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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for radiofrequency ablation (RFA) (CPT code 64625). Schmidt and colleagues found that RFA may offer a potential benefit as a therapeutic modality, although limited data support its use as a primary treatment modality. Yang and colleagues concluded that the current evidence suggests that RFA can provide relief of pain that originates from the posterior sacroiliac joint complex. However, the authors noted that the literature is limited by variability in patient selection criteria, specific nerves targeted for ablation, and the types of RFA technology and technique utilized. This patient presents with complaints of grade 6/10 low back and buttock pain. Clinical examination findings revealed tenderness to palpation over the bilateral sacroiliac joints and two positive sacroiliac joint provocative tests. The patient has undergone two sacroiliac joint injections, most recently on 6/10/20, with 70% relief of pain for three weeks. She has reportedly exhausted conservative treatment including pain medications, anti-inflammatory medications, and physical therapy. Her provider has recommended RFA of the left sacroiliac joint. Current evidence-based peer-reviewed medical literature indicates that there are limited data supporting the safety and efficacy of RFA in this clinical setting. Moreover, there is a lack of large volume peer-reviewed outcome studies with long-term follow-up to support the use of RFA for this patient. For these reasons, the requested RFA (CPT code 64625) is not 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 RFA (CPT code 64625) is not 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 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 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: Medical Necessity
Decision: Upheld

A 58-year-old female enrollee requested upper extremity joint magnetic resonance imaging (right and left) for evaluation of the enrollees medical condition.  Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested services.  The current medical evidence does not support the requested magnetic resonance imaging in this clinical setting.  There are no red flags which would require upper extremity imaging, such as trauma, infection, or tumor.  The upper extremity reflexes are intact, and there is no atrophy or mass.  The patients physical examination did not address the rotator cuff of either shoulder, and there is no notation implying abnormality of the brachial plexus.  There is reference to a planned nerve conduction study.  Absent results of such an exam, there is no documented indication for upper extremity magnetic resonance imaging.  Also, there is no evidence that conservative management, including physical therapy, has been tried.  All told, upper extremity joint magnetic resonance imaging (right and left) is not medically indicated for the evaluation of this patient.
Appeal type: Experimental/Investigational
Decision: Upheld

A 38-year-old female enrollee requested authorization and coverage of a nucleoplasty. The Health Plan denied the request indicating that the requested procedure is considered investigational for treatment of the enrollees back pain.Three physician reviewers performed an experimental/investigational Independent Medical Review. All three physician reviewers concluded that the requested procedure is not likely to be more beneficial for treatment of the enrollee's medical condition than any available standard therapy. Because all three physician reviewers concluded that the requested procedure is not likely to be more beneficial for treatment of the enrollee's medical condition than any available standard therapy, the Health Plans denial has been upheld.
Appeal type: Medical Necessity
Decision: Upheld

A 63-year-old female enrollee has requested authorization and coverage for lumbar spinal fusion surgery at L4-5 with intervertebral device for treatment of the enrollees spinal stenosis.  Findings:  The physician reviewer found that based on review of the records provided, it is not medically necessary for this patient to undergo an anterior to posterior L4-5 fusion with intervertebral device combined with lumbar laminectomy and discectomy. A limited surgical approach is more likely to relieve the patients central spinal stenosis without the necessity for fusion. Instrumented fusion is most efficacious for documented instability either post fracture or acquired through degenerative or congenital spondylolisthesis. However, none of these diagnoses are reported in this patient. The presence of predominantly central spinal stenosis is likely to lend itself to a limited laminectomy and partial medial facetectomy without introducing instability. In the medical literature, Atlas and colleagues have documented, in a 10-year prospective observational cohort study of lumbar spinal stenosis, that patients initially treated with surgery had less severe leg pain symptoms and greater improvement in back specific functional status than non-surgically treated patients. This patient meets the criteria of severe spinal stenosis and the laminectomy approved by the Health Plan is medically appropriate and consistent with the standard of care in this setting. The issue of complex anterior to posterior fusion, as has been proposed in this case, is addressed by Deyo and colleagues in their recent publication. A retrospective cohort study of patients was performed on 31,543 patients who underwent surgery for spinal stenosis in 2004 with follow-up through 2008. Complex fusion combined with decompression had a higher re-operation rate at four years than other procedures. Consistent with these findings, the requested surgery has not been established as medically necessary for treatment of the patients spinal stenosis.
Appeal type: Medical Necessity
Decision: Overturned

