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

A 50-year-old female enrollee has requested the Flexitouch system (E0652, E0656, E0669) for treatment of her lymphedema. Findings:  The physician reviewer found that lymphedema management should be highly individualized and designed to meet the needs of the individual patient. In the case under review, the patient has failed conservative management techniques and has demonstrated a good response to the prescribed therapy with the Flexitouch system. The treating physician noted the importance of using the device to address the patient's combined extremity and genital lymphedema. Device selection is critical to the success of home-based lymphedema therapy and should take into account the mechanism of action and functionality of the device, as noted by Mayrovitz.  Programmable devices that provide truncal and proximal clearance are highly desirable for an effective home program. In this patients case, the Flexitouch system (E0652, E0656, E0669) is medically indicated.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for a polysomnogram supervised sleep study. In this case, the patient presented with a clinical presentation that is suggestive of a sleep related breathing disorder. The patient was noted to snore, have excessive daytime sleepiness, frequent arousals from sleep, and disturbed/restless sleep and weight gain. Given the symptoms present that are consistent with obstructive sleep apnea (OSA), testing for OSA is reasonable. However, there has been a shift from testing in the attended environment to the unattended setting. Current literature including randomized controlled trials have demonstrated equivalence in diagnosis and outcomes with provision of services in attended versus unattended settings. Overall, the attended sleep study would exceed this patients clinical and diagnostic needs. For these reasons, the requested polysomnogram supervised sleep study is not medically necessary for evaluation of this patients medical condition. 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 is board certified in neurology with sub-specialty 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: Medical Necessity
Decision: Upheld

The patient is a 67-year-old female who developed a wound infection following urgent colon surgery in April 2006.  Her wound healed by secondary intention, and photographs show a red, raised scar consistent with a recently healed wound. The patient is displeased with the scar and has requested authorization for scar revision surgery, which has been denied by the Health Plan.Review of the submitted clinical evidence demonstrates the proposed scar revision is not medically necessary. The patients general surgeon indicated in June 2006 that the patient was not having any functional problems with her scar. As recently as May 2006, the patient did not express any dissatisfaction or concerns regarding her scar. In the absence of a functional problem, scar revision is not medically necessary. Furthermore, the patients scar is only three months old. Most plastic surgeons recommend that a scar be allowed to mature for at least six months before proceeding with scar revision.  It is very likely that the quality and aesthetics of the scar will improve over time.For the reasons set forth above, I have determined the requested procedure is not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld

A 28-year-old female has requested a T1-rho cartilage scan for evaluation of her patellofemoral pain.  Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested diagnostic procedure.  T1-rho mapping has been shown to be effective in visualizing early changes in osteoarthritis, and is a promising technique for evaluating early cartilage damage.  Along with other new techniques, it may be of value in characterizing changes in articular cartilage, and may be eventually helpful in detecting morphological cartilaginous changes earlier than conventional MRI.  However, this method of evaluation has been used primarily in the research setting.  At this time, there is a paucity of reported clinical information to support the technique.  All told, the requested T1-rho cartilage scan is not medically indicated for the evaluation of this patient.
Appeal type: Medical Necessity
Decision: Upheld

A female enrollee requested genetic testing for predisposition for breast cancer (BRCA1, BRCA2, or BRCA analysis rearrangement test (BART)) for medical evaluation of her breast pain and family history of breast cancer.  Findings:  The physician reviewer found that the records do not include documentation of a consultation with a genetic counselor to support the requested testing at this time. According to the U.S. Preventive Services Task Force recommendations, women with positive screening results should receive genetic counseling and, if indicated after counseling, BRCA testing. Thus, the requested genetic testing for predisposition for breast cancer (BRCA1, BRCA2, or BRCA analysis rearrangement test (BART)) is not supported as medically necessary for evaluation of this patients medical condition at this time.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Synvisc One injections for both knees. The Health Plan has denied this request indicating that the requested service is not medically necessary for treatment of the enrollees osteoarthritis.This patient presents with bilateral knee pain. Clinical examination findings have been consistent with the reported diagnosis of severe bilateral knee osteoarthritis. He has reportedly failed reasonable conservative treatment, including activity modification and non-steroidal anti-inflammatory drugs (NSAIDs). Prior Synvisc One injections to the bilateral knees have provided significant pain reduction for six months and allowed for medication reduction. Evidence based medical peer-reviewed literature supports the use of viscosupplementation injections for the treatment of pain in patients with osteoarthritis of the knee. Repeat viscosupplementation injections have been found to be safe and effective and allow for delay of knee replacement surgery.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: Medical Necessity
Decision: Upheld

