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

A 53-year-old female enrollee has requested adult substance abuse sub-acute/residential treatment center rehabilitation services for the treatment of her behavioral health problems. Findings:  The physician reviewer found that the submitted clinical evidence demonstrates that the patient had been drinking heavily for some years and was depressed. She entered a detoxification program which appears to have been successful. Shortly after completing detoxification, she entered the substance abuse sub-acute/residential treatment center. At this time, she was not psychotic, homicidal or suicidal. She was not experiencing any particular medical problems. She had gained some limited degree of control of her drinking. She had remained sober from the time of discharge from the detoxification center to the night before admission to the residential facility when she reported relapsing. This was an eleven-day period of sobriety that took place without any documented supervision. She had a family member who was positively involved in her care. In the recent past, the patient failed to respond favorably to basic outpatient treatment, including the use of antidepressants and Campral. However, she had not attempted care in an intensive outpatient program, nor had she been treated in a partial hospital program. All told, the patient did not require 24/7 professional care and observation during the period at issue. She could have been safely and effectively treated at a less intensive level of care.
Appeal type: Medical Necessity
Decision: Upheld

A 51-year-old male has requested a Lap-band procedure for treatment of obesity.  Findings:  The physician reviewer found that the patient does not meet nationally accepted medical necessity criteria for consideration of weight loss surgery despite his comorbidities. There is potential that further attempts at conservative weight loss will be successful. Furthermore, as the patient has the potential for further weight loss through conservative means, the risks of weight loss surgery outweigh the potential benefits of the procedure.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested sofosbuvir/velpatasvir (Epclusa 400-100 mg) for treatment of the enrollees hepatitis C.  Findings: The physician reviewer found that according to joint guidelines issued by the American Association for the Study of Liver and the Infectious Diseases Society of America, all patients with chronic hepatitis C should be treated except those with life expectancy less than 12 months due to non-liver-related conditions.  Per the guidelines, patients with cirrhosis are high priority for treatment.  Per the guidelines, Epclusa for 24 weeks is recommended as first-line therapy for ribavirin-ineligible genotype 3 patients with decompensated cirrhosis.  This patient is ribavirin-ineligible due to anemia.  For these reasons, sofosbuvir/velpatasvir (Epclusa 400-100 mg) for 24 weeks is medically indicated for the treatment of this patient.Final Result: The reviewer determined that the requested medication regimen 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 sub-specialty certification in gastroenterology 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 authorization and coverage for Orthovisc (hyaluronan) injections series to both knees. Findings:  The physician reviewer found that Evidence from systematic reviews and randomized controlled trials indicate that although viscosupplementation may relieve knee pain in some patients with osteoarthritis, data has not established which patients will benefit. Guidelines from the American Academy of Orthopedic Surgeons (AAOS) indicate that the data on safety and efficacy of viscosupplementation remain inconclusive. As such, the AAOS does not currently recommend viscosupplementation as standard treatment for osteoarthritis of the knees. Viscosupplementation is reserved for patients with a history of lasting benefit from prior injections and in cases where the remaining options are limited. In this case, the patient presents with a history of osteoarthritis of both knees primarily involving the patellofemoral joints which has not improved despite arthroscopic debridement and chondroplasties. However, the patient benefitted from viscosupplementation on multiple occasions since 2011. The last series of injections were given in October 2019. In light of the patients recurrent bilateral knee pain, the provider has recommended repeat viscosupplementation with Orthovisc injections. Given the current support in the medical literature, the requested Orthovisc (hyaluronan) injections series to both knees are medically necessary for treatment for this patient. Final Result: The reviewer determined that the requested services are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in 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: Experimental/Investigational
Decision: Upheld

A 20-year-old male paraplegic has requested authorization and coverage for an Easy Stand Glider.  Findings:  Two physician reviewers found that the Easy Stand Glider shows considerable promise in that it may well improve upper body strength, lower extremity circulation and decrease the chance of pressure ulcers. Based on the current peer-reviewed medical literature, there is some evidence which suggests that the Easy Stand Glider may improve activity and function. However, there is not yet sufficient scientific evidence to demonstrate that the Easy Stand Glider is superior to available standard wheelchairs.
Appeal type: Medical Necessity
Decision: Overturned