A 19-year-old female enrollee has requested residential treatment center level of care for the treatment of her behavioral health issues. Findings:  The physician reviewer found that the overall medical documentation supports a finding of medical necessity for residential care for this patient. She was impulsive with mood instability and was unable to manage her own safety without high levels of staff support. The level of care provided is consistent with Child and Adolescent Level of Care Utilization System (CALOCUS) criteria as there was evidence of severe functional impairment in this case.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patients parent has requested reimbursement and prospective authorization and coverage for residential treatment center (RTC) services for 45 days. The records document that the patients mental health has deteriorated over the last year with significant depressive symptoms, suicidal ideation and near attempts. The patient has engaged in self-harm and reports auditory hallucinations. The patient has demonstrated a decrease in her ability to function and has not been able to sustain a functional level outside of the hospital setting for a prolonged time and has required treatment in the emergency department due to suicidal ideation. The patient presents with symptoms of gender dysphoria that should be further evaluated. Based on the current practice parameter from the American Academy of Child and Adolescent Psychiatry (AACAP), RTC has been the appropriate and least restrictive treatment setting for this patient. Given the level of ongoing, difficult to treat depression, suicidal ideation, and mood lability mixed with auditory hallucinations, the patient requires the supervision and monitoring provided at the RTC level of care. The records document the patient has been treated with several recent admissions and discharges. This suggests that the patient decompensates quickly after discharge. Recent sessions from therapy show that although the patient is not expressing overt suicidal ideation, is not stable for care in a less restrictive setting than RTC. Therefore, RTC services being provided for 45 days were and are medically necessary for treatment of this patient. Final Result: The reviewer determined that the services at issue were and are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in psychiatry with subspecialty certification in child and adolescent 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: Upheld

A 64-year-old male enrollee has requested an X-Stop Interspinous Process Decompression procedure for the treatment of his moderate lumbar stenosis and intermittent neurogenic claudication. Findings:  Three physician reviewers found that there are no long-term outcome studies to establish the safety and efficacy of the X-Stop device after the device has been implanted. The existing literature is all relatively short-term data.  There is some concern for subsidence of the implant over time and loss of its initial distracting effect on the osteoporotic spinous processes. This 64-year-old patient would present significant concerns for osteoporotic bone based on age alone. Furthermore, significant numbers for outcomes of X-Stop procedures have not been well-defined in the literature, especially in the mid-term and long-term. The gold standard procedure in this case is lumbar decompression using a traditional and simple laminectomy with in situ fusion which can be performed using the laminectomy local bone. This does not involve the placement of metallic spinal hardware adjacent to osteoporotic spinous processes. There is ample literature to support the gold standard simple laminectomy procedure and the laminectomy with in situ fusion. X-Stop is not the most appropriate procedure for this patient and is considered experimental for treatment of this patient.
Appeal type: Medical Necessity
Decision: Overturned

A female enrollee requested Harvoni for eight weeks for medical treatment of her chronic hepatitis C virus genotype 1b.  Findings:  Two physician reviewers found that as per the American Association for the Study of Liver Diseases (AASLD) and Infectious Diseases Society of America (IDSA) guidelines, all patients with chronic active hepatitis C are eligible for treatment and should be treated with U.S. Food and Drug Administration (FDA) approved antiviral therapy regardless of fibrosis score. All told, the requested Harvoni for eight weeks is supported as medically necessary for treatment of this patients hepatitis C infection.
Appeal type: Medical Necessity
Decision: Upheld

