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

The enrollee has requested reimbursement for fertility preservation services received. The Health Plan has denied the services at issue as not medically necessary.The American College of Obstetricians and Gynecologists (ACOG) indicates that an important clinical predictor of outcomes in the observational studies of oocyte preservation and in-vitro fertilization is the age of the oocyte when frozen or vitrified. Outcomes of four published randomized controlled trials demonstrated that fresh and frozen oocytes yield similar pregnancy rates in in-vitro fertilization cycles, supporting the use of these technologies in well-selected patients aged 35 years and younger. The medical records for this female patient indicate that cryopreservation of oocytes was performed at the age in anticipation of breast cancer therapy. However, the age exceeds the currently recommended limit for oocyte cryopreservation because this age is already subject to primary ovarian insufficiency and aneuploidy. Final Result: The reviewer determined that the services at issue were 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 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

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the positron emission tomography/computed tomography (PET/CT) scan. Findings:  Three physician reviewers found that in this patients case, the guidelines do not support the efficacy of the PET/CT scan at issue. This patient presented with an incidental finding of a 4 mm pulmonary nodule, noted on a CT scan. The Society of Thoracic Imaging and Diagnosis, otherwise known as the Fleischner Society, is a well-known organization that has established guidelines for the evaluation of incidentally detected pulmonary nodules. These evidence based guidelines were revised in 2017 and are widely used throughout radiology.  For incidentally detected nodules that are greater than 8 mm, the Fleischner Society guidelines call for either a follow up CT scan in three months, and/or a PET/CT, and/or a biopsy.  For a nodule detected incidentally that measures less than 6 mm, in low risk patients, the Society does not recommend any further evaluation. In high risk patients, the Society recommends an optional CT scan in 12 months.  For nodules between 6 to 8 mm, follow up CT scans are recommended between 6 to 12 months. The National Comprehensive Cancer Network (NCCN) also has issued guidelines based on the National Lung Screening Trial (NLST) which also suggests that PET/CT scanning is only appropriate for solid nodules greater than 8 mm in diameter. In this patients case, the records do not show whether he is a low or high risk patient. His nodule was measured at 4 mm. Thus, a PET/CT scan would not be routinely performed under both the Fleischner Society and the NCCN guidelines. Final Result: 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: All three physician reviewers 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: Experimental/Investigational
Decision: Overturned

A 61-year-old female enrollee has requested for positron emission tomography for evaluation of her history of uterine carcinosarcoma.  Findings:  Three physician reviewers found that uterine carcinosarcomas are rare and highly aggressive tumors with a poor prognosis.  As noted by Khan and colleagues, PET scanning is a reliable and accurate diagnostic method for detecting recurrent or metastatic gynecologic cancer, particularly lymph node metastases.  In this patients case, her provider followed the National Comprehensive Cancer Network guidelines by obtaining a follow-up CT scan.  He then detected an abnormality, and to resolve whether the adenopathy was significant, he obtained a PET scan.  The initial PET scan revealed metabolically active nodes.   In this clinical setting, the provider could have either started chemotherapy empirically or he could have repeated the PET scan to confirm the activity and to direct a surgeon to biopsy a specific node.  In this patients case, the PET scan allowed the patient to avoid invasive surgery or chemotherapy.  Thus, the PET scan was likely to have been more efficacious than other methods of evaluating this patient.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement and prospective authorization and coverage for inpatient medical/surgical treatment. The records provided for review document that this patients wound care has required the use of a wound VAC that is changed every three days. He is also receiving three parental antibiotics that will be ongoing until six to eight weeks after the wound closes. He requires skilled physical and occupational therapy for activities of daily living and a Clinitron bed. He is non-weight bearing on the left lower extremity. Documentation shows an improving wound bed without evidence of acute infection or exposed bone. The providers progress notes indicate that the patient has been afebrile and hemodynamically stable. He is tolerating oral analgesics and oral nutrition without complications. The patient continues to require physical and occupational therapy, wound care every three days and daily parental antibiotics. The records do not support the medical necessity of inpatient medical/surgical treatment for management of this patients medical condition. The patients laboratory values are stable and improving, which suggests that the infection is being appropriately treated. Parental antibiotics and a wound VAC do not require inpatient hospitalization. All told, inpatient medical/surgical treatment was not and is not medically necessary for 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 internal 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 39-year-old female with neck pain that radiates to the right shoulder and arm. She has evidence of cervical disc disease. The patient has had symptoms for many years and has had a course of conservative treatment that has included medications, splints, and therapy. She has continued pain. A request has been made for anterior cervical discectomy and fusion. The Health Plan has determined the requested procedure is not medically necessary.While the MRI does not reveal a large disc herniation, the patient has radicular complaints and chronic pain. The patient has elected to proceed with surgery. The patient has attempted and failed conservative therapy. It is unlikely that further conservative therapy will be beneficial for the patient. It is likely that she will continue to have pain. Furthermore, she meets accepted criteria for consideration of cervical discectomy and fusion. 