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

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the anesthesia services. The records document that this patient has an ASA preoperative physical status classification score of 2. According to the current medical literature, intravenous sedation performed by a non-anesthesiologist and non-certified registered nurse anesthetist is well supported, given the patients low preoperative physical status classification score. For these reasons, the anesthesia services were not medically necessary for evaluation of the patients medical condition. Final Result: The reviewer determined that the services at issue were 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 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 authorization and coverage for LifeVest external cardiac defibrillator. Findings:  The physician reviewers found that there is potential for recovery of left ventricular function over time with medical therapy and there was no documented indication for immediate placement of a defibrillator such as sustained or inducible ventricular tachycardia, unexplained syncope or aborted sudden cardiac arrest. Placement of a prophylactic defibrillator is not recommended until at least 90 days have elapsed where continued left ventricular dysfunction ejection fraction is less than or equal to 35% is documented to persist in spite of appropriate treatment. A prophylactic defibrillator, wearable or implantable, before this time has not been demonstrated to improve outcome. Studies evaluating wearable defibrillators during periods of increased risk where criteria for implantable defibrillators have not yet been met are largely comprised of registry data without adequate control groups. At this time, prophylactic wearable external defibrillator would be indicated only if accepted criteria for an implantable defibrillator were met and an implantable defibrillator could not be placed, needed to be significantly delayed due to infection, or required explanation. Final Result: The reviewers determined that the requested device is 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: the physician reviewers are board certified in internal medicine with sub-specialty certification in cardiovascular disease 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: Overturned

The patient is a 49-year-old female who had a body mass index (BMI) of 36. She has had exacerbation of obesity related comorbidities including traumatic arthritis of the knee, and biopsy-proven reflux esophagitis. The patient tried and failed conventional weight loss therapies. Her degenerative joint disease made escalated exercise problematic. For these reasons, it was recommended the patient undergo gastric bypass surgery. The Health Plan has denied coverage for the procedure at issue on the basis it was not medically necessary.The patient had a BMI of 36 and documented comorbidities including hypertension, venous stasis, degenerative arthritis and esophagitis despite PPIs. While her knee degenerative joint disease was initially traumatic in nature, her excess weight caused acceleration of the arthritis. Though the patient had a BMI of less than 40, her comorbidities were severe enough to warrant weight loss surgery. The patient met nationally accepted criteria for weight loss surgery. Gastric bypass surgery was medically indicated and necessary for this patient as it was not likely she would have been able to lose weight and maintain the weight loss through non-surgical means. Therefore, I have determined the procedure at issue was medically necessary for treatment of the patients medical condition. The Health Plans denial should be overturned.
Appeal type: Experimental/Investigational
Decision: Upheld

A 59-year-old female enrollee has requested PET/CT scan for evaluation of her adenocarcinoma of the right parotid gland.   Findings:  Two physician reviewers found that there is no support in the literature to support ongoing yearly PET/CT scans to follow-up on apparently cured parotid adenocarcinoma. The National Cancer Center Network (NCCN) guidelines recommend regular follow-up physical examinations in this setting, as well as chest imaging as clinically indicated. The NCCN guidelines do not include PET/CT for regular follow-up for parotid adenocarcinoma. Additionally, PET/CT scans can occasionally detect false positives. It is well known that tonsillar activity can be normal in PET scans, and this patient underwent a surgical procedure that revealed normal tonsil tissue. The overall cure rate for stage 1 parotid cancer is as high as 96%. In this patients clinical situation, follow-up PET/CT scan is not likely to be of significant value unless there is clinical evidence for recurrence.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for facial feminization surgeries and vocal feminization surgery. The Health Plan has denied this request indicating that the requested services are not medically necessary for treatment of the enrollees gender dysphoria and are not reconstructive in nature.Findings: Overall, facial feminization surgeries and vocal feminization surgery are medically necessary for treatment of this patients gender dysphoria.With regard to whether the requested services are considered reconstructive in nature, the submitted documentation demonstrates that the patients facial features constitute an abnormal body structure. The requests appear to be consistent with addressing gender related abnormalities. The record supports that this patients facial features constitute an abnormal body structure for the female gender. In the same way that genitalia and breasts are abnormal structures in a patient who is diagnosed with gender dysphoria, these facial structures are inconsistent with this patients gender identity.  Masculinized facial features due to the effects of testosterone are also aberrant in the same manner. This patients facial features and masculine voice are considered a congenital defect since the patient is a female and the masculinized features are a congenital abnormality. Furthermore, the requested surgeries would create a normal appearance to the extent possible and are likely to result in more than a minimal improvement in the patients appearance. In addition, improvement in this patients mental health and functioning are both secondary benefits. Therefore, the requested facial feminization surgeries and vocal feminization surgery satisfy the criteria for reconstructive surgeries as defined in California law. Final Result: The reviewer determined that that the requested services are medically necessary for treatment of the patients medical condition and are reconstructive in nature. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in plastic surgery with expertise in transgender 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: Upheld