This patient is a 15-year-old female who is status post a motorcycle accident with resultant medial collateral ligament, medial meniscus, and anterior cruciate ligament injury requiring arthroscopy and repair of the MCL in January 2005. Prior to surgery the patient was provided with an over-the-counter brace for protection. A custom molded brace has been requested postoperatively to allow normal ADLs, assist in rehabilitation, and shorten healing time. At issue is whether the requested equipment is medically necessary for the patients postoperative rehabilitation.The American Association of Orthopaedic Surgeons position statement indicates after ACL reconstruction there may be a role for rehabilitation braces used in the early post-surgical phase, but functional braces used later during recovery appear to provide no added protection. There is no documented evidence that knee bracing of any type prevents injury during high load activities or sports activities. Additionally, in the case of this patient, there is no documentation of loss of activities of daily living. In most cases of ACL and MCL surgery, the goal of rehabilitation is to strengthen the stabilizing muscle of the knee as well as to heal the ACL repair. The use of bracing generally tends to weaken rather than strengthen the affected muscles and therefore, is ineffective. Based upon the information set forth above, I have determined that the requested equipment is not medically necessary for treatment of the patients medical condition. Accordingly, the Health Plans denial should be upheld.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary:  An enrollee has requested a water circulating cold pad with pump for treatment of her symptoms related to her right knee surgery.   Findings:  Three physician reviewers found that there is insufficient evidence in the peer-reviewed literature to support cooling devices following non-major orthopedic surgeries. According to researchers, use of a cooling device in patients undergoing routine knee arthroscopy without a history of thromboembolism did not result in thromboprophylaxis (reduced risk of blood clot formation). All told, there is inadequate evidence that the use of cooling devices results in improved clinical outcomes in this setting. Based upon the submitted records and review of the peer-reviewed literature, there is a lack of evidence to support the water circulating cold pad with pump for this patient. As such, the device at issue was not likely to be more beneficial for treatment of this 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: Experimental/Investigational
Decision: Overturned

A 49-year-old male enrollee has requested for use of a Real-Time Heart Monitor for evaluation of his syncope and atrial fibrillation.  Findings:  Two physician reviewers found that Rothman and colleagues studied the real-time heart monitor in their large, multicenter controlled trial of 266 patients with persistent symptoms who had previously undergone Holter monitoring which failed to diagnose an arrhythmia. The patients were randomized to conventional external loop monitoring (self or loop activated for symptoms) versus a real-time continuous monitoring group with the CardioNet. The authors found a statistically significant difference in the diagnosis of arrhythmia in the real-time monitoring group. In addition, Joshi and colleagues conducted a retrospective analysis of 100 patients undergoing treatment for known arrhythmias who were evaluated with real-time heart monitors. The authors found that a number of treatment changes were made based on findings from the real-time monitors, but there was no follow-up to determine whether patient outcomes were improved as a result of this new information.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The enrollee has requested authorization and coverage for physical therapy with a therapist that does not use assistants and can treat more than two body parts per therapy sessions. Based on the available records, the provider did not document a rationale for continued supervised physical therapy. For each of the patients diagnoses, she has received treatment including initial supervised therapy followed by transition to an independent home rehabilitation program. Without documentation of a condition that requires the services of a skilled physical therapist, the requested physical therapy is not indicated. Thus, the requested physical therapy with a therapist that does not use assistants and can treat more than two body parts per therapy session is not medically necessary for treatment of this 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 physical medicine and rehabilitation 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: Urgent Care
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested surgical services on an emergent or urgent basis. The physician reviewer found that review of the submitted documentation demonstrates that a prudent layperson would not have sought immediate medical attention on the date in question. Upon review of the submitted medical records, the patient presented with a ruptured left breast implant and pain of the left breast. However, this pain was not an acute condition that could reasonably be expected to require immediate medical attention. There is no evidence that a ruptured silicone implant would place the patients health in serious jeopardy, or serious impairment or dysfunction. In sum, the patient was not suffering from a serious medical condition that was likely to place the patients health in serious jeopardy, cause serious impairment to body functions or cause serious dysfunction to a body organ or part. Thus, the services not meet prudent layperson criteria for emergency care.  Further, it has not been established that criteria for urgently needed services were met on the date in dispute. In this case, there is no evidence that serious deterioration of the patients health would have occurred if the patient did not have her implants replaced. The patients pain and radiographic work-up are consistent with timely evaluation of her condition. The patient was noted to have had her surgery after a preoperative evaluation. Based on the documentation submitted for review a prudent layperson in a similar situation would not have believed immediate medical attention was necessary to prevent serious deterioration of ones health. In sum, based on the patients clinical presentation, the patient did not meet prudent layperson criteria for urgently needed services. As such, the Health Plans denial should be upheld.  Final Result: The reviewer determined that the patients symptoms did not meet prudent layperson criteria for emergency care or urgently needed services. Therefore, the Health Plans denial should be upheld.  Credentials/Qualifications: The reviewer is board certified in plastic and reconstructive 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

