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

The patient has requested authorization and coverage for cervical magnetic resonance imaging (MRI) without contrast and lumbar MRI without contrast. The American College of Radiology (ACR) guideline states that MRI is appropriate for patients with new or increasing cervical radiculopathy and for patients with chronic neck pain when radiographs show degenerative changes, and particularly after failure of conservative management. Lumbar spine MRI is helpful when a patient has completed a minimum of six weeks of conservative treatment and has failed to show substantial improvement on clinical reevaluation. This patient presents with a history of progressive chronic neck and back pain. The patient reports severe neck and back pain, which has worsened and is limiting ability to function. Clinical examination revealed diminished upper and lower extremity reflexes, hand weakness, and positive straight leg raise with radiculopathy. The most recent MRI studies were reported a few years ago with prior surgical consultations. He has failed recent conservative treatment including medications and daily home exercise, as well as physical therapy, chiropractic care, and acupuncture. Given the significant change in the patients signs and symptoms, as well as functional limitations and reflex changes, the requested cervical MRI without contrast and lumbar MRI without contrast are medically necessary for evaluation of this patient. Final Result: The reviewer determined that the requested services are medically necessary for evaluation 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: Upheld

A 59-year-old female enrollee has requested for metal on metal hip resurfacing for treatment of her osteoarthritis of the left hip. Findings:  The physician reviewer found that while metal on metal hip resurfacing is a newer procedure, it has not shown any long-term benefit over standard total hip replacement surgery. While there is a theoretic decreased wear rate with metal on metal prostheses, there are still unknown problems with metal ion release. There is also increased risk of intraoperative and postoperative complication with femoral neck fracture. There is no good orthopedic literature indicating that a metal on metal resurfacing hip prosthesis is any better for long-term care of a patient with degenerative arthritis of the hip than a standard hip procedure.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for an InCourage high frequency chest wall oscillation device. Researchers note that respiratory care is of the utmost importance in caring for patients with neuromuscular disease because it is a major determinant of quality of life and survival. In this case, the patient has neuromuscular diaphragmatic weakness from spinocerebellar ataxia, a progressive disease with a high risk for poor pulmonary clearance, mucous retention, and secondary pulmonary infections. She has tried and failed mucous clearance programs including manual chest physical therapy and flutter valves. In this clinical setting, the requested device is medically indicated to optimize mucous clearance, improve pulmonary hygiene, and minimize the risk of pulmonary infections. Therefore, an InCourage high frequency chest wall oscillation device is medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested device 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 in pulmonary disease and critical care 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: Experimental/Investigational
Decision: Upheld

A 56-year-old male enrollee has requested a total ankle replacement for the treatment of his left ankle pain. Findings:  Two physician reviewers found that total ankle replacement procedures have had a high failure rate in the past, but more recent designs and techniques have had more promising results. However, equivalence of arthroplasty with fusion has not yet been sufficiently established (Yalamanchili and colleagues). Reports of short-term results have been encouraging, but reports of mid-term results are few and often have not been validated by independent observers (Cracchiolo and Deorio). According to an article by Marx and Mizel, the role of arthroplasty as a viable alternative to arthrodesis remains the subject of debate. There remains a need for long-term and comparative studies (Haddad and colleagues). Until longer term studies have been completed, there is insufficient evidence to support the conclusion that total ankle replacement is a superior option in this setting.
Appeal type: Experimental/Investigational
Decision: Upheld

An enrollee has requested authorization and coverage for right leg sacroiliac (SI) joint fusion. SI fusion may be beneficial as a last line of therapy as treatment for SI joint infection, tumor involving the sacrum, disabling pain due to sacroiliitis due to spondyloarthropathy, or SI pain due to severe traumatic injury. SI joint fusion is not recommended for mechanical low back pain, non-specific low back pain, degenerative sacroiliitis, SI joint osteoarthritis, or SI joint-mediated pain. The North American Spine Society (NASS) supports SI fusion under limited conditions, if stringent diagnostic criteria have been met. The NASS recommends diagnostic intra-articular injections with local anesthetic resulting in at least 75% pain relief as a criterion for diagnosing pain related to the SI joint. A confirmatory injection is also recommended. Diagnostic imaging to rule out destructive lesions or inflammatory arthropathy of the SI joint, hip pathology, and/or neural compression or other degenerative condition of the lumbar spine that could cause low back or buttock pain are also recommended. A trial of at least one successful therapeutic intra-articular corticosteroid injection is then recommended. In this case, the patient has been diagnosed with right SI joint dysfunction. However, there are no objective imaging or laboratory findings to indicate the presence of SI joint infection, tumor, and sacroiliitis due to spondyloarthropathy or post-traumatic arthritis. Although NASS does note some evidence supporting SI fusion for SI joint-mediated pain, the quality of evidence is low. Given these findings, the requested right leg SI joint fusion 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 right leg SI joint fusion 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

