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

Nature of Statutory Criteria/Case Summary:  An enrollee has requested authorization and coverage for an orthopedic specialist consult. Findings:  The physician reviewer found that Kane and colleagues state, Double crush syndrome is a distinct compression at two or more locations along the course of a peripheral nerve that can coexist and synergistically increase symptom intensity. The authors conclude, Treating practitioners should be aware of the possibility of concomitant cervical radiculopathy and carpal tunnel syndrome, as well as the presence of underlying systemic neuropathy. In this case, the patient had positive Tinels test and Phalens test. Additionally, the patient has been treated with nonsteroidal anti-inflammatory drugs (NSAIDs), wrist brace, and gabapentin, without significant improvement. X-rays of the cervical spine revealed moderate encroachment right C5-6 level, further complicating the diagnosis. Given that there were sufficient records supporting carpal tunnel syndrome, along with the uncertainty of cervical spine involvement, an orthopedic hand/upper extremity specialist consult would be appropriate. Therefore, the requested orthopedic specialist consult is medically necessary for treatment of the patients medical condition.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 overturn.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

The patient is a 12-year-old male who has been followed conservatively for short stature for some years. He has a diagnosis of constitutional delayed adolescence. However, in February 2006 he was noted to have a bone age which was not delayed, being reported at 11 years but read by his endocrinologist at 10-11 years. He has had a modest growth rate of 3.6 cm/year at the time of the office visit.  Using his height and a bone age of 11 years, his adult height prediction from the Greulich and Pyle tables would approximate 54.7 inches. If the patients endocrinologist is correct in her bone age reading, the patient might grow to 56.3 (at a bone age of 10 years). The work-up has excluded several endocrine causes of short stature including GH deficiency. At issue is whether growth hormone therapy is medically necessary for treatment of the patients medical condition.This patient with idiopathic short stature has an adult height prediction that is in the low normal range and would not strictly fit all of the FDA criteria of July 2003 for GH therapy for idiopathic short stature. Although GH therapy for idiopathic short stature is considered a medically approved application, in this instance the patients degree of short stature and his adult height prediction do not rise to the level of medical necessity. Therefore, I have determined the requested therapy is not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned

The patient was diagnosed with bilateral knee osteoarthritis. The patient has been treated with bilateral knee surgeries and multiple bilateral knee viscosupplementation injections. The patient reported significant improvement with prior knee viscosupplementation injections. A few months after, the patient reported left knee pain. Physical examination findings included tenderness over the medial left knee. The patient has requested authorization and coverage for Supartz (hyaluronic acid) injections in both knees. The Health Plan denied the request and reported the requested services are not medically necessary for the treatment of this patient. At issue in this case is whether Supartz (hyaluronic acid) injections in both knees are medically necessary for the treatment of the patients medical condition. Review of the current medical literature pertaining to viscosupplementation reveals mixed results.  Although viscosupplementation may relieve knee pain in some patients with osteoarthritis, it is unknown which patients will benefit. Viscosupplementation can only be recommended in patients with a history of lasting benefit from prior injections and in carefully selected cases where the options are limited. A clinical trial found that viscosupplementation increased functional scores in patients with severe osteoarthritis of the knee, especially within three months of injection. In this case, viscosupplementation has been tried for several years, with favorable results. Furthermore, the patients options are limited. The patient has tried and failed conservative treatments with the alternative being a total knee arthroplasty. The medical evidence supports the requested services in this clinical setting. Therefore, Supartz (hyaluronic acid) injections in both knees are 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 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: An enrollee has requested reimbursement and prospective authorization and coverage for any or all of the chiropractic services utilizing the Thompsons method and trigger-point therapy provided from beginning of April 2021, and onward for a total of 16 visits over a 12-month period.The medical literature supports the use of chiropractic treatments and trigger point therapy for low back pain. A study by researchers found, compression at myofascial trigger points (MTrPs) is effective to treat acute low back pain compared with compression at non-MTrPs and superficial massage. A study by medical literature found, At 12 weeks, the greatest differences from the no-manipulation control were found for 12 sessions. The authors concluded, 12 visits yielded the most favorable results. In this case, the patient is experiencing ongoing chronic low back pain and has received chiropractic treatments in the past. Additionally, the requested services exceed the number of visits indicated by the medical literature. The medical literature only supports 12 of the 16 requested chiropractic visits. Therefore, the chiropractic services utilizing the Thompsons method and trigger-point therapy provided from beginning of April 2021, and going forward for a total of 12 visits over a 12-month period were and are  medically necessary for treatment of the patients medical condition.Final Result: The reviewer determined that some of the services at issue were and are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be partially overturned.Credentials/Qualifications: The reviewer is board certified in chiropractic 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 53-year-old female who is seeking authorization for the medication Provigil for treatment of idiopathic hypersomnolence. Clinical findings include severe daytime sleepiness, debilitating fatigue and sleepiness associated with chronic pain, a previous episode of encephalitis, and chronic pain syndrome with severe head pain. A prior polysomnography demonstrated periodic limb movement disorder. The patient has attempted a number of medications without benefit. The patients provider has recommended Provigil. The Health Plan has denied authorization for Provigil.The patients episode of encephalitis has resulted in chronic pain leading to treatment with many different medications including analgesics and various forms of benzodiazepines. Based upon the information submitted, it is not clear that a diagnosis of idiopathic hypersomnolence has been established. For example, her sleep study actually provided a different diagnosis (restless leg syndrome) than idiopathic hypersomnolence. Furthermore, there is potential her medication regimen is responsible for the fatigue and, according to the patient, some of her sleep disturbance is related to her chronic pain. For these reasons, a diagnosis of idiopathic hypersomnolence has not been established. Therefore, I have determined the requested medication is not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for an amniotic membrane graft. This patient has a history of persistent neurotrophic keratitis in the right eye. The provider performed an in-office procedure to place an amniotic membrane over the cornea. The evidence for the efficacy of amniotic membrane for use in this clinical setting is limited. Although this patients condition did not substantially improve with Timolol ophthalmic solution, prednisolone acetate ophthalmic suspension, and Polytrim, there are remaining established therapies including Oxervate available for use in this patients care. All told, the amniotic membrane graft was likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Findings:  Three of the three physician reviewers found the amniotic membrane graft was likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Final Result: The reviewers determined that the services at issue were likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: Physician reviewers 1, 2, and 3 are board certified in ophthalmology 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