The patient has requested authorization and coverage for facial feminization surgeries. 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. WPATHs SOC further noted that, other surgeries for assisting in body feminization includerhinoplastyfacial bone reduction, face-lift, and blepharoplasty. This patients providers report that the patient experiences anxiety and depression from the presence of masculine facial features. The patient is committed to feminine transformation, given her treatment history with hormone therapy. The patient meets the WPATH criteria for gender dysphoria and indication for facial feminization surgery based upon clinical documentation of persistent gender dysphoria related to masculine facial features associated with social dysfunction. The requested facial feminization surgeries are medically necessary to help alleviate the patients gender dysphoria and related distress. Therefore, the requested facial feminization surgeries are medically necessary for treatment of this patient. Final Result: The reviewer determined that the requested services are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in 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: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for single photon emission computed tomography (SPECT) brain scan (procedure code 78607).Findings:  Three physician reviewers found that the patient was evaluated for mood changes and irritability, for which SPECT study was performed. While SPECT scanning has shown promise in the evaluation of several neurological conditions, routine use of SPECT scans for diagnosis and treatment is yet to be established in this clinical setting. There is a lack of support for SPECT scans for neuropsychiatric disorders without evidence of cerebrovascular disease. In sum, SPECT brain scan (procedure code 78607) was not likely to have been more efficacious than other methods of evaluating this patient. Final Result: The 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 1, 2 and 3 are board certified in diagnostic radiology 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

The patient is a 51-year-old female who has been diagnosed with a meniscal tear and osteochondral lesion of the medial femoral condyle. She underwent arthroscopic surgery in October 2004. Post-operatively she was also diagnosed with grade 3-4 chondral lesion of the medial femoral condyle. Her physician has suggested orthovisc injections. The Health Plan has determined orthovisc injections are not medically necessary for treatment of the patients medical condition.The patient has been diagnosed with a meniscal tear and osteochondral lesion of the medial femoral condyle. Orthovisc injections are appropriate for refractory cases of osteoarthritis. There is no data to suggest or support the use of orthovisc injections with osteochondral deficits of the knee with meniscal pathology. Furthermore, there is no data to support the use of orthovisc injections as post-operative care after arthroscopy for meniscal and condyle deficits. Therefore, I have determined that the requested injections are not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld

A 53-year-old female has requested coverage for a past bilateral breast MRI for evaluation of her breast pain.  Findings:  The physician reviewer found that this patient presented with right breast pain with a history of breast implants, and no breast abnormalities were noted on physical examination.  She was referred for a breast MRI as a screening study for breast cancer and also as a diagnostic study to evaluate the patients right breast pain.  Per the submitted records, the patient did not undergo a recent mammography or breast ultrasound prior to the MRI study.  Patients who have breast implants can safely undergo mammography, and mammography is the gold standard for screening of breast cancer and to evaluate breast abnormalities and/or breast symptoms.  The indications for a screening breast MRI are well-established in the peer-reviewed medical literature.  The American Cancer Society has published guidelines for screening breast MRI which include patients who are at high-risk of developing breast cancer.  Screening breast MRI studies are utilized in conjunction with mammography.  This patient has a calculated lifetime risk of developing breast cancer of 9.6%.  She has no personal or family history of BRCA mutation.  The patient has no history of radiation therapy to the chest wall.  Therefore, she does not meet the established criteria for screening breast MRI.  In addition, breast MRI is not to be used in lieu of mammography for breast cancer screening. In regards to a diagnostic breast MRI, this patient does not meet the established guidelines for a diagnostic breast MRI.  The American College of Radiology and American Society of Breast Surgeons recommend the use of diagnostic breast MRI for the evaluation of an inconclusive finding following standard evaluation (this includes physical examination, mammogram, and breast ultrasound), for evaluation of patients with a new diagnosis of breast cancer, for patients with a prior diagnosis of breast cancer when there is concern of scar tissue versus recurrent breast cancer, to evaluate patients with suspected ruptured breast implants, and for evaluation of patients with positive axillary lymph nodes for breast cancer with negative mammography.  This patient does not have an inconclusive finding following standard evaluation.  She does not have a new diagnosis of breast cancer or a prior personal history of breast cancer.  The patient does have breast implants, but there is no clinical evidence of suspected implant rupture.  Therefore, this patient does not meet the established criteria for a diagnostic breast MRI.
Appeal type: Medical Necessity
Decision: Upheld

A male enrollee requested a wireless capsule endoscopy for medical evaluation of his history of intestinal tuberculosis and small bowel obstruction.  Findings:  The physician reviewer found that wireless capsule endoscopy of the small bowel may be indicated to diagnose the site of obscure gastrointestinal bleeding in adults, confirm suspected Crohns disease, and evaluate small bowel tumors. This patients records do not include documentation of any of these indications. In addition, the provider noted concern for a possible stricture, which places the patient at risk for capsule retention. Further, a wireless capsule endoscopy will not allow the provider to obtain a culture which is required to support the diagnosis of intestinal tuberculosis. All told, the requested wireless capsule endoscopy is not medically necessary for evaluation of this patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld

A 37-year-old male enrollee has requested coverage for hernia surgery for treatment of his bilateral inguinal hernias. Findings:  The physician reviewer found that there is no evidence that the inguinal hernia is causing his pain or contributing to any gastrointestinal symptoms.
Appeal type: Experimental/Investigational
Decision: Overturned