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for additional facial feminization performed at the same time as the approved facial feminization surgeries. Researchers noted that, facial feminization surgery can include forehead remodeling, rhinoplasty, mentoplasty, thyroid chondroplasty, and voice alteration procedures. Forehead remodeling reduces male brow bossing, rhinoplasty reduces a prominent, masculine nose, and mentoplasty shapes the mandible. Patient satisfaction after facial feminization surgery is high. The authors noted that the reduction of gender dysphoria has psychological and social benefits and significantly affects patient outcome. This patients medical records support a diagnosis of gender dysphoria. However, the documentation does not demonstrate that the requested additional facial feminization surgeries are medically necessary for this patient. With regard to upper/lower lip augmentation/filling, the photographs provided for review reveal that the lower and upper lips are pouted. Based on the photographs, lip fullness is not a gender-defining feature in this patient. Therefore, the requested upper/lower lip augmentation/filling is not medically necessary. The submental/neck liposuction is not medically necessary, as the photographs do not show a collection of fat that is outside the wide range of normal for a female appearance. Fatty tissue fullness of the submental/neck region is not a gender-defining feature in this patient. Thus, a submental/neck liposuction is not medically necessary. The requested cheek/midface augmentation with fat grafting is not supported as the photographs show jowl formation with ptosis of the malar fat into the jowl area. This is a facial change characteristic of aging and is not a gender-defining feature in this patient. Accordingly, the cheek/midface augmentation with fat grafting is not medically necessary. A lower lid blepharoplasty is not indicated as the photographs show excess lower lid skin and fatty tissue, which is a lower lid change characteristic of aging and is not a gender-defining feature in this patient. A lower lid blepharoplasty is not medically necessary for this patient. Given these findings, the requested additional facial feminization performed at the same time as the approved facial feminization surgeries are 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 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: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the functional endoscopic sinus surgery (FESS) for treatment of the enrollees chronic pansinusitis, septal deviation, bilateral nasal valve collapse, bilateral inferior turbinate hypertrophy and dysphagia. Findings:  The physician reviewer found that the FESS provided was not medically necessary for treatment of the patients medical condition. While sinus ostial dilation can be an appropriate therapeutic option for patients with chronic sinusitis and recurrent acute sinusitis, the criteria have not been met in this patient. The American Academy of Otolaryngology  Head and Neck Surgery (AAOHNS) defines chronic rhinosinusitis (CRS) as a clinical disorder characterized by inflammation of the mucosa of the nose and paranasal sinuses with associated signs and symptoms of 12 week consecutive duration. CRS is characterized by two or more symptoms, one of which is nasal blockage/obstruction/congestion or nasal discharge (anterior/posterior nasal drip), with or without facial pain or pressure and reduction or loss of smell with endoscopic evidence of mucopurulence, edema, and/or polyps and/or CT presence of mucosal thickening or air fluid levels in the sinuses. And the AAOHNSF defines recurrent acute sinusitis as four or more recurrent episodes of acute rhinosinusitis with complete clearing of symptoms between episodes over a one year period. In this case, CRS was not documented in this patient. There was no documentation of 12 weeks of consecutive disease. Recurrent acute sinusitis was also not documented in this patient. There was no documentation of four or more recurrent episodes over a one year period. There was no documentation of chronology of disease, symptoms or treatment. There was no documentation that he was treated with maximal medical therapy prior to the CT scan. The AAOHNSF defines maximal medical therapy as: oral antibiotics of two to four weeks duration for patients with CRS, systemic and/or topical steroids, saline irrigations, topical and/or systemic decongestants, treatment of concomitant allergic rhinitis, including avoidance measures, pharmacotherapy, and/or immunotherapy. There was only CT evidence of sinus disease in the maxillary sinuses and right anterior ethmoids. The posterior ethmoids, frontal and sphenoid sinuses were normal. There was no documentation of findings of nasal endoscopy suggestive of sinus disease. Therefore, sinus surgery was not medically necessary in this case. Final Result: The reviewer determined that the surgery at issue was 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 otolaryngology and 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

