of demonstrating an otherwise occult tumor or abscess. Final Result: The reviewers determined that the service at issue was 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: Reviewers 1, 2, and 3 are board certified in diagnostic radiology and is 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: Experimental/Investigational
Decision: Upheld

A 59-year-old female enrollee has requested the X-Stop procedure for the treatment her lumbar spondylolisthesis. Findings:  Two physician reviewers found that there is no outcome data to demonstrate that the X-Stop procedure is more effective for treatment of degenerative spondylolisthesis than laminectomy and fusion.  Laminectomy and fusion is the gold standard procedure for the patients condition. More outcome data is needed to establish the X-Stop procedure as an effective, long-term treatment for this diagnosis. Additionally, outcome data showing that the X-Stop procedure is more effective than laminectomy and fusion is lacking.
Appeal type: Medical Necessity
Decision: Overturned

The patient is a 27-year-old female with a body mass index (BMI) of 45. She has failed numerous attempts at conservative weight loss. The patient has undergone a psychological evaluation and is an appropriate candidate for weight loss surgery. The Health Plan has denied coverage for gastric bypass surgery on the basis that it is not medically necessary for treatment of the patients morbid obesity.With a BMI of 45 the patient meets nationally accepted medical necessity criteria for consideration of weight loss surgery. The patient has undergone a psychological evaluation and is considered an appropriate candidate for weight loss surgery. It is unlikely the patient will be able to lose weight and maintain the weight loss through non-surgical means. Furthermore, there is no scientific evidence demonstrating that structured diet or exercise plans have been successful in the treatment of the obese. In fact, the Swedish obesity study identifies that even though there may be reduction or resolution of some symptoms with diet and exercise, surgery has the longest and best long-term outcome for the obese. Therefore, I have determined that the requested procedure is medically necessary for treatment of the patients medical condition. The Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for modafinil 100 mg tablets. Consistent with data reported by the American Academy of Sleep Medicine (AASM), the U.S. Food and Drug Administration (FDA) has approved modafinil for the treatment OSA patients who have sleepiness despite effective CPAP treatment and lack any other identifiable cause for their sleepiness. This patient has a history of OSA that has partially responded to CPAP use. However, the patient has continued to report daytime sleepiness with use of CPAP. The patient did reportedly experience improvement in her daytime sleepiness with modafinil. Given these findings, the requested modafinil 100 mg tablets are medically necessary for treatment of this patient. 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 internal medicine with subspecialty certification in sleep 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: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for hormone implants (subcutaneous testosterone implants), codes S0189, 11980 and J3490. Findings:  Three physician reviewers found that the diagnosis of testosterone deficiency is not well-defined in women, as there is a lack of biochemical criteria for this diagnosis. Current guidelines recommend against the generalized use of testosterone. Testosterone replacement therapies in postmenopausal women are not approved by the U.S. Food and Drug Administration (FDA) because of limited clinical trial data, limited efficacy compared with placebo and concerns regarding long-term safety. In sum, the superior effectiveness of hormone implants (subcutaneous testosterone implants), codes S0189, 11980 and J3490 has not been established. Final Result: The reviewers determined that the services at issue were not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: Physician reviewers 1, 2 and 3 are board certified in internal medicine with sub-specialty certification in endocrinology, diabetes and metabolism 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 59-year-old female enrollee has requested a Lap-Band procedure for treatment of her obesity. Findings:  The physician reviewer found that the submitted documentation fails to establish the medical necessity of the requested procedure at this time. In order to establish the medical necessity of the Lap-Band procedure, a thorough evaluation is indicated. Specifically, a dietary evaluation, psychological evaluation and medical clearance must be obtained prior to proceeding with the requested surgery. There must be documentation that treatable metabolic causes of obesity have been ruled out.  The medical records provided do not demonstrate that these evaluations have been performed.  All told, the requested Lap-Band procedure is not medically indicated at this time.
Appeal type: Experimental/Investigational
Decision: Upheld

A 30-year-old female has requested coverage for osteoarticular transfer system procedure (OATS) for treatment of her osteochondritis dissecans.  Findings:  Two physician reviewers found that the patient underwent partial medial and lateral meniscectomy, abrasion arthroplasty and drilling of the defect, reconstruction extra- and intra-articular of the medial patellofemoral ligament, multicompartmental synovectomy, and chondroplasty. At this time, she has requested authorization and coverage for osteoarticular transfer system (OATS) procedure. Although the results of retrospective or case series studies on the OATS procedure are encouraging, well designed prospective trials with long-term follow-up are lacking to establish the durability of the repair and transplanted tissue. Further, long-term data are still needed to determine the effects of the OATS procedure on the development of osteoarthritis of the knee and results compared to standard treatments such as abrasion arthroplasty. For these reasons, the OATS procedure is unlikely to provide this patient with superior results beyond that expected with conventional modalities.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for mastectomy simple complete (CPT 19303 x 2) and nipple/areola reconstruction (CPT 19350 x 2) surgeries. The American Psychiatric Association (APA) including non-binary patients in the diagnosis of gender dysphoria. The World Professional Association for Transgender Health (WPATH) Standards of Care (SOC) acknowledges that, For certain patients, an intervention like a reduction rhinoplasty can have a radical and permanent effect on their quality of life, and therefore is much more medically necessary than for somebody without gender dysphoria. WPATH supports medical and surgical treatments for gender dysphoria in the presence of persistent, well-documented gender dysphoria (Coleman, et al.). This patient has persistent, well-documented gender dysphoria, and meets the WPATH criteria for chest surgery. Given these findings, the mastectomy simple complete (CPT 19303 x 2) and nipple/areola reconstruction (CPT 19350 x 2) surgeries were medically necessary for 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 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.