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

Nature of Statutory Criteria/Case Summary: An enrollee has requested coverage of a cooling or combined cooling/heating device (polar care unit) for treatment of the enrollees anterior cruciate ligament (ACL) reconstruction. Findings: Two physician reviewers found that there is a lack of scientific evidence showing the use of cooling devices improve outcomes following ACL surgery. Further, these devices are not included in any evidence-based treatment guidelines. Some studies have suggested short-term pain relief, but no effect on long-term outcomes. Cooling is frequently recommended after surgery, but can be accomplished with readily available materials such as bags of ice. Adie and colleagues review of commercial cold therapy following total knee replacement surgery concluded that potential benefits of cryotherapy on blood loss, postoperative pain, and range of motion may be too small to justify its use, and the quality of the evidence was very low or low for all main outcomes. The authors further noted that well-designed randomized trials are required to improve the quality of the evidence. Based on the available scientific data, the cooling or combined cooling/heating device (polar care unit) was not more likely to be more beneficial than standard available alternatives for this patient following ACL surgery.  Final Result: Two reviewers determined that the device 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 physician reviewers are 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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for monitored anesthesia care (MAC) services to be used during bilateral selective nerve root block. The records provided for review indicate that this patient has an American Society of Anesthesiology (ASA) preoperative physical status classification score of 2. According to the American Society of Anesthesiologists (ASA), intravenous sedation performed by a non-anesthesiologist and non-certified registered nurse anesthetist is well supported for patients with a low preoperative physical status classification score. Although the location of the procedure is a high risk area, this risk would be reduced by avoiding the use of local anesthetic. The high risk of a total spinal or seizure from the injection of Lidocaine would be minimized and the need for another provider to be present for resuscitative purposes would likewise be decreased. Since this patient has already had the procedure done for diagnostic purposes, the addition of a local anesthetic would be for therapeutic purposes. For these reasons, the requested MAC services, to be used during bilateral selective nerve root block, are not medically necessary for treatment of the 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 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

The patient has requested authorization and coverage for liposuction and excess skin removal of the upper arms and excess skin removal of the legs. Researchers found that lipedema is a disorder characterized by localized adiposity of the lower extremities, often occurring in females with a family history of the condition. Lipedema causes pain and is typically unresponsive to weight loss. This patients records do not support a diagnosis of lipedema in the upper arms or legs. There is no history of inability to lose weight, because the patient lost weight from approximately 400 pounds to as low as 149 pounds. The photographs reviewed show lax arms, which are typical of massive weight loss. There is no evidence of persistent fatty tissue in the arms. There is no report of functional issues from skin laxity or intertrigo. In addition, the patient has lax tissue of her thighs from massive weight loss.  There is no report of a recurrent rash underneath her skin folds. For these reasons, the requested liposuction and excess skin removal of the upper arms and excess skin removal surgery of the legs are not medically necessary to treat the patients medical condition. The patients excess arm and leg tissue is a normal structural change that is an accommodative response to loss of body mass. The appearance of the patient is normal and consistent with the gain and loss of weight. There are no functional deficits documented due to the patients condition. There is no report of a recurrent rash underneath her skin folds. There is no report of appropriate medical treatment of a rash or of failure of appropriate medical treatment of a rash. The patient does not have a functional problem with a rash that has been demonstrated to be resistant to appropriate medical treatment. Furthermore, the requested procedure will not improve function or create a more than minimal appearance in the patient. Therefore, the requested liposuction and excess skin removal of the upper arms and excess skin removal surgery of the legs are not reconstructive in nature for this patient. Final Result: The reviewer determined that the requested services are not medically necessary and not reconstructive in nature for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in plastic 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

