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 bilateral genicular nerve block with ultrasound guidance. This patient presents with ongoing knee pain with imaging demonstrating progression of severe right patellofemoral arthrosis, moderate joint effusion with synovitis, and a large Bakers cyst with synovitis. The provider has recommended treatment with genicular nerve blocks. Genicular nerve blocks and genicular nerve ablations have been demonstrated to be effective in the treatment of patients with chronic knee pain. Studies have demonstrated that when a patient experiences significant pain relief and functional benefit with genicular nerve blocks, ablation of the nerves can provide longer-term pain relief (Fitzpatrick, et al.; McCormick, et al.). The requested genicular nerve block is a minimally invasive procedure compared to knee surgery and is indicated to be performed as a treatment option prior to more invasive surgery. Therefore, the requested bilateral genicular nerve block with ultrasound guidance 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 bilateral genicular nerve block with ultrasound guidance 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 reviewer 1 is board certified in physical medicine and rehabilitation with subspecialty certification in pain management and is actively practicing. Physician reviewer 2 is board certified in anesthesiology with subspecialty certification in pain management and is actively practicing. Physician reviewer 3 is board certified in anesthesiology with subspecialty certification in pain management 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 Monovisc injection in the right knee.Current medical literature pertaining to viscosupplementation reveals mixed results. Evidence from eight systematic reviews and six randomized controlled trials indicates that although viscosupplementation may relieve knee pain in some individuals with osteoarthritis, it is not known which individuals will benefit. Different studies have tried mixing hyaluronic acid with corticosteroids, platelet-rich plasma, and other agents to make it more effective. The current evidence is limited, and guidelines from organizations such as the American Academy of Orthopedic Surgeons indicate that the evidence is not conclusive. As such, the Academy does not currently support viscosupplementation as standard treatment for osteoarthritis of the knees. In light of the foregoing, viscosupplementation can only be recommended in individuals with a history of lasting benefit from prior injections, and in carefully selected cases where everything else has been tried, and the options are limited. In this case, the patients options are clearly limited. The patient has tried and failed other conservative treatments with the alternative being a total knee arthroplasty for mild to moderate osteoarthritis. Under these circumstances, the requested Monovisc injection in the right knee is medically necessary to treat the patients medical condition.Final Result: The reviewer determined that the requested services are medically necessary to treat 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: Overturned

Nature of Statutory Criteria/Case Summary: The patient is a transgender female who was diagnosed with gender dysphoria. The enrollees provider noted that the hair on the patients face, chest, and stomach exacerbated her gender dysphoria and caused stress, anxiety, and depression. The patient has requested reimbursement and prospective authorization and coverage for previous and future laser hair removal. The presence of facial hair causes many transgender women distress due to gender dysphoria. Findings:  The physician reviewer found that a nationally recognized health organization lists facial hair removal as a medically necessary treatment. Hair removal through electrolysis and laser treatments are options to help alleviate gender dysphoria. Hormone therapy alone is insufficient for complete facial and body hair removal. Current medical evidence supports the services at issue in this clinical setting. Therefore, laser hair removal was and is medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested service was and 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 psychiatry 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: An enrollee has requested reimbursement for all or any of the residential treatment center services provided. Review of the submitted documentation supports the medical necessity of the services at issue. The patient had failed a step-down to lower level of care. Medical guidelines recommend  that residential treatment or similar care higher than outpatient is indicated for patients who do not meet the clinical criteria for hospitalization but whose lives and social interactions have come to focus predominantly on substance use[and who] lack sufficient social and vocational skills and drug-free social supports to maintain abstinence in an outpatient setting. The submitted documentation demonstrates the patient required a safe and stable living environment in order to develop his recovery skills. As such, he met criteria for American Society of Addiction Medicine (ASAM) Level III treatment, which includes residential treatment level of care. All told, the residential treatment center services were in accordance with generally accepted standards of medical practice and clinically appropriate for the patient's illness; therefore, the services at issue were medically necessary.Final Result: The reviewer determined that the services at issue were 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 psychiatry 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