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 a L4-L5 artificial disc replacement surgical procedure (CPT 22857). The submitted documentation supports the medical necessity of the requested service. The U.S. Food and Drug Administration (FDA) has approved ProDisc-L total disc replacement for spinal arthroplasty in skeletally mature patients with degenerative disc disease (DDD) at one or two consecutive levels from L3 to S1. The FDA further notes that the patient should have no more than grade 1 spondylolisthesis at the involved level(s) and have failed at least six months of conservative treatment. The FDA notes that contraindications include active systemic or site infection, osteopenia or osteoporosis, bony lumbar spinal stenosis, isolated radicular compression syndromes especially due to disc herniation, and pars defect. In a follow-up at the five-year mark of 236 patients who underwent either ProDisc-L total disc replacement (TDR) or fusions, researchers noted that the TDR group had significantly better improvement on some scales, and while TDR patients avoid the stiffness of fusion and are more satisfied than fusion patients, both fusion and TDR were reasonable surgical options in this specific patient population. In this case, the patient is being treated for low back pain. Recent records noted that the patient had developed urinary urgency. She also reported increased pain involving the lower back and legs. There is sufficient support for the requested service in this clinical setting. Therefore, the requested L4-L5 artificial disc replacement surgical procedure (CPT 22857) is medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested service 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 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 authorization and coverage for Gamunex-C infusions every four weeks at an outpatient hospital infusion center. This patient has clinical findings consistent with common variable immune disease (CVID) and requires immunoglobulin replacement therapy to reduce her risk of infections. Per her provider, she has a history of frequent adverse reactions to previous infusions for her diagnosis of rheumatoid arthritis. Moreover, the patient has experienced issues with her providers obtaining peripheral access and she has required use of ultrasound guidance. During her first infusion of Gamunex-C, she reported pain at the infusion site as well as significant headaches. Given the patients response to her first infusion of Gamunex-C, it is appropriate to administer her IVIG at an outpatient infusion center where she can be closely monitored and evaluated throughout the infusion process. All told, the requested Gamunex-C infusions every four weeks at an outpatient hospital infusion center 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 internal medicine with subspecialty certification in allergy and immunology 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: An enrollee has requested authorization and coverage for phentermine. Findings:  The physician reviewer found that The request for phentermine has not been established as medically necessary for treatment of the patients medical condition. The decision to initiate drug therapy in overweight patients should be made only after a careful evaluation of risks and benefits. The first step is evaluation of the patient, which should include determination of the body mass index (BMI), the distribution of fat based upon the waist circumference, and investigations for comorbid conditions such as diabetes mellitus, dyslipidemia, hypertension, heart disease, sleep apnea, and symptomatic osteoarthritis. According to studies Anti-obesity drugs can be useful adjuncts to diet and exercise for adults with obesity and a BMI greater than 30 kg/m2, who have failed to achieve weight loss goals through diet and exercise alone. In this case, the patients BMI is 29.9 kg/m2 previously which was the last documentation of her weight provided for review. More recently, a telephone appointment reports that she tried phentermine in the past but has not been able to sustain weight loss and has requested another course. There is no documentation of current weight, BMI, blood pressure and cardiovascular exam provided. Phentermine is to be prescribed with careful evaluation of the patients obesity, comorbidities, cardiovascular risk and follow up visits. Evaluation for conditions contributing to obesity should be performed. The patient should be evaluated for obesity management where the goals of therapy, treatment options for long-term management are discussed and informed. In sum, phentermine 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 physician reviewer is board certified in internal medicine with sub-specialty certification in endocrinology, diabetes and metabolism 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 40-year-old female has requested coverage for panniculectomy, abdominoplasty, and rectus diastasis repair for treatment of her excess skin following gastric bypass surgery.  