A 52-year-old female enrollee has requested chiropractic care for treatment of her pain. Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the services at issue.  The records do not demonstrate that additional chiropractic care was indicated during a specified time frame.  The submitted office notes do not include documentation indicating how the patient was responding to treatment on each office visit.  Additionally, the records do not show that periodic re-examinations were performed to document the patients progress.  There is a lack of support for the services at issue in this clinical setting.  All told, chiropractic care was not medically indicated.
Appeal type: Medical Necessity
Decision: Overturned

A 45-year-old female has requested gastric bypass surgery without first completing the Medical Groups six-month supervised dietary counseling  program for treatment of morbid obesity.  Findings:  The physician reviewer found that this patient clearly meets the criteria set by the National Institutes of Health for surgical treatment of obesity with a high BMI and co-morbidities that will likely be ameliorated or eliminated by bariatric surgery. With regard to the preoperative dietary counseling  program, there is no scientific evidence demonstrating that structured diet or exercise plans have been successful in the treatment of the morbidly obese. In fact, the Swedish obesity study identified that even though there may be reduction or resolution of some symptoms with diet and exercise, surgery has the longest and best long-term outcome for these patients. In addition, recent studies indicate that bariatric surgery is associated with decreased over all mortality for the morbidly obese. The psychological evaluation indicates the patient is an appropriate candidate for the gastric bypass procedure.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patients parent has requested reimbursement for air ambulance services provided by Mercy Air Service, Inc.Findings:  The physician reviewer found that the circumstances of the COVID-19 pandemic have mandated a change to standard management of infantile spasms. The authors note that the initial evaluation for infantile spasms typically includes an inpatient admission for video electroencephalography (EEG) and that the hospital admission allows the clinical team to confirm the diagnosis, begin treatment, investigate the etiology via brain magnetic resonance imaging and other testing, and provide counseling to the family. In this case, the patient had a suspected diagnosis of infantile spasms, a potentially serious medical condition requiring urgent evaluation and treatment. Per the submitted notes, ground ambulance was not available or safe due to riots. Air transportation was the only mode of transportation available to the patient. Given that the patient required urgent inpatient treatment, the services at issue were medically indicated. Therefore, air ambulance services provided by Mercy Air Service, Inc. were medically necessary for the treatment of this patient.Final Result: The reviewer determined that the service at issue was 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 neurology with special qualification in child neurology 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 breast tomosynthesis for evaluation of her medical condition.   Findings:  Two physician reviewers found that the current medical evidence supports the services at issue in this clinical setting.  Breast tomosynthesis provides advantages to radiologists interpreting mammograms.  This tomographic method often allows the reader to separate dense glandular elements from underlying mass/architectural distortion, resulting in a decrease in callbacks, increase in detection of small cancers and increase in overall diagnostic accuracy compared to two-dimensional imaging alone.  Thus, the addition of breast tomosynthesis to the usual two-dimensional protocol was likely of greater benefit to the patient than had her examination been done with two-dimensional imaging alone. 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 three reviewers are board certified in diagnostic radiology 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: Overturned

Nature of Statutory Criteria/Case Summary: The patient has been diagnosed with irritable bowel syndrome with diarrhea (IBS-D). The patient reported diarrhea, nausea, and unintentional weight loss. The patient underwent a colonoscopy that revealed non-bleeding internal hemorrhoids. The random colon biopsies obtained were noted to be negative for adenomatous change or malignancy. The patient reported diarrhea and abdominal cramping, which improved after bowel movements. In the Health Plan Prescription Drug Prior Authorization or Step Therapy Exception Request Form, the provider noted loperamide was ineffective. A computed tomography scan of the abdomen and pelvis showed a distended gallbladder, diverticulosis, and a stable right lung nodule. An ultrasound of the abdomen, showed multiple gallstones in a nondilated gallbladder. The patient has requested authorization and coverage for Xifaxan 550 mg three (3) tablets daily for fourteen (14) days. The Health Plan denied the request and reported the requested medication is not medically necessary for the treatment of this patient. At issue in this case is whether Xifaxan 550 mg three (3) tablets daily for fourteen (14) days is medically necessary for the treatment of the patients medical condition. Ford and colleagues stated, We suggest the non-absorbable antibiotic rifaximin for reduction in global irritable bowel syndrome (IBS) symptoms, as well as bloating in non-constipated IBS patients. Authors reported, In a phase three study of patients with relapsing symptoms of IBS-D, repeat rifaximin treatment was efficacious and well tolerated. The authors also noted, Rifaximin was approved by the U.S. Food and Drug Administration (FDA) in May 2015 for the treatment of IBS-D in adults. In this case, the patient has been diagnosed with IBS-D. The patient reported diarrhea and cramping abdominal pain relieved after bowel movements. The patient has tried and failed treatment with loperamide. The medical evidence supports the requested medication in this clinical setting. Therefore, Xifaxan 550 mg three (3) tablets daily for fourteen (14) days is medically necessary for the treatment of this patient. 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 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