The patient is a 64-year-old male status post anteroapical myocardial infarction (MI). He underwent stent implant with persistent ST elevation and abnormal flow post procedure. He also underwent a repeat angiogram demonstrating occlusion of the distal LAD with an ejection fraction of 32%. The patient has requested reimbursement of an in-home external defibrillator, which was provided prior to internal defibrillation. The Health Plan has denied authorization for the equipment at issue indicating an external defibrillator was not medically necessary. The patient met criteria for implant of an internal defibrillator by MADIT III criteria, post myocardial infarction with an ejection fraction of 32%. This was discovered at the time of cardiac catheterization. The evidenced based approach would be to implant an internal defibrillator after recognition of having criteria met for malignant arrhythmia risk. If there is concern over risk of sudden death after recognition of risk by catheterization, it is not uncommon to perform defibrillator implant before discharge, or to transfer to a facility that has implant capacity. As the patient met criteria for internal defibrillation, there was no medical indication for an external defibrillator, which has not been proven to reduce mortality. Therefore, I have determined that the equipment at issue was not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary:   An enrollee has requested the water circulating cold pad with pump (CPT code E0218) for treatment of the enrollees knee pain status post total knee arthroplasty.  Three physician reviewers found that cooling is commonly recommended after surgery to diminish pain and swelling, but can be accomplished with readily available materials such as a bag of ice. Currently, there is a lack of scientific evidence of improved functional outcomes with the use of commercial cooling units and as a result, such units are not included in evidence based treatment algorithms. Adie and colleagues conducted a systematic review and concluded there is insufficient evidence of benefit to recommend the use of commercial cooling units after knee replacement surgery. Su and colleagues found a paucity of data demonstrating functional benefit of a cryopneumatic device after knee arthroplasty. All told, there is a lack of scientific evidence to support the use of commercial cooling units after knee arthroplasty and no evidence the use of such devices improve patient outcomes. Thus, the water circulating cold pad with pump (CPT code E0218) was not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Final Result: Three 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 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: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for virtual colonoscopy/computed tomography colonography of the abdomen and pelvis. Findings:  The physician reviewer found that the American College of Radiology (ACR) guidelines for virtual colonoscopy states that the indications for a computed tomography colonography examination include screening examination in individuals who are at average or moderate risk for developing colorectal carcinoma. The U.S. Preventive Services Task Force recommends computed tomography colonography as a colorectal cancer screening test and stated that, if colonoscopy is not available or is unacceptable to a patient, recommended alternative strategies include flexible sigmoidoscopy every five to 10 years or CT colonography every five years. The documented disadvantages of computed tomography (CT) colonography versus colonoscopy include radiation exposure, missed flat lesions, and the need for subsequent colonoscopy to evaluate positive or equivocal findings (Pickhardt, et al). This patients records do not include documentation to support an indication for virtual colonoscopy in lieu of standard colonoscopy. For these reasons, the requested virtual colonoscopy/computed tomography colonography of the abdomen and pelvis is not medically necessary for this patient.Final Result: The reviewer determined that the requested services are not medically necessary for evaluation of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer board certified in internal medicine with subspecialty 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: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for right sacroiliac (SI) joint fusion surgery (CPT 27279). The International Society for Advancement of Spine Surgery (ISASS) provided criteria for sacroiliac (SI) joint fusion (Lorio, et al.). The requirements include significant SI joint pain confirmed by at least three positive SI joint provocative tests, confirmation of the SI joint as a pain generator with at least 75% decrease in pain following fluoroscopically guided diagnostic intra-articular SI joint block in the immediate post-injection period, and failure to respond to at least six months of non-surgical treatment. The ISASS noted that additional or alternative diagnoses that could be responsible for the patients ongoing pain or disability should be evaluated and ruled-out. Based on the records provided for review, this patient presents with persistent pain over the right SI joint with chronic SI joint dysfunction. She reports that her pain is worse with walking, sitting, standing, and laying down. The patient has also experienced balance issues due to leg weakness. Clinical examination findings included four positive provocative tests and a positive Fortins finger sign. Diagnostic and therapeutic SI joint injections reportedly produced 80% of pain relief. The provider documented that the patient has failed conservative treatment consisting of physical therapy, activity modification, medications, and injections. There is reported imaging evidence of SI joint degeneration and no concurrent lumbar spine pathology. Current-evidence based medical literature supports minimally invasive SI joint fusion for patients with SI joint dysfunction due to degenerative sacroiliitis or SI joint disruption. Duhon and colleagues reported strong evidence that minimally invasive SI joint fusion using triangular porous coated implants placed across the SI joint improved pain, disability and quality of life at 24 months in patients with SI joint dysfunction due to degenerative sacroiliitis and SI joint disruption. Therefore, the requested right SI joint fusion (CPT 27279) is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Findings:  Two of the three physician reviewers found the requested right SI joint fusion (CPT 27279) 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: Experimental/Investigational
Decision: Overturned