A 29-year-old male enrollee has requested for a Medtronic continuous glucose monitoring system for treatment of his type I diabetes. Findings:  Three physician reviewers found that since their inception several years ago, continuous glucose monitoring systems have proven to be useful tools in finding unexpected hypo and hyperglycemia in insulin treated patients who are not in good control. Recent reports of monitoring of up to three months have shown improvement in A1C levels as well as in detecting unexpected hypo and hyperglycemia.The requested CGMS device is not experimental and its use in this setting is clinically indicated. The patients endocrinologist should monitor the patients use of the CGMS several times a year to help guide changes in his food intake and insulin regimen.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient is a 54-year-old male who was diagnosed with erectile dysfunction and Peyronie's disease. The patient had an episode of ischemic priapism, which was likely secondary to medication management of his bipolar disorder. The patient was treated with an operative shunt. Since the time of shunt placement, intracavernosal injections and vacuum erection devices have failed to provide adequate penile tumescence for penetration. The patient has requested coverage for a penile prosthesis. The Health Plan denied the request and reported that the requested device is not medically necessary for the treatment of this patient. At issue in this case is whether a penile prosthesis is medically necessary for the treatment of the patients medical condition. Studies show that a penile implant is a reliable and safe solution for the management of erectile dysfunction, resulting in high couple satisfaction ratings. Patients diagnosed with concomitant Peyronies disease and erectile dysfunction can safely and effectively have an inflatable penile prosthesis placed with similar outcomes as patients without Peyronies disease. In this case, the patient has failed pharmacologic and mechanical treatment to provide functional erections. End-stage erectile dysfunction after ischemic priapism often leads to a penile prosthesis being the final treatment option for achieving adequate erections to maintain sexual activity. The medical evidence supports the requested device in this clinical setting. Therefore, the requested penile prosthesis is medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested services are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in urology 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:  An enrollee has requested a Botox injection on the forehead for treatment of his hyperhidrosis. Findings: The physician reviewer found that hyperhidrosis is excessive sweating beyond that required to return body temperature to normal. It can be localized or generalized, commonly affecting the axillae, palms, soles or face, and can have a substantial negative effect on a patients quality of life. Botox acts by inhibiting the release of acetylcholine at the presynaptic membrane of cholinergic neurons. Botox has revolutionized the treatment of focal hyperhidrosis in recent years and has dramatically reduced the need for invasive surgical techniques to control severe focal hyperhidrosis unresponsive to topical therapies. There is growing evidence that Botox is an efficient and appropriate treatment for forehead hyperhidrosis. Previous treatment of this patient with Botox has been very effective. Therefore, it should be considered as the most appropriate and should not be substituted with other methods or surgery. Consistent with this support, the requested Botox injections on the forehead is medically necessary for treatment of this patients hyperhidrosis. Final Result: The reviewer determined that the requested medication is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.  Credentials/Qualifications: The reviewer is board certified in dermatology 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

A 29-year-old female enrollee has requested coverage for percutaneous neuromodulation therapy (PNT) for treatment of her spinal pain.Findings:  Three physician reviewers found that a review of the national treatment guidelines indicates PNT is an investigational treatment. Studies such as the Balzar study have demonstrated some initial promise, but lack a control group or data on long-term outcomes. Additional clinical study is needed before PNT can be recommended for the treatment of spinal pain.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a five-year-old male enrollee has requested coverage for speech therapy for treatment of the enrollees autism.  Findings:  The physician reviewer found that this young patient has developmental delays including the lack of recognizable speech by the age of five-years. Speech therapy for this patient is necessary, as he has no speech and can only communicate by grunts and primitive sign language. The patient has a congenital brain disorder, probably of genetic etiology, as his twin brother has the identical disorder. His inability to speak is due to a failure of brain development, which does not differ significantly in speech failure from the dominant hemisphere infarct in a stroke patient. The acquisition is different but the end deficit is similar and speech therapy is required by patients with either of these conditions. The publication by Stone and Yoder reviewed 35 autistic children and reported that the acquisition of speech was directly dependent on the numbers of hours the patient received in speech therapy. This is reiterated by Myers and colleagues who state that speech therapy is necessary in the autistic child as patients with autism spectrum disorders have deficits in social communication, and treatment by a speech-language pathologist usually is appropriate. Goldstein reports the success of varying techniques of speech therapy as being successful in autistic patients. Moreover, the report by the Speech-Language-Hearing Association states that speech therapy is effective at any age for autistic patients.  Based upon the available scientific data as well as this patients severe speech and language delays, I have concluded that speech therapy is medically necessary for management of his condition as recommended by his provider.