A 52-year-old female enrollee has requested bilateral replacement of breast implants due to a ruptured right breast implant/injury for treatment of her medical condition. Findings:  The physician reviewer found that this patients initial bilateral breast augmentation was a cosmetic surgery. If a patient were to have painful symptomatic grade IV capsular contracture and/or rupture of a silicone gel implant, its removal with a capsulectomy would be considered medically necessary and not cosmetic. Such removal of the capsule and implant with or without placement of a new implant would alleviate any pain and would prevent migration of the gel to adjacent areas where it could cause additional medical problems. In this patients case, it is reported that her implants were saline and not silicone. In any event, surgery for visible but non-painful capsular contractures (Grade III), or palpable but not visible or painful capsules (Grade II) would be considered cosmetic in nature and not medically necessary. Replacement of this patients saline implants (originally placed for cosmetic reasons) with new breast implants would not be considered medically necessary. In the absence of the presence of silicone gel or painful capsular contracture (as is the case here as this patient has reported pain only immediately following the implant rupture), any implant related surgery including implant removal would be considered cosmetic and not medically necessary under general concepts of medical necessity. This determination is independent of whom or what caused the rupture of the saline implant. Furthermore, the patients present right breast condition, containing a ruptured right saline breast implant, does not constitute an abnormal structure of the body. It is a normal breast, as per the mammogram results, albeit with a deflated saline implant.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a 16-year-old male has requested past and future coverage for residential treatment level of care services and partial hospitalization program level of care services for various dates at issue for treatment of his behavioral health issues.   Findings:  The physician reviewer found that according to the patients admitting and discharge notes, he was admitted to work on the issues of lying, maintaining peer relationships, mood management and continued abstinence from marijuana. Prior to this admission, the patient had been treated in a wilderness program. There is no evidence in the record that the patient was uncooperative, either at admission, or during his treatment. He never was noted to be a danger to himself or to others. He had no medical issues that required 24-hour monitoring and had the ability to perform his routine activities of daily living (ADLs). For these reasons, he does not meet the Milliman Care Criteria for partial hospitalization program (PHP), or residential treatment center (RTC) services. Additionally, since his discharge from the wilderness program, there was no evidence that he was unable to control his marijuana usage or that virtually all of his daily activities revolved around it. Thus, he does not meet the Texas Commission on Alcohol and Drug Abuse (TCADA) treatment guidelines for PHP or RTC level of care services from the date at issue and forward. The record contains one note labeled as a 15-minute addendum. Since the provider was monitoring the patients medication, these services were medically necessary. From the record, the provider did a routine check on a date at issue, and made an addendum to this record on said date. As such, this brief visit with a 15-minute addendum was considered medically necessary for his care as part of his routine medication management. However, the remainder of services including RTC services are not supported as medically necessary based on the records provided for review.
Appeal type: Medical Necessity
Decision: Upheld