Nature of Statutory Criteria/Case Summary:  An enrollee has requested reimbursement and prospective authorization and coverage for Optune Plus Transducers Tumor Treating Fields (TTF) services.Optune has been approved by the U.S. Food and Drug Administration (FDA) for the treatment of recurrent glioblastoma. Approval was based on results of a clinical trial that randomized 237 patients to TTF or chemotherapy. Similar survival was observed in the two arms, and TTF therapy was associated with lower toxicity and improved quality of life. A subsequent open-label randomized trial in patients with newly diagnosed glioblastoma showed prolonged progression-free and overall survival in the group assigned to TTF when used in combination with post-radiation temozolomide. At this time, however, there is a lack of data supporting retreatment with Optune after progression with first-line use of Optune. This patient has already been treated with Optune, with progression. Therefore, Optune Plus Transducers TTF services provided and forward were not and are not medically necessary 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 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: Medical Necessity
Decision: Upheld

The patient is a 52-year-old female who has a history of two caesarian sections, hysterectomy, diverticulitis and colostomy. She has an abdominal pannus with scar tissue. The patient reports experiencing skin rashes and recurrent yeast infections. She has requested authorization and coverage for a panniculectomy, which has been denied by the Health Plan.The Health Plans denial should be upheld. The information submitted does not demonstrate the patient meets accepted criteria for authorization of a panniculectomy. Although the patient has an abdominal pannus, there is not documented evidence of intertrigo or panniculitis that has failed to respond to conservative therapy. Furthermore, there is a lack of evidence demonstrating significant functional impairment. Therefore, I have determined the requested procedure is not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld

A 48-year-old female enrollee has requested anterior lumbar interbody fusion at L5-S1 with posterior discectomy (including CPT codes 63030, 20930, 22851, 22845 and 22558) for treatment of her low back pain. Findings:  The physician reviewer found that this patient does not have evidence of lumbar spinal deformity, instability, or a herniated lumbar disc as a cause for her radiculopathy. In addition, she does not have a recurrent disc herniation. Thus, given the patients current clinical history and radiographic findings, she is not a candidate for fusion or a discectomy. For these reasons, the requested surgery is not medically necessary for management of her condition.
Appeal type: Medical Necessity
Decision: Overturned

A 68-year-old female enrollee has requested authorization and coverage for a bilateral mammaplasty reduction. Findings:  The physician reviewer found that as noted by the American Society of Plastic Surgeons, the necessity for reduction mammaplasty should be based upon the probability of relieving the clinical signs and symptoms of symptomatic breast hypertrophy.  The American Society of Plastic Surgeons has noted that the definition of symptomatic breast hypertrophy should focus on the degree of symptomatology. They noted that non-surgical therapies, such as physical therapy, support bras, exercise and medications, have been found to be ineffective in providing permanent relief of breast hypertrophy symptoms.  Given the severity of this patients bra strap grooving and physical symptoms, in the absence of any spinal pathology, the proposed surgery is likely to alleviate her symptoms.  The current medical evidence supports the medical necessity of the requested procedure.