A 58-year-old male enrollee has requested for helical tomotherapy intensity modulated radiation therapy for treatment of his stage IIIB non-small-cell lung cancer of the left lung. Findings:  Two physician reviewers found that pre-clinical dosimetry studies have not demonstrated that IMRT increases the lung volume. A recent study by Sura and colleagues confirms the efficacy and tolerability of IMRT with lung cancer. Indications for IMRT include unfavorable tumor geometry, proximity of the tumor to critical organs and/or small lung volumes. This patient has tumors in close proximity to critical organs and arguably the total extent of the tumor (large cranial-caudal extent) represents unfavorable geometry. Tomotherapy is well-suited for this particular case since the patient has a large extent of disease in the cranial-caudal direction.
Appeal type: Experimental/Investigational
Decision: Overturned

The enrollee requested authorization and coverage for a right hip sacroiliac joint fusion. The enrollee has severe and persistent bilateral back and buttock pain, appearing to originate from the sacroiliac joint. Due to persistent pain and failure of conservative treatment, sacroiliac joint injection was recommended for diagnostic and therapeutic reasons. This was performed and provided complete pain relief for one day; afterwards, the pain slowly returned. The symptoms are worsening, despite anti-inflammatory medication. She attended four to five sessions of physical therapy, but stated the therapy aggravated her pain. The orthopedic surgeon believes sacroiliac joint fusion would benefit her. Literature shows surgical fusion of the sacroiliac joint is an option for those who have not improved with comprehensive, non-operative treatment. Minimally invasive surgery has yielded good outcomes, high satisfaction, and lower morbidity and earlier recovery than traditional open approaches. Additionally, minimally invasive sacroiliac joint fusion has become the preferred intervention because it has demonstrated superior outcomes to open sacroiliac joint fusion and non-operative care.   Final Result: Three of the three reviewers determined that the requested services are likely to be more beneficial than any available standard therapy for treatment of the enrollees medical condition. Credentials/Qualifications: Three reviewers are board certified in orthopedic surgery 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: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for LINX procedure - laparoscopy, surgical, esophageal sphincter augmentation procedure, placement of sphincter augmentation device (CPT 43284). The current medical literature lacks randomized controlled clinical trials with long-term follow-up demonstrating that LINX is safer or more effective than standard surgical anti-reflux procedures. One evidence review concluded that the long-term safety and efficacy of LINX  both alone and in comparison to current GERD therapies - remains to be determined (Sheu and Rattner). Another best-evidence review concluded that long-term comparative outcome data past one year are needed in order to further understand the efficacy of magnetic sphincter augmentation (Skubleny, et al.). When compared to surgical fundoplication, LINX has been associated with severe dysphagia requiring endoscopic intervention (Sheu, et al.). The currently available peer-reviewed literature does not support the conclusion that LINX is more likely to be beneficial for this patients GERD than standard treatment including surgical fundoplication. For these reasons, the requested LINX procedure - laparoscopy, surgical, esophageal sphincter augmentation procedure, placement of sphincter augmentation device (CPT 43284) is not 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 LINX procedure - laparoscopy, surgical, esophageal sphincter augmentation procedure, placement of sphincter augmentation device (CPT 43284) is not 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 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 subspecialty certification in gastroenterology and are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

A 58-year-old male enrollee has requested a positron emission tomography/computed tomography scan for evaluation of his oral pharynx cancer. Findings:  The physician reviewer found that in clinical practice, it is widely accepted that PET/CT is a more sensitive test with which to diagnose head and neck tumor recurrence than any other stand alone imaging modality. In addition, the goal in treatment is to detect tumor recurrence prior to manifestation of symptoms in order to improve the patients prognosis. PET/CT plays a crucial role in the detection of metastatic disease or local recurrence in head and neck malignancies and is the standard of care. Schoder and colleagues found in their study of 68 patients that, PET/CT images were essential in determining the exact anatomic location for 100 lesions. The authors concluded that, PET/CT is more accurate than PET alone in the detection and anatomic localization of head and neck cancer and has the clear potential to affect patient care. For these reasons, the performance of a PET/CT scan in this patient more than one year after the most recent imaging study is medically reasonable and should be approved.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary:   An enrollee has requested shoe inserts and orthopedic footwear for treatment of the enrollees medical condition.  Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested equipment.  Per current guidelines, inserts and shoe modifications are medically indicated if they are on a shoe that is an integral part of a medically necessary leg brace, if they are medically necessary for the proper functioning of the brace.  There is a lack of support for the requested shoe inserts and orthopedic footwear in this patients case.  The shoes recommended by the provider appear to be standard over-the-counter sneakers, and the recommended insoles are also over-the-counter standard insoles.  All told, the requested shoe inserts and orthopedic footwear are not medically indicated for the treatment of this patient.   Final Result: The reviewer determined that the requested equipment 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 podiatry 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.