Physician 1: The patient is a 47-year-old male who has a long history of progressive back and leg pain. He has tried medications, physical therapy, and chiropractic all without any sustained relief. A CT scan performed in February 2005 showed lumbosacral spine discogenic bulge at mid L3-4, focal disc herniation at L4-5, and almost total obliteration of disc space at L5-S1. His physician has recommend the patient undergo disc replacement at L5-S1. The Health Plan has denied coverage for artificial disc replacement indicating the requested procedure is considered investigational.The patient is a male with multi-level degenerative disc disease with chronic low back pain. He has not had improvement with conservative measures. Unfortunately, artificial disc replacement is of unproven efficacy for the treatment of chronic low back pain. The long-term results of this procedure are not yet known. Further studies are needed to determine outcomes beyond two years. Therefore, I have determined that the requested procedure is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Plans denial should be upheld. Physician 2: The patient is a 47-year-old man with a diagnosis of degenerative disc disease. He has requested coverage for artificial disc replacement surgery. The Health Plan has denied coverage for the requested procedure on the basis it is considered investigational.There is little data supporting the long-term efficacy of artificial disc replacement. There is presently at least a 35% failure rate associated with this procedure. Additionally, revision remains a potentially life threatening proposition. At present, the efficacy of disc replacement remains unproven. Therefore, I have determined that the requested procedure is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Plans denial should be upheld. Physician 3: The patient is a 47-year-old male who has a long history of back pain caused by degenerative disc disease. He has undergone several conservative management therapies, which have not produced relief for his pain. The patient has requested authorization and coverage for artificial disc replacement surgery. The Health Plan indicates the efficacy of artificial disc replacement has not been established.Artificial disc replacement has only recently been FDA approved. The procedure is of unproven efficacy. Long-term results are unknown and the procedures risks, long-term viability, and complications are unclear. Though a small study has been completed and short-term results are favorable, further studies and results are needed. As such, the procedure cannot be recommended at this time. Therefore, I have determined the requested procedure is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld

A 50-year-old female has requested coverage for past and future bilateral facet joint injections for treatment of her neck pain.  Findings:  The physician reviewer found that the physical examination performed on the date at issue did not indicate whether the patients pain was derived from the facets.  The imaging studies are significant for multilevel cervical degenerative disc disease and neural foraminal narrowing.  It is difficult to determine the true pathology of the patients chronic pain, as the physical examination and imaging studies are indicative of cervical radicular syndrome.  Additionally, the medical literature provides evidence for diagnostic facet injections.  However, per the submitted documentation, the technique used during the cervical facet injections was therapeutic and not diagnostic. Ackerman and colleagues noted that non-radicular pain may be difficult to accurately diagnose and treat. The facet joint as a source of spine pain is controversial.  The diagnosis of facet joint pain is made by diagnostic facet joint or median nerve branch injections with a local anesthetic.   Ackerman and colleagues performed a randomized controlled trial to determine if the results of diagnostic facet joint injections are influenced by the technique used to perform these injections. The results demonstrated that local anesthetic injections are useful for diagnosis of non-radicular spine pain, but may yield false positive results with respect to facet pain depending on the technique utilized.  The current medical evidence does not support the services at issue in this patients case.
Appeal type: Medical Necessity
Decision: Upheld

A male enrollee requested facet block injections using monitored anesthesia care for medical treatment of this chronic back pain.  Findings:  The physician reviewer found that the physical exam was not evident of facet pain. In addition, facet injections with monitored anesthesia care are not medically necessary because the sedation interferes with the results of the injection. Moreover, there is no clinical indication for monitored anesthesia with the requested procedure such as extreme anxiety or severe conditions requiring monitored anesthesia. The evidence obtained from the literature review suggests that controlled comparative local anesthetic blocks of facet joints without intravenous sedation are reproducible, reasonably accurate and safe. Based on the documentation submitted for review and the peer-reviewed literature cited above, the requested services are not medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Repatha SureClick 140 mg/mL Pen. The submitted documentation supports the requested medication in this clinical setting. In this patients case, the records document coronary disease, hyperlipidemia and marked intolerance to statin medications. Repatha (evolocumab) is a proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitor studied in and approved for patients with heterozygous familial hypercholesterolemia or for patients with documented atherosclerotic heart disease who require additional lowering of low-density lipoprotein (LDL) cholesterol. This patient fits the latter criteria. Several prospective randomized trials have demonstrated the safety and efficacy of the requested medication at lowering LDL cholesterol and improved cardiac outcomes in this setting. Therefore, Repatha SureClick 140 mg/mL Pen is medically necessary for the 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 sub-specialty 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.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a 10-year-old male enrollee has requested for mental health outpatient group treatments for treatment of the enrollees attention deficit/hyperactivity disorder, obsessive-compulsive disorder and generalized anxiety disorder. Findings:  The physician reviewer found that the current medical literature, there are no absolute clinical guidelines as to duration and frequency of treatment for obsessive-compulsive disorder and generalized anxiety disorder.  However, there is strong evidence indicating that patients with attention deficit/hyperactivity disorder and comorbid disorders benefit from an adjunctive psychosocial intervention. In most trials of anxiety disorders, monotherapies are effective.  However, combination treatment is almost always superior.
Appeal type: Medical Necessity
Decision: Upheld