Findings:  The physician reviewer found that the overlap of the lower abdominal pannus as seen in the photographs and clinically documented would be considered an abnormal enlargement of the abdominal skin. Obesity can be considered a disease and would thus have led to the abnormal overlapping of the abdominal skin that worsens with correction of the underlying disease. In addition, the requested surgery is being performed to improve function and would create a normal appearance to the extent possible. The patients records from more than one provider describe the presence of functional problems as a result of the overlapping skin. The photographs support this as well. The functional problems documented include rashes, dermatitis, malodor and causing discomfort with physical activity. Each of these complaints is a known problem associated with an abdominal pannus following severe weight loss. The American Society of Plastic Surgeons (ASPS) has addressed this issue and noted that, When surgery to remove extensive skin redundancy and fat folds is performed solely to enhance a patients appearance in the absence of any signs or symptoms of functional abnormalities, the procedure should be considered cosmetic in nature and not a compensable procedure. For example, a panniculectomy to eliminate a large hanging abdominal panniculus and its associated symptoms would be considered reconstructive. Based on the documentation provided, there is no evidence that the requested surgery is being performed solely to enhance the patients appearance. Instead, the records indicate the procedure has been recommended to improve functional problems for the patients lower abdominal pannus. However, applying the recommendations from the ASPS, the diastasis rectus repair as well as treatment of the upper abdominal pannus would not be expected to treat a functional problem. As discussed above, the photographs show that the lower abdominal pannus is significantly overhanging, while the upper pannus is not as significant. Attempts to treat the functional problems have been documented as well, including topical antibiotics, steroids and other creams. The patient has functional issues related to the significant lower overhanging tissue, which can be reliably treated with a successful panniculectomy. Moreover, a panniculectomy would offer more than a minimal improvement in the appearance. The photographs show a significant condition and a panniculectomy would be expected to adequately treat this condition. Based on review of the available records, the panniculectomy should be covered as the likely source of the patients functional impairment. Diastasis rectus repair and upper abdomen pannus would not create much of a functional deficit and therefore have not been demonstrated to be reconstructive in nature or medically necessary.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for CPT code 81420 cell-free DNA testing for evaluation of the enrollees pregnancy. Findings:  The physician reviewer found that The American College of Obstetricians and Gynecologists (ACOG) and the Society for Maternal-Fetal Medicine recommended cell-free DNA testing as a screening option for women at increased risk of fetal aneuploidy. This population has been defined as women 35 years or older, fetuses with ultrasonographic findings indicative of an increased risk of aneuploidy, women with a history of trisomy-affected offspring, a parent carrying a balanced Robertsonian translocation with an increased risk of trisomy 13 or trisomy 21, and women with positive first trimester or second trimester screening test results. Since this patient has a normal ultrasound, the aneuploidy risk for this patient in this pregnancy does not warrant cell-free DNA testing for aneuploidy. While a positive association between paternal age and the incidence of aneuploidy has been reported, this is likely due to a close correlation between paternal age and maternal age. Studies that have controlled for maternal age, have not shown an increase in the incidence of trisomy 13, 18 or 21. Testing for genomic sequencing is also not medically indicated due to lack of related family history. All told, the requested CPT code 81420 cell-free DNA testing to be performed is not supported as medically necessary for evaluation of this patients pregnancy. Final Result: The reviewer determined that the requested testing is 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 obstetrics and gynecology with sub-specialty certification in maternal fetal 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

An enrollee has requested reimbursement for breast Cancer Index (BCI) testing. Hormone receptor-positive breast cancer responds to adjuvant anti-estrogen therapies such as aromatase inhibitors and tamoxifen. These drugs are usually administered for five years after mastectomy. However, patients are at risk for recurrence for nearly 15 years after diagnosis and initial surgical resection. A biomarker may help providers identify those patients at higher risk and making them candidates for extended anti-estrogen therapy. BCI is a gene expression test that generates a risk for five-year recurrence for use in this clinical setting. In one well-controlled clinical study, the BCI was a good prognostic marker of breast cancer recurrence and performed better than the OncotypeDX gene expression test. Given this support, the BCI testing was 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 evaluation 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 internal medicine with subspecialty certification in medical oncology and is actively practicing. Physician reviewer 2 is board certified in internal medicine with subspecialty certifications in medical oncology and hematology and is actively practicing. Physician reviewer 3 is board certified in internal medicine with subspecialty certifications in medical oncology and hematology 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.