A 44-year-old male enrollee has requested Avastin in combination with other chemotherapy drugs for treatment of his stage 4 non-small cell lung cancer (NSCLC). Findings:  Two physician reviewers found that upon review of the currently available peer reviewed medical literature there remains uncertainty regarding standard regimens for this patients condition. Sandler and colleagues found that Avastin prolongs survival in patients when given in combination with paclitaxel/carboplatin in first-line therapy. Further, Herbst and colleagues reported that Avastin has also been effectively combined with docetaxel or pemetrexed. Importantly, in the latter study, Avastin was combined with single agents and showed an advantage in terms of survival rates. In addition, Blakely and colleagues concluded that Avastin has been shown to be effective as part of other regimens in the treatment of NSCLC. Given this support for the utility of Avastin in the treatment of NSCLC, the proposed combination is medically reasonable and likely to provide him with improved health outcomes when compared with alternative therapies.
Appeal type: Medical Necessity
Decision: Overturned

A 58-year-old female enrollee has requested the medication Zyvox for the treatment of her right knee infection. Findings:  The physician reviewer found that the patient could have been treated with a penicillin or cephalosporin, linezolid, tetracycline, trimethoprim-sulfamethoxazole or vancomycin. However, she has a history of anaphylaxis to the penicillin and an allergy to sulfamethoxazole. This means the penicillins, cephalosporins and trimethoprim-sulfamethoxazole cannot be used. The remaining options are vancomycin, tetracyclines and linezolid. Vancomycin is not available except in parenteral formulation.   Because of the patients skin disease, her physicians did not want her to receive parenteral therapy. Tetracyclines (doxycycline) have been used for treatment of community-acquired methicillin-resistant Staphylococcus aureus infection.  These drugs are not usually used in severe infections.  There is a lack of data to justify their use in infected joints.  Thus, due to the organisms resistance pattern, the patients allergies and the presence of skin disease preventing use of intravenous therapy, the only possible drug for her infection was Zyvox.  The Health Plans denial is inappropriate.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Genetic cancer screening (CPT codes 81321 and 81323). Applying the International Breast Cancer Intervention Study (IBIS) risk assessment tool, this patient has a 10-year risk of breast cancer of 7.6%, and a lifetime risk of breast cancer of 19%. Although there is ample data to support genetic testing in patients with a 20% lifetime risk of developing cancer, this patients lifetime risk of 19% falls just short of this cut-off. However, the National Comprehensive Cancer Network (NCCN) just released updated guidelines to direct genetic testing in this clinical setting. The NCCN states that testing is warranted for patients with a first-degree relative who would meet testing criteria. As this patients sister had breast cancer diagnosed at 30 years, she meets the requirement with a first-degree relative with breast cancer diagnosed under 45 years. Given these findings, the records support high-risk breast cancer screening, including genetic testing for hereditary predisposition to breast and ovarian cancers for this patient. All told, the requested genetic cancer screening (CPT codes 81321 and 81323) is medically necessary for this patient.Final Result: The reviewer determined that the requested services are medically necessary for evaluation of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in pediatrics with subspecialty certifications in genetics and clinical biochemical genetics 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 3-year-and-10-month-old male enrollee has requested for applied behavioral analysis (ABA), speech therapy, occupational therapy and neuropsychological evaluation for treatment of the enrollees autistic spectrum disorder and developmental delay. Findings:  The physician reviewer found that all of the services being requested by the patients parent are now the standard recommendations for autistic children; 26 hours of ABA (which includes 5 hours of supervision), 2 hours of occupational therapy, and 2 hours of speech therapy are now the recommendations of most centers treating autistic children. The need for a neuropsychologist would be to monitor changes or the lack of improvement in these programs. These interventions are all medical and are not instructional, remedial, or caretaking procedures. The programs are directed toward improving the patients communicative skills, socialization, and physical fine motor abilities.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the Zoll LifeVest wearable cardioverter defibrillator worn for 60 days. The documented high risk of sudden cardiac death in patients with severe left ventricular dysfunction has led to the recommendation of implantable cardioverter defibrillators in this group of patients. Data from multiple trials have advocated the use of a Zoll LifeVest wearable cardioverter defibrillator after an initial diagnosis of severe left ventricular dysfunction with an ejection fraction less than or equal to 35% (Kutyifa, et al.; Klein, et al.; Epstein, et al.). This patients ejection fraction was 15-20%. The recommended timing of placement of a LifeVest based on current American College of Cardiology (ACC), American Heart Association (AHA), and Heart Rhythm Society (HRS) guidelines is within 40 days of an acute myocardial infarction or within 90 days of an initial diagnosis of CHF with a severely reduced ejection fraction, as this patient. Accordingly, Zoll LifeVest wearable cardioverter defibrillator worn for 60 days from was likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Findings:  Two of the three physician reviewers found the Zoll LifeVest wearable cardioverter defibrillator worn for 60 days from was likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Final Result: The reviewers determined that the services at issue were 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 internal medicine with subspecialty certification in cardiovascular disease 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.