Findings:  The physician reviewer found that an enrollee has requested reimbursement and prospective authorization and coverage for percutaneous tibial nerve stimulation (PTNS) (CPT 64566) received 6/16/21, 6/23/21, 6/30/21, 7/7/21, 7/14/21, 7/21/21, 7/28/21, 8/4/21 and going forward.According to the American Urology Association guidelines and current literature, the first-line treatments for patients with overactive bladders are behavioral therapies, followed by pharmacologic management. For patients who have failed behavioral therapies and pharmacologic management, such as intravesical botulinum injections, PTNS is the next non-surgical option for care. In this case, the patient has failed behavioral therapies and treatment with pharmacologic management, such as intravesical botulinum injections. Additionally, the patient has received PTNS, with no reports of adverse reactions. Therefore, PTNS (CPT 64566) received 6/16/21, 6/23/21, 6/30/21, 7/7/21, 7/14/21, 7/21/21, 7/28/21, 8/4/21 and going forward were and are medically necessary for treatment of the patients medical condition.Final Result: The reviewer determined that the services at issue were and are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for four hours per week of applied behavior analysis (ABA) services for six months. A definition of medical necessity that includes health-care services that a provider, exercising a prudent clinical judgment, would provide to a patient for the purpose of evaluating, diagnosing, or treating an illness, injury, disease, or its symptoms and are: (a) required to meet the essential health needs of the patient; (b) consistent with the diagnosis of the condition for which they are required; (c) consistent in type, frequency, and duration of treatment with scientifically based guidelines as determined by medical research; (d) required for purposes other than the convenience of the provider or the comfort of the patient; and (e) rendered in the least intensive setting that is appropriate for the delivery of health care. Based on the current information provided for review, there is a lack of updated diagnostic information and treatment plan. Thus, the requested services are not required to meet the essential health needs of the patient and are not consistent with the diagnosis of the condition for which they are required. The patient needs an updated diagnostic make-up and treatment plan to meet the criteria outlined. In the absence of a current diagnostic work-up and treatment plan, the patient does not meet the criteria for medical necessity. Therefore, four hours per week of ABA services for six months are 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 a licensed B.C.B.A board certified in psychology 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: A female enrollee has requested reimbursement for the blood test (Guardant360 biopsy-free tumor sequencing test). Per medical guidelines, evaluation for T790M mutation is appropriate in this clinical setting. Guardant360 testing offers a comprehensive panel of molecular genetic markers on an individual patients tumor in an attempt to identify markers than can help guide therapy decision making. Guardant360 provides genetic testing to guide therapy, and this is the subject of an ongoing phase II trial, the entire panel was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. However, as the patient showed evidence of progression while on Tarceva, the portion of the Guardant360 test analyzing for the T790M mutation was indicated. Thus, the T790M portion of the blood test (Guardant360 biopsy-free tumor sequencing test) was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy, while the remainder of the Guardant360 testing performed was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.One reviewer found that the blood test (Guardant360 biopsy-free tumor sequencing test) was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Final Result: Two of the three reviewers determined that a portion of the testing 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 partially overturned.Credentials/Qualifications:  One reviewer is board certified in internal medicine with sub-specialty certification in medical oncology and is actively practicing. One Reviewer is board certified in internal medicine with sub-specialty certification in medical oncology and is actively practicing.  One Reviewer is board certified in internal medicine with sub-specialty certification in medical oncology and is 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: Overturned

A 37-year-old female has requested participation in a weight loss program for treatment of her morbid obesity.  Findings:  The physician reviewer found that the submitted documentation demonstrates the medical necessity of the requested services in this patients case.  Obesity is associated with diabetes, hypertension, hyperlipidemia, cancer, osteoarthritis, obstructive sleep apnea, cardiovascular disease, and asthma.  The prevention of obesity involves both increasing physical activity and dietary modification to reduce caloric intake.  Lifestyle modification, including diet, physical activity, and behavior therapy, have been shown to induce clinically significant weight loss.  Weight loss strategies that use dietary, physical activity or behavioral interventions can produce significant improvement and long-term weight loss results.  The medical documentation indicates the patient had significant weight loss with the structured diet program provided by a medical center.  Her potential for significant and sustained weight loss will improve with the present program.  All told, the requested participation in a weight loss program at the center is medically indicated for the treatment of this patient.