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

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for eight units of additional physical therapy. Total knee arthroplasty is the definitive treatment for highly symptomatic end stage knee arthropathy that has failed to resolve with conservative management. Direction and oversight of a trained physical therapist for a rehabilitation program is initially clinically appropriate.  Strengthening and functional activities are advanced on an individual basis, depending on factors such as other impairments, comorbidities, tolerance, and goals. Large, randomized clinical trials, meta-analyses and reviews, nonetheless, have not demonstrated a significant benefit of intensive or prolonged standard formal therapy programs in this clinical setting, even for patients considered to be at high risk for poor outcomes. Arthrofibrosis, a pathological stiffening of a joint, is incompletely understood but occurs not uncommonly following total knee arthroplasty. Range of motion loss at the knee can be significantly functionally impairing. Prevention and treatment for post-TKA arthrofibrosis includes controlling pain and inflammation as optimally as possible to encourage rehabilitation participation and mobility. A relatively aggressive range of motion program is critical, requiring a high level of patient commitment and compliance. In the present case, the patient underwent a total knee arthroplasty, which was followed by physical therapy. His postoperative knee range of motion was severely compromised. He developed arthrofibrosis, and he underwent manipulation under anesthesia, where right knee range of motion was found to be 120 degrees. The next day, he had 78 degrees of flexion. He continued therapy and made range of motion gains on a steady but slow and incremental basis. At this juncture, there is no expected marginal benefit with respect to clinical course or outcomes from ongoing physical therapy over a continued conservative management program of appropriate exercise and modalities that can be performed independently. Overall, the patient has maximized the benefit he is expected to derive from an individually tailored and supervised outpatient therapy program following his elective knee arthroplasty. All told, the requested eight units of additional physical therapy is not medically necessary for treatment of this patient. Final Result: The reviewer determined that the requested services are not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in physical medicine and rehabilitation 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

Nature of Statutory Criteria/Case Summary: An enrollee has requested an implantable occipital nerve stimulator for the treatment of her medical condition. Findings: Two physician reviewers found that the records indicate a diagnosis consistent with chronic migraine, as well as multiple other diagnoses. The patient appears to have tried multiple oral migraine preventives, including anti-seizure and antidepressant medications. Nerve stimulators, including occipital and trigeminal territory electrodes, appear promising in existing and ongoing studies for chronic headache, including chronic migraine. However, study results are inconsistent, with some studies showing no benefit to stimulation. The records do not indicate that she has been treated with Botox, which is proven to be beneficial for chronic migraine. Therefore, the superior efficacy of the requested implantable occipital nerve stimulator has not been established. Final Result: Two reviewers determined that the requested device is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: All three physician reviewers are board certified in neurology 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: Overturned

Nature of Statutory Criteria/Case Summary:   An enrollee has requested abdominoplasty for treatment of her medical condition.  Findings:  The physician reviewer found that the patient has significant abdominal pain secondary to severe rectus diastasis.  This is a significant abnormal condition of severe loss of abdominal competence.  This condition is related to her previous pregnancy, which has caused her significant abnormal abdominal wall incompetence.  Although it is not clear that her functional deficit would likely be improved, the appearance is severely abnormal and her planned treatment would attempt to create a more normal appearance.  Based upon review of the photographs and examination, the proposed surgery would create more than a minimal improvement and thus should be considered reconstructive surgery.  All told, the requested abdominoplasty is reconstructive in nature.  Final Result: The reviewer determined that the requested services are reconstructive in nature for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.  Credentials/Qualifications: The reviewer is board certified in plastic 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 authorization and coverage for testosterone pellet, 75 mg.According to Shoskes and colleagues, the goal of testosterone replacement therapy is to return serum testosterone levels to within physiologic range and improve symptoms in hypogonadal men. Some of the symptoms aimed to improve upon include decreased libido, erectile dysfunction, infertility, hot flashes, depressed mood, and loss of muscle mass or hair. There is evidence that testosterone pellets are effective in the treatment of hypogonadism. Given the patients ongoing treatment with testosterone, replacement by an effective means is the only pertinent issue, and any replacement can be titrated and used safely to achieve normal levels with efficacy. Thus, testosterone pellet, 75 mg is medically necessary for the treatment of the patients medical condition.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 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: Upheld