A 28-year-old female enrollee has requested bilateral breast reduction mammoplasty for treatment of her macromastia. Findings:  The physician reviewer found that this patient complained of back, neck and shoulder pain, which is typical of symptomatic macromastia. The surgeons preauthorization letter indicates that the patients symptoms were mild and does not document that she had tried any conservative therapies for her musculoskeletal symptoms. While conservative therapy is of little value in the management of symptomatic macromastia, attempts at conservative therapy provide credence to the patients complaints and indicate that symptoms are severe enough that the patient is compelled to search for treatments. The records do not include any supporting documentation from the patients PCP that confirms that this patient had disabling musculoskeletal symptoms from her macromastia. In addition, the weight of the reduction (right  340 grams, left  360 grams) falls below the 22nd percentile on the Schnur scale, which is an accepted guideline to determine if a reduction is medically necessary or cosmetic.
Appeal type: Medical Necessity
Decision: Overturned

A 63-year-old male enrollee has requested continued speech therapy for treatment of his status post stroke.  Findings:  The physician reviewer found that the submitted documentation establishes the medical necessity of the requested speech therapy. This patient has residual aphasia following a stroke. Speech therapy efforts have been associated with substantial language and articulation gains.  The submitted records document specific clinical and functional goals.  The literature documents that recovery from acquired brain injury occurs at varying paces, and to differing degrees.  It is standard of care to continue rehabilitation services for as long as needed, if the patient is making documented clinical progress towards reasonable goals. This patient has been documented to be making progress, and his progress has not plateaued at this time.  All told, continued speech therapy is medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Overturned

A 39-year-old female has requested coverage for past residential treatment services provided for treatment of her depression.  Findings:  The physician reviewer found that modern psychiatric practice aims to place patients in the least restrictive treatment setting.  In general and if feasible, community intervention settings are thought to offer optimization of treatment gains. However, in this case the patient had failed two such treatments and was referred to residential treatment by her psychiatrist.  The current guidelines established by the American Psychiatric Association (APA) state, The psychiatrist should determine the least restrictive setting for treatment that will be most likely not only to address the patient's safety, but also to promote improvement in the patient's condition. The determination of an appropriate setting for treatment should include consideration of the patient's symptom severity, co-occurring psychiatric or general medical conditions, available support system, and level of functioning.In this particular case, residential placement was appropriate to fully treat this high-risk patient and was consistent with standards of good medical practice in the United States.  As mentioned above, this patient had failed the less restrictive settings of intensive outpatient care and partial hospitalization. Her persistent affective and mood symptomatologies, coupled with enduring negative schemas, marital stress and unique psychosocial stressors, would have more than likely undermined efforts at a lower level of care, creating a potential for relapse and risk for acute hospitalization. All told, the residential treatment services at issue were medically necessary for treatment of the patients medical conditions.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Repatha SureClick 140 mg/ml pen injector. In this case, the records document coronary artery disease, hyperlipidemia and intolerance to multiple statin medications, except pravastatin. The patients LDL is significantly above a goal of less than 70 mg/dL while on pravastatin alone.  Zetia was recently added, but there is no follow-up LDL level reported since starting this medication. The addition of Zetia in this setting has been shown to improve outcome.  Repatha is a proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitor studied in and approved only for patients with heterozygous familial hypercholesterolemia or for patients with documented atherosclerotic heart disease who require additional lowering of LDL cholesterol. Based on the records, this patient does not meet either of these criteria since her LDL while on the combination of pravastatin and ezetimibe is not reported. Therefore, Repatha SureClick 140 mg/ml pen injector is not medically necessary for the treatment of this patient. 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 internal medicine with sub-specialty 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.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for bilateral Monovisc injections in the knees (HCPCS J7327). Per the medical literature, although viscosupplementation may relieve knee pain in some individuals with osteoarthritis, it is not known as to which individuals will benefit. The current evidence is limited, and guidelines from organizations such as the American Academy of Orthopedic Surgeons indicate that the evidence is not conclusive. In light of the foregoing, viscosupplementation can only be recommended in individuals with a history of lasting benefit from prior injections, and in carefully selected cases where everything else has been tried, and the options are limited. In this case, the patient has a documented benefit from bilateral Monovisc injections and her provider has recommended repeat viscosupplementation. Given the patients limited options, with the alternative being total knee arthroplasties, and based on the current medical literature, the requested services are medically indicated. Therefore, bilateral Monovisc injections in the knees (HCPCS J7327) are medically necessary for the 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 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.