The parent of a 16-year-old female enrollee has requested  for acute inpatient psychiatric services for treatment of her depression. Findings:  The physician reviewer found that according to the record, she reported feeling suicidal with a plan to her school counselor and refused to contract for safely upon admission. The enrollee also had an acute psychiatric admission approximately one month earlier. Her admitting diagnoses included major depression, post-traumatic stress disorder and parent-child relational problems and she was taking Lexapro for depression. The enrollees treatment plan included individual therapy, group therapy and family therapy. There is a reported history of severe family conflict and a remote history of physical abuse and there was reluctance on the part of the enrollee to return home.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested genetic sequencing for periodic fever syndrome. Findings:  Three physician reviewers found that this patient has an unknown inflammatory disease and while the genetic sequencing for periodic fever syndrome and autoinflammatory disease is not 100% sensitive, medical studies support the use of this test for this patient. Medical studies have shown that genetic sequencing may help distinguish between diagnoses such as, tumor necrosis factor receptor-associated periodic syndrome (TRAPS); Familial Mediterranean fever (FMF); Hyper-IgD syndrome (HIDS); periodic fever, aphthous stomatitis, pharyngitis and cervical adenitis (PFAPA), to name a few. These are usually pediatric conditions; however, these conditions can occur in adults and can be difficult to diagnose. As in this case, most rheumatologists would obtain testing when they are unsure of the diagnosis and are considering treatment options. Many patients with autoinflammatory disease have a heterogeneous disease course and have incomplete symptoms so not all have the classic disease manifestation, thus making diagnosis difficult. The use of genetic sequencing may provide a definitive diagnosis and may present a better option for the patient prior to initiating treatment. For all these reasons, genetic sequencing is likely to be more efficacious than standard methods of evaluating this patients periodic fever syndrome.  Final Result: Three reviewers determined that the requested services are 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 three reviewers are board certified in rheumatology, 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 40-year-old female enrollee requested MiniMed 530G with Enlite (E0784, A9277 and A9276 for medical treatment of her diabetes.  Findings:  Three physician reviewers found that the requested equipment is likely to be superior over other available options.  The medical records are consistent with some degree of hypoglycemic unawareness.  The MiniMed 530G with Enlite is likely to lower the amount of time this patient spends in the hypoglycemic range overnight.  There is sufficient support for the requested equipment in this clinical setting.  Thus, the requested MiniMed 530G with Enlite (E0784, A9277 and A9276) is likely to be more efficacious than other available alternatives.
Appeal type: Medical Necessity
Decision: Overturned

The patient has requested authorization and coverage for nose reconstruction surgery (CPT 30450  rhinoplasty secondary major revision; 21230  graft rib cartilage autogenous face/chin/nose/ear). The records provided for review support the presence of a functional complaint with physical examination findings consistent with a functional issue given the presence of both internal and external nasal valve collapse. Additionally, the two prior surgeries were reportedly undertaken for a functional issue, and the second surgery was related to a traumatic event. The proposed surgery is typically undertaken to improve function by opening the nasal airway. The proposed grafts are to open the nasal airway at the internal nasal valve, and to prevent the nostril from collapsing during inspiration. Furthermore, as the patient has already undergone a prior septoplasty, and prior ear cartilage graft harvest at his previous two procedures, use of costal cartilage is an appropriate graft option. Given these findings, the requested nose reconstruction surgery (CPT 30450  rhinoplasty secondary major revision; 21230  graft rib cartilage autogenous face/chin/nose/ear) is medically necessary for treatment of this patient. The California reconstructive surgery statute requires health insurers to cover reconstructive surgeries, defined as surgery performed to correct or repair abnormal structures of the body caused by congenital defects, developmental abnormalities, trauma, infection, tumors, or disease to do either of the following: (1) to improve function; (2) to create a normal appearance, to the extent possible. The medical records note that this patient has a history of nasal obstruction and trauma that has been treated with nasal steroid sprays and two surgeries. The requested surgery will address the patients functional issues and was recommended to improve the patients breathing. All told, the requested nose reconstruction surgery (CPT 30450  rhinoplasty secondary major revision; 21230  graft rib cartilage autogenous face/chin/nose/ear) is reconstructive in nature for treatment of this patient.Final Result: The reviewer determined that the requested services are medically necessary and reconstructive in nature 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 prescription medication Trulance 3 mg tablet, once a day. Findings:  The physician reviewer found that the U.S. Food and Drug Administration approves the use of Trulance for the treatment of chronic idiopathic constipation (CIC). Miner and colleagues found that plecanatide was effective in improving constipation and its related symptoms with a low rate of adverse events. Chey noted that the American College of Gastroenterology (ACG) includes fiber, stimulant laxatives, and lubiprostone as evidence-based approaches to managing IBS and CIC. In this case, the patient has constipation without an identifiable cause on clinical examination or colonoscopy. Current guidelines recommend the use of stimulant laxatives and osmotic laxatives, and then advanced agents, such as Linzess and Amitiza. The current guidelines do not recommend attempting Trulance before the formulary alternatives Linzess or Amitiza. Therefore, prescription medication Trulance 3 mg tablet, once a day is not medically necessary for the treatment of this patient.   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 internal medicine with sub-specialty certification in gastroenterology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

A male enrollee requested semimembranosus tenotomy and exploration of the sciatic nerve for medical treatment of his hamstring tendinosis.   Findings:  The physician reviewer found that the requested semimembranosus tenotomy and exploration of the sciatic nerve is not medically necessary for treatment of this patients medical condition.  There is a lack of clinical justification for exploration of the sciatic nerve or release of the semimembranosus tendon. There is no indication that he has piriformis syndrome or significant hamstring pathology. Thus, the requested semimembranosus tenotomy and exploration of the sciatic nerve is not supported as medically necessary.