The patient is a 23-year-old male who requests circumcision. His request is based on a desire for more sensitivity of the penis and reduced pain during intercourse. His examination by the urologist demonstrated a normal penile foreskin and glans penis. The patients past urologic history includes a repair of ureteropelvic junction obstruction of the kidney three years ago. There is no evidence the patients history of ureteropelvic junction pyeloplasty is relevant to his current complaints. The Health Plan has denied coverage for circumcision citing lack of medical necessity.There is no medical indication for circumcision on an adult male who is not having difficulty with phimosis or complications thereof. The urologists examination of the patient demonstrated no such medical indication. The penile exam was normal. Furthermore, though the patient wishes to undergo the procedure in part to increase sensitivity, there are some reports that circumcision can blunt rather than enhance sensitivity. For these reasons, I have determined that the requested procedure is not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for dopamine transporter single photon emission computerized tomography (DAT SPECT) scan for evaluation of the enrollee who has a history of tremors.Findings:  The physician reviewer found that the patient presented to the provider experiencing balance disorder and uncontrolled tremors. The patient is enrolled in physical therapy once a week. The patient reported that tremors have decreased in intensity since stopping Zyprexa, but the patients anxiety aggravates tremors. The provider recommended diagnostic imaging to determine the etiology of the tremors. The patient has requested authorization and coverage for dopamine transporter single photon emission computerized tomography (DAT SPECT) scan. The Health Plan denied this request and reported that the requested services are investigational for the evaluation of this patients medical condition. DAT SPECT is an acceptable diagnostic technique for the assessment of tremor. In patients where the cause of tremor is not known or is likely to be caused by other diagnoses such as essential tremor, the use of a DAT SPECT scan can be helpful in determining the correct diagnosis. This scan has been widely used by clinicians when there is a question of the etiology of tremor. The early diagnosis of the cause of a tremor allows for better control of symptoms and allows the patient to access available resources quicker. Based on the information provided in the medical records, this patient is likely to benefit significantly from having the DAT SPECT scan over the available standard options for the evaluation of this patients medical condition. Final Result: The 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: Physician reviewer number one is board certified in 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.Physician reviewer number two is board certified in 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.Physician reviewer number three is board certified in 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: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Vascepa for treatment of the enrollee who has a history of coronary artery disease and dyslipidemia. Findings:  The physician reviewer found that there is a lack of support in the documentation provided for the requested medication in this clinical setting. In this circumstance, treatment of hypertriglyceridemia is being considered to help reduced overall cardiovascular risk. Randomized trials have not directly compared most agents for the reduction of cardiovascular risk in patients with hypertriglyceridemia.  Although statin therapy is generally less effective in reducing triglyceride levels compared to fibrates, fish oil preparations or niacin, the proven efficacy of statins to reduce cardiovascular risk is compelling and makes them the preferred agents when cardiovascular risk reduction is the main aim of treatment.  Accordingly, most expert consensus guidelines focus on statin use in this setting. It is uncertain whether specifically targeting treatment to lower triglyceride levels reduces overall cardiovascular risk.  In addition, there are no well controlled randomized trials comparing various non statin therapies.  Moreover, a study, which conducted a randomized trial assessing the addition of niacin to statin therapy, did not demonstrate benefit.  Overall, since the patients hypertriglyceridemia is not severe (not greater or equal to 500mg/dl) and since there is no documented treatment failure or intolerance to other preferred non statin medications, the documentation provided does not support an indication for the requested medication. Therefore, Vascepa is not medically necessary for the treatment of this patients medical condition. Final Result: The reviewer determined that the requested medication is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in internal medicine with sub-specialty certification in cardiovascular disease 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 46-year-old female has requested a panniculectomy for treatment of an abdominal scar.  Findings:  The physician reviewer found that according to the American Society of Plastic Surgery (ASPS) Position Paper Treatment of Skin Redundancy For Obese and Massive Weight Loss Patients, when surgery to remove extensive skin redundancy and fat folds is performed solely to enhance a patient's appearance in the absence of any signs or symptoms of functional abnormalities, the procedure should be considered cosmetic in nature and not a compensable procedure. For example, a panniculectomy to eliminate a large hanging abdominal panniculus and its associated symptoms would be considered reconstructive. In situations where a circumferential treatment approach is utilized to also treat the residual back and hip rolls or the ptotic buttock tissue, only the anterior portion of the procedures would be considered reconstructive, the remaining portion of the procedure would be considered cosmetic. Only in rare circumstances will buttock, thigh or arm lifts be needed to treat functional abnormalities. Typically these procedures are performed to improve appearance and are therefore cosmetic in nature.   The patient does not have a large hanging pannus, and she does not have medical record documentation of intertrigo or other associated symptoms. She has a 3 cm scar that is said to be painful. Initial treatment of a painful scar consists of intralesional steroid injections and silicone patch pressure.  If the scar pain persists, a 3 cm scar revision would be the next step in treatment.  This patient does not meet the ASPS guidelines for a panniculectomy.  Removal of excess abdominal skin in the absence of significant symptoms is a cosmetic procedure.  Treatment of her painful scar is appropriate, but a panniculectomy is not medically necessary
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for sofosbuvir/velpatasvir . According to the most recent joint guidelines issued by the American Association for the Study of Liver Diseases  and the Infectious Diseases Society of America all patients with chronic hepatitis C should be treated, except those with limited life expectancy due to non-liver-related conditions. The guidelines recommend that all patients should be treated, regardless of fibrosis stage. The guidelines recommend that patients should be treated with Epclusa . guidelines cite data showing reduced survival with delayed treatment. For these reasons, sofosbuvir/velpatasvir are medically necessary for the treatment of this patient.  Final Result: The reviewer determined that the requested medication regimen 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: Overturned

