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

An enrollee has requested authorization and coverage for per-oral endoscopic myotomy (POEM) procedure. The records provided for review document achalasia with esophagogastric junction outflow obstruction and Jackhammer esophagus. Jackhammer esophagus is a manifestation of the hypertensive type of esophageal dysmotility. Contractions, as in this patients case, are high amplitude, and involve most of the esophagus. Symptoms may include dysphagia and chest pain. As with this patient, Jackhammer esophagus can progress to achalasia, which is a motility disorder of the esophagus characterized by the absence of peristalsis and a defective relaxation of the lower esophageal sphincter (LES). Current treatment options of achalasia are directed at relieving the functional obstruction at the level of the LES. Bhayani and colleagues compared Heller myotomy with the POEM procedure. The authors found that POEM required a shorter hospitalization while patient symptoms and esophageal physiology were equally improved with both procedures. Talukdar and colleagues aimed to determine comparative efficacy of POEM versus laparoscopic Heller myotomy. Minami and colleagues reported that, POEM could be a curative standard treatment of choice for esophageal achalasia. Given these findings, the requested POEM procedure 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 POEM procedure is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for right knee arthroscopy (partial meniscectomy and limited synovectomy). Researchers concluded that there is a paucity of evidence that operative approaches are superior to conservative measures as the first-line treatment of older patients with knee pain and meniscal tears. From the available data, a trial of conservative therapy is recommended for the treatment of degenerative meniscal tears in older patients in the absence of mechanical symptoms, such as knee locking. Researchers performed a systematic review of the role for arthroscopic meniscectomy in patients with degenerative knee changes. The authors reported that two randomized controlled trials showed a benefit of arthroscopic surgery in patients with limited degenerative joint disease compared with conservative treatment. A study concluded that positive McMurray sign suggests good postoperative outcomes for patients with meniscal tears associated with osteoarthritis. This patient is being treated for primary osteoarthritis of the right knee. MRI demonstrated grade 4 cartilage fissuring seated within the patellar articular surface in the midline femoral trochlea, grade 2 cartilage thinning in the medial compartment, and subtle fraying at the inner inferior surface of the body of the medial meniscus and small effusion within the knee. X-rays showed small patellar osteophytes. However, detailed documentation is not evident regarding trial and failure of recent, reasonable and comprehensive less invasive conservative care measures. The provider recommended treatment with diclofenac and the patient presented for follow-up, representing a trial of the medication for approximately one month. There is a lack of documentation that the patient has exhausted conservative options, including physical therapy. Furthermore, significant mechanical symptoms are not evident based on the available records. For these reasons, the requested right knee arthroscopy (partial meniscectomy and limited synovectomy) is 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 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

Nature of Statutory Criteria/Case Summary: The patient has been diagnosed with encephalopathy, hemiplegia and hemiparesis following cerebrovascular infarction, and dysphagia. The patient was admitted to a skilled nursing facility. The patient received physical therapy, occupational therapy, and speech therapy. The patient was noted to be status post eight cerebrovascular accidents and percutaneous endoscopic gastrostomy (PEG) tube placement for dysphasia. The patient utilized safe swallowing strategies with 80% plus accuracy with moderate to maximal cues. In cognitive communication therapy and instruction, the patient recalled four out of four steps. The patient completed swallow rehabilitation exercises with 100% accuracy with moderate to maximal cues. The physical therapist noted that the patient was able to safely complete transfers requiring contact guard assist/stand by assistance (CGA/SBA). The patient required a front-wheeled walker (FWW) and CGA for safe ambulation. The patient has requested reimbursement and prospective authorization and coverage for (SNF) services. The Health Plan denied the request and reported the services at issue were not and are not medically necessary for the treatment of this patient. At issue in this case is whether skilled nursing facility (SNF) services were and/or are medically necessary for the treatment of the patients medical condition. In this case, the documentation does not indicate that the patient has a tracheostomy tube, complex wound care or other SNF level skilled nursing need. The patient has been able to tolerate oral intake. His PEG tube does not require a SNF admission. This patients current functional level does not require ongoing SNF level skilled therapy services with the specialized skill, knowledge and judgment of a qualified therapist required to safely and effectively provide medically necessary and reasonable treatment only in a SNF. He does not require these skilled nursing or skilled therapy services (or a combination of these services) daily. The medical evidence does not support the services at issue in this case. Therefore, skilled nursing facility (SNF) services were not and are not medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested services 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 physical medicine and rehabilitation with sub-specialty certification in neuromuscular 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

