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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for vein embolization and sclerotherapy. Pelvic congestion syndrome has been suggested to include symptoms such as pelvic pain, heavy menstrual bleeding, vaginal and vulvar varicosities, and painful intercourse. Diagnosis is corroborated by the radiological finding of dilated ovarian and other pelvic veins. The records provided for review document that imaging findings were consistent with severe gonadal vein reflux and dilated pelvic varicosities, including vulvar varicosities. A computed tomography (CT) of the abdomen and pelvis revealed prominent bilateral gonadal veins, with prominent bilateral adnexal, periuterine and perivaginal veins, prominent superficial veins in the left upper thigh, and sclerotic changes on the iliac side of the sacroiliac joint. The patients provider has recommended treatment with vein embolization and sclerotherapy. Recent studies suggest that ovarian and pelvic vein embolization can be performed with a high safety rate, excellent radiological success, and good clinical improvement at two-year follow-up (Hansrani, et al.; Gloviczki, et al.; Daniels, et al.). Given this support, the requested vein embolization and sclerotherapy are 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 vein embolization and sclerotherapy are 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 surgery with subspecialty certification in general vascular 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

The patient is a 58-year-old female who is status post gastric bypass surgery.  She has lost a significant amount of weight and had excess skin as a result, particularly in the abdominal area where there was a hanging panniculus. The patient reports a history of refractory skin rashes and/or infections.  Her primary care provider has not submitted documentation of a chronic skin condition that has persisted despite appropriate medical treatment. The patient was evaluated for panniculectomy and the procedure was performed in May 2006.  The patients request for reimbursement of the costs incurred was denied by the Health Plan due to a lack of medical necessity.While the patients history of infections may be correct, the submitted records do not document failed medical management of her intertrigo over an extended period of time such that surgery was the only treatment remaining to control her infections. Her condition did not meet the ASPRS criteria for third party coverage of skin resection following massive weight loss. According to the ASPRS Position Paper, Treatment of Skin Redundancy Following Massive Weight Loss, skin resection is medically necessary if panniculitis or uncontrollable intertrigo is present. The records do not document panniculitis or the failure of medically supervised conservative therapy to control such a condition. Surgical intervention should be reserved for patients that have failed optimal medical management for intertrigo, which is not the case for this patient. A panniculectomy was not medically indicated.Based upon the information set forth above, I have determined the procedure 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: The parent of an enrollee has requested reimbursement for food allergy panel testing. Findings:  Two of the three physician reviewers found that there is a lack of support for the services at issue in this patients case. A study noted testing for blood IgG against different foods is performed with large-scale screening for hundreds of foods. However, many serum samples show positive IgG results without corresponding clinical symptoms. These findings, combined with the lack of convincing evidence for histamine-releasing properties of IgG in humans, and lack of any controlled studies on the diagnostic value of IgG testing in food allergy, do not provide any basis for the hypothesis that food-specific IgG should be attributed with an effector role in food hypersensitivity. IgG diagnostic testing, which includes IgG food sensitivity and IgG subclass testing, is not clinically useful, relevant, or a valid method for evaluating for food allergy, or dermatitis due to an ingested food, or food intolerance that may be contributing to dermatitis or other skin or allergic condition. Therefore, food allergy panel testing was not likely to have been superior over other methods of evaluating this patient. Final Result: The reviewers determined that the services at issue were not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: Physician reviewers 1 and 3 are board certified in pediatrics and allergy and immunology and are actively practicing. Physician reviewers 2 is board certified in allergy and immunology 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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for services as recommended by Jonathan Goldman, MD including hold osimertinib, start carboplatin/pemetrexed with or without pembrolizumab followed by maintenance pemetrexed with or without pembrolizumab, dexamethasone prior to initiation, folic acid 1 mg tablet, megestrol 40 mg/mL suspension, cyanocobalamin 1000 mcg/mL inject 1000 mcg, and central nervous system (CNS) involvement, including a complete metabolic work-up for treatment of the enrollees epidermal growth factor receptor (EGFR) positive metastatic adenocarcinoma of the lung.  Findings:  The physician reviewer found that this is a patient with metastatic NSCLC who has been treated with chemotherapy and radiation therapy. Several studies have shown that systemic chemotherapy can prolong survival compared to best supportive care. Pemetrexed has also been shown to prolong survival in this clinical setting and is approved for use in advanced NSCLC by the U.S. Food and Drug Administration (FDA). All the recommendations provided by Dr. Goldman are medically necessary and appropriate. Thus, the requested services as recommended by Jonathan Goldman, MD including hold osimertinib, start carboplatin/pemetrexed with or without pembrolizumab followed by maintenance pemetrexed with or without pembrolizumab, dexamethasone prior to initiation, folic acid 1 mg tablet, megestrol 40 mg/mL suspension, cyanocobalamin 1000 mcg/mL; inject 1000 mcg, and CNS involvement, including a complete metabolic work-up are medically necessary for evaluation and treatment of this patients NSCLC. Final Result: The reviewer determined that