A 58-year-old female enrollee, with Hypersomnia, has requested authorization and coverage for Provigil. Findings:  The physician reviewer found that Provigil has been used successfully to treat this disorder. Its properties include the ability to promote wakefulness. This makes Provigil a potentially important tool for treating the excessive diurnal somnolence that can accompany sleep disorders.
Appeal type: Medical Necessity
Decision: Upheld

The parent of a thirteen year-old male with the diagnosis of autism is requesting reimbursement and prospective authorization and coverage for speech therapy.  Reviewers Findings:The reviewing physician reviewed of the progress reports from the patients speech therapy and found that they do not indicate there has been functional gain from report to report.  The reviewing physician found that the Health Plan denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for intensive outpatient program (IOP) services. The medical records provided for review do not support the medical necessity of IOP services. The patient was not suicidal or homicidal. He was not violent or aggressive. There were no emotional, behavioral, or cognitive barriers to step down to outpatient level of care. Other than chronic neck pain and the depression and anxiety, he was medically and psychiatrically stable. These diagnoses and his medication regimen could have been safely and adequately provided in the outpatient setting. The patient made little progress in IOP. Although his craving scores were low, his depression and anxiety remained in the moderate range, and motivation was poor. Given these findings, the IOP services provided were not medically necessary for treatment of this patients medical condition. Final Result: The reviewer determined that the services at issue were 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 with sub-specialty certification in addiction medicine and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: enrollee has requested authorization and coverage for a powered wheelchair with accessories (HCPCS codes K0861 - power wheelchair, group 3 standard, multiple power option, cling/solid seat/back, patient weight capacity up to and including 300 pounds, E1007 - wheelchair accessory, power seating system, combination tilt and recline, with mechanical shear reduction, E2361 - batteries x 2, E2377 - expandable controller, E2313 - harness for expandable controller, E2373 - expandable controller Q-logic, E2331 - attendant control, E2300 - seat elevation, K0108 - transit option, E2311 - multiple actuator, E0978 - lap belt, K0040 - angle adjusted footplates x 2, E0955 - head rest, E0951 - shoe holder x 2, E0952 - padded straps x 2, E2615 - power mounting hardware, and K0955 - seat/back cushion) for treatment of the enrollee, who has cerebral palsy. Findings:  The physician reviewer found that Powered mobility devices can play an important role in maintenance of independence for adults with cerebral palsy.  In this case, the records do not indicate that the patient is able to safely and independently operate a power wheelchair. The patient is specifically reported to be dependent for functional mobility. The records, moreover, indicate that she has intermittent dyskinetic movements of her neck placing it into severe extension.  She has spastic movements of her eyes and arms as well. She has minimal voluntary upper extremity control. These issues, as reported by her examining physician and physical therapist, preclude safe and reliable operation of a power mobility device. There is no documentation related to a power mobility driving trial, with documented abilities to identify obstacles, avoid collisions, and quickly process and react, which are skills required to safely operate a power mobility device.  Proper assessment of safety issues is important to minimize risk.  Overall, there are no indications that a properly fitted manual wheelchair with tilt-in-space and other features to accommodate her posture, tone and pressure relief needs, would not meet the patients needs. A power wheelchair with attendant controls so that it can be operated by a caregiver is a caregiver convenience and not a medical necessity.  All told, the requested equipment is not medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested equipment 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 physical medicine and rehabilitation 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.