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested authorization and coverage for the medication Omnitrope Pen 10. The submitted documentation does not support that the requested medication is medically necessary. In 2016, a published guidelines and recommendations for growth hormone (GH) use. These guidelines indicate that the decision to treat patients with idiopathic short stature (ISS) should be made on case-by-case basis. The guidelines also suggested that a follow-up assessment of benefit in Height SDS and psychosocial impact should be performed 12 months after GH initiation and dose optimization. In this case, the patient has been on growth hormone off and on due to a history of poor compliance. The patient has not started puberty yet, and he continues to maintain a delay in bone age versus chronological age. His last height prediction is more than the mid-parental height. The patient has been prescribed growth hormone therapy for 5 years, but he has shown a poor response to GH therapy, which could be due to poor compliance or partial resistance to growth hormone action. He has poor growth velocity despite the fact that he has been on growth hormone therapy, hence he did not experience any significant benefit from GH treatment. At the current stage, the patients predicted adult height is better than the mid-parental height, and growth hormone therapy has not benefited him in the past 5 years. Under these circumstances, the medical records do not support that there is benefit in treating this patient further with growth hormone therapy. Accordingly, Omnitrope Pen 10 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 reviewer is board certified in pediatrics, with subspecialty certification in pediatric endocrinology, 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 51-year-old female enrollee has requested the prescription drug Starlix for the treatment of her diabetes. Findings:  The physician reviewer found that this patient has diabetes, which was diet-controlled until recently. Progression of diabetes is consistent with elevated postprandial glucose levels and loss of early postprandial insulin response. The patient developed hypoglycemia with sulfonylurea. A glinide is a good choice for treatment of this patient. According to the patients Health Plan, Prandin is the preferred non-formulary medication, and Starlix may only be approved if the patient fails or has a reaction to Prandin. In this case, it is medically appropriate that Starlix should precede Prandin, as Starlix is less potent. Starlix may be safer in this patient, who is at risk for hypoglycemia.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for insertion of an artificial intervertebral disc at C5-6 and C6-7 for treatment of the enrollees spinal stenosis. Findings:  Three physician reviewers found that the evidence based medical peer-reviewed literature supports the use of two-level contiguous cervical artificial disc replacement (ADR) as an option over anterior cervical discectomy and fusion for the treatment of symptomatic degenerative disc disease. This patient presents with neck pain radiating into the left arm with weakness and numbness. Functional difficulty was noted in activities of daily living and work ability. Clinical exam findings are consistent with imaging evidence of degenerative disc disease at the C5-6 and C6-7 levels with plausible neural compression. Comprehensive conservative non-operative treatment has been tried and failed to provide sustained improvement. Final Result: Three reviewers determined that the procedure at issue was 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: All three physician reviewers 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

An enrollee has requested reimbursement for laboratory testing CPT 82523GA. N-terminal telopeptide of type I collagen (NTX) is a biochemical marker of type I collagen breakdown. Current data suggests that NTX measurement during the rapid phase of bone loss may be useful in assessing the rate of ongoing bone loss (Shieh, et al.). Higher levels of early post-menopausal NTX have been most strongly associated with greater bone loss across the menopausal transition, and more strongly associated with rate of bone loss in the lumbar spine than in the femoral neck. Prior studies have also found that higher levels of bone resorption markers are associated with faster rates of bone loss and it can be used in perimenopausal patients to determine those at higher risk of faster bone loss (Shieh, et al.; Vasikaran, et al.). NTX data is also used to monitor response to bisphosphonates for osteoporosis, as a decrease in NTX has been associated with an increase in spine bone density (Baxter, et al.). The measurement of the NTX was likely to be more beneficial for evaluation of this patients osteoporosis than standard available testing. The physician reviewer found that  results of the test can help determine secondary causes and management of the patients severe osteoporosis. Given these findings, the laboratory testing CPT 82523GA was likely to be more beneficial for evaluation of the patients osteoporosis than any available standard therapy.Findings:  Two of the three physician reviewers found the laboratory testing CPT 82523GA was likely to be more beneficial for evaluation of the patients osteoporosis than any available standard therapy.Final Result: The reviewers determined that the services at issue were likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Overturned

This patient is a 50-year-old female who presented to her primary care physician with a complaint of back pain in the lower left thoracic region and occasionally radiating down the left leg. She was referred to an orthopedist who ordered MRIs of the thoracic and lumbar spine which demonstrated abnormal signal in T9 and the adjacent right 9th and 10th ribs, suspicious for metastatic disease. Abnormal signal was also reported in T11 consistent with a hemangioma. A bone scan done in May 2006 showed increased activity in the left aspect of T9-10. CT scans were obtained to further evaluate for the possibility of metastatic disease. The CT scans of the chest, abdomen and pelvis showed non-specific changes in the thoracic spine and a probable benign lesion in the lower pole of the left kidney and some small ovarian cysts. No masses or metastatic disease were identified. Tumor markers including CEA, CA 125, CA 15-3, and CA 19-9 were also obtained and were within normal range. The patient is now requesting reimbursement for the CT scans. The Health Plan denied her request indicating these diagnostic procedures were not medically necessary.The CT scans were ordered because both the MRI and the bone scan done previously suggested the possibility of metastatic disease. The CT scans were part of a diagnostic work-up based upon the patients symptoms and findings from other imaging. Katagiri, et al found that in a retrospective review of 64 patients presenting with symptoms of skeletal metastases, CT scan was essential in making the diagnoses for 78% of lung cancers, 80% of hepatocellular carcinomas, 100% of renal cancers, and 100% of pancreatic cancers. CT scans are clearly indicated when metastatic disease is suspected. Therefore I have determined the diagnostic procedures at issue were medically necessary for evaluation of the patients medical condition. The Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Upheld