the requested services are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in internal medicine with sub-specialty certification in medical oncology 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 implantation of the hypoglossal nerve stimulator (CPT 64568, 95970, and 0466T). The patient has obstructive sleep apnea (OSA) without evidence of nasal obstruction. A drug induced sleep endoscopy (DISE) demonstrated primarily anterior posterior collapse and no concentric collapse at the velum. The patient has not been able to tolerate treatment with a continuous positive airway pressure (CPAP) device. The patient is a candidate for hypoglossal nerve stimulation given his intolerance to CPAP, anterior posterior collapse, and lack of central apnea. The patient has a BMI of 34 kg/m2. However, an elevated BMI over 32 kg/m2 does not preclude the patient from undergoing hypoglossal nerve stimulation as the surgery is successfully performed in patients with a BMI over 32 kg/m2. All told, the requested implantation of the hypoglossal nerve stimulator (CPT 64568, 95970, and 0466T) is likely to be more beneficial for treatment of the patients condition than any available standard therapy.Findings:  Two of the three physician reviewers found the requested implantation of the hypoglossal nerve stimulator (CPT 64568, 95970, and 0466T) is likely to be more beneficial for treatment of the patients 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 reviewer 1 is board certified in otolaryngology and is actively practicing. Physician reviewer 2 is board certified in otolaryngology and is actively practicing. Physician reviewer 3 is board certified in internal medicine with subspecialty certification in sleep medicine 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: Upheld

Nature of Statutory Criteria/Case Summary: an enrollee has requested authorization and coverage for magnetic resonance imaging (MRI) (CPT code 73721). Findings:  The physician reviewer found that According to the medical literature MRI of the knee is not medically necessary in the absence of a detailed physical exam or in the absence of a supervised four week trial of conservative treatment, including analgesics, bracing, and physical therapy. In the absence of a detailed physical examination and documentation showing failure of conservative treatment. Final Result: The reviewer determined that the requested diagnostic procedure is not medically necessary for evaluation of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: the physician reviewer is board certified in diagnostic radiology 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 patients parent has requested authorization and coverage for an intensive inpatient feeding program, CPT codes 92526, 99223, and 99233. Current medical literature on pediatric feeding disorders supports the use of multidisciplinary programs that incorporate behavioral intervention with nutritional management. Romano and colleagues report that management of non-organic feeding disorders may be on an inpatient or outpatient basis. In an evidence-based systemic review, Gosa and colleagues concluded that joint nutrition and behavior intervention programs, systematic desensitization, and operant conditioning behavioral therapy approaches may be effective in improving the functional feeding and swallowing outcomes in children. In this case, the patient is four years old and does not eat solid food despite participating in outpatient feeding programs since age one-and-a-half. The records noted that the patient had undergone medical evaluation, including EGD, without explanatory findings, and was considered to have oral aversion and oral motor dysphagia. Although the patient has not yet developed pathological sequelae of the feeding disorder, such as being underweight or having a micronutrient deficiency, he is functionally disabled and at risk of complications due to his acceptance of a very narrow range of foods, and at this point, warrants a higher level of care. Given that the patient has not benefited from appropriate outpatient interventions for his highly atypical and age-inappropriate pattern of oral intake, the requested services are medically indicated. Therefore, an intensive inpatient feeding program, CPT codes 92526, 99223, and 99233 is medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested service is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in pediatrics with sub-specialty certification in pediatric 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: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The parent of a male enrollee has requested authorization and coverage for procedure codes 21143 for Lefort I osteotomy, and 21085 for impression and preparation for an oral surgical splint for treatment of the enrollees dentofacial deformity.  Findings:  The physician reviewer found that there is sufficient support in the medical literature for the requested procedures in this clinical setting. Based on the documentation and the photographs submitted, this patient has a well-documented maxillofacial skeletal deformity that cannot be corrected with orthodontics alone. This patient has significant overjet and overbite making it very difficult for the patient to chew his food. The proposed procedures would result in improved musculoskeletal and dento-osseous relationships and improvement in mastication. For these reasons, procedure codes 21143 for Lefort I osteotomy, and 21085 for impression and preparation for an oral surgical splint are medically necessary for treatment of this patients dental condition. With regards to whether the requested procedures are considered reconstructive in nature, the records reveal that this patient has well-documented maxillofacial skeletal deformity.  