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested laparoscopic radiofrequency ablation for treatment of her symptomatic uterine fibroids. Three physician reviewers found that the requested services are not likely to be more effective for this patient than other available options. There are an number of non-surgical and surgical treatments options for heavy periods and fibroids, including nonsteroidal anti-inflammatory drugs (NSAIDs), progestins, oral contraceptives, Lupron, uterine artery embolization, minimally-invasive surgery such as laparoscopic myomectomy, and abdominal myomectomy or hysterectomy, which can also be done in a minimally-invasive fashion (mini-laparotomy). Radiofrequency ablation is a new alternative, with initial small studies indicating that in appropriate patients it may become a reasonable surgical alternative for patients with fibroids. Given that this is a relatively new procedure, the studies available are mostly observational studies. Although this procedure may be an option for patients with fibroids in the future, there is still insufficient evidence available at this time to conclude that it is more beneficial than other available treatments. As such, the requested services are not likely to be more beneficial for treatment of the patients medical condition than other standard therapies.  Final Result: Three reviewers determined that that the requested services are 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 obstetrics and gynecology 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:   An enrollee has requested inpatient mental health services for treatment of her behavioral health conditions. Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the services at issue. The American Psychiatric Associations clinical practice guideline supports placement in the least restrictive setting. In reviewing the symptom severity, the psychiatric admission history anticipated a five-day hospitalization.  Further, the documentation noted the absence of suicidality and medical comorbidity besides hypertension and obesity.  There was no mention of cognitive impairment, psychosis or posttraumatic stress disorder symptoms in the psychiatry note, while substance use and alcohol consumption were denied.  The physical examination was unremarkable.  She denied hallucinations or thoughts of self-harm.  In terms of support, the patients spouse was involved in her treatment.  The patient had a psychiatrist in the community and was receptive to an intensive aftercare program.  Regarding level of functioning, the patient was attending to activities of daily living and self-ambulatory.  Although distressed, she commanded the cognitive faculties needed to address her discord.   All told, inpatient mental health services were not and are not medically indicated for the treatment of this patient.   Final Result: The reviewer determined that the services at issue 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 psychiatry 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 reimbursement for computed tomography (CT) coronary angiography.Findings:  Two physician reviewers found that the preparation for ablation procedures involves imaging of the left atrium and the pulmonary veins.  This is done in order to define the anatomy of the pulmonary veins which is essential to the safety and success of the ablation procedure. There are different imaging techniques for this purpose, including CT coronary angiography, cardiac magnetic resonance imaging (MRI), or transesophageal echocardiography by ultrasound.  The use of these techniques is well accepted and considered standard for ablations.  There is sufficient support for the services at issue in this clinical setting.  Final Result: Two 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. Credentials/Qualifications: All physician reviewers are board certified in internal medicine with sub-specialty 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.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary:    An enrollee has requested a magnetic resonance imaging (MRI) of the left hip, and/or left upper leg, and/or left lower leg, and/or left foot for evaluation of her left leg pain.  The physician review found that according to the providers note, the patients symptoms may be related to L4 radiculitis. In addition, the recent MRI scan of the lumbar spine revealed findings which are compatible with nerve compression at the L4 and L5 levels. Thus, the additional imaging requested by the patient is not indicated until she has been evaluated by a spine specialist who can correlate the abnormal spinal MRI findings with the patients clinical symptoms. Also, due to the negative physical exam of the left leg including a negative Homans sign there are no clinical signs to indicate further testing for deep venous thrombosis. If there are any clinical findings which become suspicious for deep venous thrombosis, then a venous ultrasound would be indicated at that time. However, based on the available information, the requested MRI of the left hip, left upper leg, left lower leg, and/or left foot are not supported as medically necessary for evaluation and treatment 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 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

The patient is a 46-year-old male who had a malignant melanoma, stage 2, depth of invasion of 0.76 mm with partial regression excised by an out-of-network head and neck surgeon in June 2005. The lesion was on the left posterior scalp. Previously, he went to an in-network dermatologist in 2003. The dermatologist froze the lesion with liquid nitrogen. The spot became larger and darker. In 2004, the dermatologist froze the lesion again. In April 2005, because the spot was larger and darker, the primary care physician again referred the patient to the in-network dermatologist who wanted to again treat the lesion with liquid nitrogren. The patient requested a biopsy, which revealed a melanoma.The patient is now requesting follow-up total body skin exams from an out-of-network provider. The Health Plan has denied the patients request indicating that the proposed care is within the scope of practice of the patient primary care physician or the in-network dermatologist.The patient has malignant melanoma and is status post recent excision. It is not within the primary care providers scope of practice to access this melanoma patients skin for recurrent or new melanoma. Furthermore, the patient indicates the in-network dermatology clinic, which has treated him in the past is the only dermatology clinic available in-network. The Health Plan has not provided evidence another in-network dermatology clinic is available to provide follow-up care for the patient. Therefore, I have determined the requested referral is medically necessary for evaluation of the patients medical condition. The Health Plans denial should be overturned.