The patient is a 17-year-old female who has hidradenitis suppurativa. She has been treated with oral antibiotics. She has had unspecified topical treatments. Her physician has requested coverage for laser hair destruction for the patients hidradenitis and possible folliculitis. The Health Plan has denied the request on the basis that laser hair destruction is not medically necessary for treatment of the patients medical condition.Laser therapy other than CO2, has not been described specifically for hidradenitis.  In this case, there is no medical justification for laser hair destruction. Based upon the information provided, it does not appear the patient has undergone a full workup. In addition, it appears that conservative treatments have not been exhausted. Furthermore, the efficacy of the requested procedure has not been established in peer-reviewed medical literature. As such, there is no medical justification for use of laser hair destruction in this case. Therefore, I have determined that the requested procedure is 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 authorization and coverage for a LINX Reflux Management System (LINX device) with cruroplasty. Current medical literature has not established the safety and efficacy of the LINX procedure. Lipham and colleagues note in a multicenter, prospective, single-arm study of patients, that sphincter augmentation with the LINX Reflux Management System provided long-term clinical benefits without safety issues, as demonstrated by reduced esophageal acid exposure, improved quality of life related to gastroesophageal reflux disease (GERD), and cessation of dependence on proton-pump inhibitors (PPIs), with minimal side effects and no safety issues. However, Sheu and Rattner note that the long-term safety and efficacy of LINX  both alone and compared to current GERD therapies  remains to be determined. Bauer and colleagues note the possibility of adverse events, including erosion through the esophagus. The requested service has not been rigorously tested in randomized controlled trials against alternative therapies and therefore, it is not possible to not establish an individualized benefit in this case. Due to the lack of consensus among national and local health care providers, there are no set standard protocols regarding the terms and conditions for use. Therefore, a LINX Reflux Management System (LINX device) with cruroplasty is not likely to be more beneficial for treatment of the patients condition than any available standard therapy.Final Result: The reviewers determined that the requested service 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: Physician reviewers 1, 2, and 3 are board certified in internal medicine with sub-specialty certification in gastroenterology and are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: A male enrollee has requested authorization and coverage for trigger point injections for treatment of the enrollees thoracic spondylosis.  Findings:  The physician reviewer found that the request for trigger point injections are not medically necessary for treatment of the patients medical condition. The documentation provided for review shows the patient is being treated for thoracic pain after a motorcycle accident in 2009. Trigger point injections are indicated when there is documentation of the presence of a twitch response as well as referred pain and after a failure of conservative treatments. In this case, the presence of a twitch response with referred pain pattern is not documented in the information provided for review. Additionally, the degree and duration of pain relief after the previous trigger point injection procedure is not documented. For these reasons, the requested services are not considered medically necessary for the 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 physical medicine and rehabilitation 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

A 50-year-old female enrollee has requested lumbar spinal fusion at L5-S1 for treatment of her low back pain with left lower extremity radiculopathy.  Findings:  The physician reviewer found that the Milliman Care Guidelines (MCG) and National Imaging Associates (NIA) criteria for decompression and fusion require a detailed history, physical, and neurological exam. The guidelines state that an indication for the procedure may include spondylolisthesis, stenosis with neurogenic claudication, instability, scoliosis, recurrent herniated nucleus pulposus (HNP), infection, cauda equine syndrome, new or progressive neurologic deficit, tumor, or hematoma, as well as imaging studies matching the patients clinical condition. This patient has chronic back and left leg pain. She is said to have a radiculopathy, but there is no substantiating history or physical exam with motor, sensory, and reflex findings to support a diagnosis of radiculopathy (Tarulli and Raynor). The operative report noted the nerve roots were decompressed on the date indicated. However, no trauma, accident, or injury occurred subsequent to the decompression on the date indicated to cause stenosis in such a short time period. The patients records only document one injection post-operatively. The records do not demonstrate the presence of recurrent HNP, evidence of recurrent stenosis, instability, or infection. Further, she does not have a progressive neurologic deficit or cauda equine syndrome. Consistent with these findings, the proposed decompression or the proposed decompression and fusion is not medically necessary for treatment of this patients medical condition.