The etiology of maxillofacial skeletal deformities may be either congenital or acquired. Deformities may be evident at birth or may manifest during subsequent growth and development, creating functional and degenerative problems. The requested procedures will improve function and create a more normal appearance in this patients case. It will also result in improved musculoskeletal and dento-osseous relationships. Moreover, these procedures will allow improvements in mastication. All told, procedure codes 21143 for Lefort I osteotomy, and 21085 for impression and preparation for an oral surgical splint are reconstructive in nature for the treatment of this patients dental condition. Final Result: The reviewer determined that the requested procedures are medically necessary and are reconstructive in nature for treatment of the patients dental condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in oral and maxillofacial 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 parent of a 17-year-old female enrollee has requested for continued residential treatment for treatment of the enrollees behavioral health problems. Findings:  The physician reviewer found that the patient has not had adequate trials of treatment at less restrictive levels of care.According to the American Academy of Child and Adolescent Psychiatry (AACAP) practice parameters, the minimal standard recommendations for substance abuse treatment are as follows: (1) the need to provide a safe environment and the ability of the adolescent to care for him or herself; (2) motivation and willingness of the adolescent and his or her other family to cooperate with treatment; (3) the patients need for structure and limit-setting that cannot be provided in a less restrictive environment; (4) the existence of additional medical or psychiatric conditions; (5) the availability of specific types of treatment settings for adolescents; (6) the adolescents and his or her familys preferences for a particular setting; and (7) treatment failure in a less restrictive setting or level of care.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a 12-year-old male enrollee has requested 12 hours per week of direct applied behavioral analysis (ABA), 2 hours per week of ABA supervision and 2 hours per week of parent consult for treatment of the enrollees autism.  Findings:  The physician reviewer found that attempting to determine the effectiveness of ABA therapy in adolescents can be difficult, as most of the ABA literature is focused on its application to young children. As ABA therapy remains one of the few effective treatments of autism spectrum disorders (ASD), the medical communitys customary and usual prescription for an autistic child, is ABA therapy. The medical literature strongly supports the treatment of autism with ABA therapy in young children. ABA therapy is well-documented as being effective in significantly improving motor, verbal, and socially interactive skills in autistic children (Myers and Johnson). When reviewing ABA as effectively applied to adolescents and adults, there is limited literature substantiating its favorable effect on this population. As such, the appropriate duration of therapy for adolescents must be determined on an individual basis. In the case of this patient, a critical examination of the psychological study performed on date indicated, in comparison to earlier assessments, demonstrates the patient has clearly improved. The patients demeanor and his ability to cooperate during the exam is itself evidence of his significant behavioral improvement. As such, continuation of ABA therapy is medically appropriate and indicated for this patient. All told, 10 hours of ABA therapy per week is medically necessary for the patient. Additionally, supervision at a frequency of two hours per month is sufficient. Further, the parents have received much guidance in the past, and as such, one hour per month of parent consult is appropriate for reporting progress.
Appeal type: Medical Necessity
Decision: Upheld

Fifty-four year-old male is requesting authorization to proceed with the osteochondral autologous transfer system (OATS) procedure.  The patient has undergone three surgeries to his right knee. The most recent was an arthroscopic subtotal medial meniscectomy in July 2005. An MRI from May 2006 showed advanced osteoarthritic changes, a five millimeter osteochondral defect involving the medial femoral condyle surface and severe chondromalacia of the medial compartment. The patient was referred for a second opinion regarding a possible total knee arthroplasty. He was seen in July 2006 and the orthopedist noted a slight effusion, tenderness to palpation over the medial aspect of the right knee and no limp. X-rays of the right knee from October 2006 showed moderate to severe degenerative changes, joint effusion and a right medial femoral condyle osteochondral defect.Reviewers Findings:The reviewing physician concluded that the patient is not a good candidate for the requested procedure because of the diffuse nature of the arthritic changes in his knee. OATS procedures are typically utilized in young patients with focal osteochondral lesions and normal surrounding cartilage.  The patients diffuse arthritic changes and severe chondromalacia would make him a poor candidate for the procedure. There are other viable, non-operative measures still available to this patient.  Therefore, the Health Plan denial should be upheld.
Appeal type: Experimental/Investigational
Decision: Upheld

A 62-year-old male enrollee has requested authorization and coverage for proton beam therapy for treatment of the enrollees prostate cancer. Findings:  Three physician reviewers found that the patient has been diagnosed with adenocarcinoma of the prostate following a transrectal ultrasound-guided biopsy of the prostate.  After diagnosis, CT of the pelvis was performed, and this demonstrated mild prominence of the right seminal vesicle.  The patient has requested authorization and coverage for proton beam therapy.  The Health Plan has denied this request and reported that the requested services are investigational for the treatment of this patient.  In this patients case, the superior effectiveness of the requested services has not been established. This patient has low-risk prostate cancer, and National Comprehensive Cancer Network guidelines favor treatment in this clinical situation.  However, proton beam therapy has not been demonstrated to be superior to photon beam therapy in this clinical scenario.  The medical literature has not demonstrated an increased benefit of proton beam therapy over intensity modulated radiation therapy or image-guided radiation therapy for the treatment of this patient.  Although the provider noted that proton beam therapy would reduce the chance of developing a secondary malignancy, this has not been established by the current medical literature.  At this time, it has not been established that proton beam therapy is likely to be more efficacious than other treatment options in this patients case.