A 53-year-old female enrollee has requested an additional 12 weeks of Harvoni for treatment of her hepatitis C virus.  Findings:  Two physician reviewers found that according to the most recent joint guidelines issued by the American Association for the Study of Liver Diseases (AASLD) and the Infectious Diseases Society of America (IDSA), all patients with chronic hepatitis C, regardless of fibrosis, should be treated except those with limited life expectancy (less than 12 months) due to non-liver-related comorbid conditions (Class I, Level A recommendation). Per AASLD/IDSA, treatment with Harvoni for 24 weeks is recommended for patients with CPT Class B or C cirrhosis, the provided records indicate the patient meets these criteria. Based on the evidence of safety and efficacy in the published literature, and clinical guidelines, the treatment of Harvoni for 24 weeks is medically necessary in this case.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for genetic testing (CPT codes 81243, 81412, and 81443). Cell-free fetal DNA-based prenatal testing through panels of syndromes based on ethnic backgrounds is indicated when the disorders included in panel testing are associated with ethnic-based syndromes that meet current consensus to be included in carrier screening. According to the American College of Obstetricians and Gynecologists (ACOG), these criteria used to include conditions that: have a carrier frequency of 1 in 100 or greater; have a well-defined phenotype; have a detrimental effect on quality of life; cause cognitive or physical impairment; require surgical or medical intervention; or have an onset early in life. Additionally, screened conditions should be able to be diagnosed prenatally and may afford opportunities for antenatal intervention to improve perinatal outcomes, changes to delivery management to optimize newborn and infant outcomes, and education of the parents about special care needs after birth. Further, ACOG has recommended offering carrier screening for four conditions in the Ashkenazi Jewish population including Canavan disease, cystic fibrosis, familial dysautonomia, Tay-Sachs. Furthermore, some experts have advocated for a more comprehensive screening panel for those of Ashkenazi Jewish descent, including tests for several diseases that are less common. This patient is noted to be of Ashkenazi Jewish descent and has a family history of Gaucher disease. Based on these findings, the requested genetic testing (CPT codes 81243, 81412, and 81443) is likely more beneficial for evaluation of this patients medical condition than any available standard therapy.Final Result: Two of the 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:  One reviewer is board certified in obstetrics and gynecology and is actively practicing. One Reviewer is board certified in obstetrics and gynecology and is actively practicing.  One Reviewer is board certified in obstetrics and gynecology with subspecialty certification in maternal and fetal medicine and is 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: The patient has requested authorization and coverage for additional four in-person physical therapy sessions (for a total of eight in-person physical therapy sessions). This patient is reported to have persistent low back pain and sciatica following a fall down stairs in April 2021. The management of the patients condition can include pharmacological agents, rehabilitation, complementary medicine, and invasive approaches. The aim of rehabilitation is to reduce pain, reduce impairment, and improve the patients quality of life (Urits, et al.). Formal rehabilitative interventions can be rendered, in conjunction with education, towards a goal of self-management, independent exercise. Exercise and physical activity have low risks for adverse effects and are encouraged in the setting of this patients type of chronic pain (Chou, et al.; Geneen, et al.; Oliveira, et al.). The records provided for review do not establish that this patient has impairments that preclude participation in a fully independent exercise program to manage her symptoms. The exercises performed in the formal setting can be done independently or substituted with independent exercise. The benefit of passive modalities such as transcutaneous electrical stimulation, traction therapy, and massage/manual therapy on a formal basis over self-applied palliative modalities and independently rendered massage/manual therapy has not been demonstrated in the medical literature (Farber and Wieland; Binny, et al.; Gibson, et al.). For these reasons, the requested additional four in-person physical therapy sessions (for a total of eight in-person physical therapy sessions) are not medically necessary for 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: Medical Necessity
Decision: Upheld

The parent of a 13-year-old male enrollee requested somatropin (recombinant human growth hormone) for medical treatment of the enrollees idiopathic short stature.  Findings:  The physician reviewer found that the patient has mild constitutional delay and his IGF-I measurement is within normal range. Growth hormone supplementation is not indicated for constitutional delay. In addition, the patient has a normal height percentile for his adult height potential.  Based on the medical literature and the documentation submitted for review, the requested medication is not medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Toremifene Citrate. Toremifene is U.S. Food and Drug Administration (FDA) approved for the treatment of metastatic breast cancer. However, Toremifene does not have an approved role for adjuvant treatment of breast cancer. The current medical literature and National Comprehensive Cancer Network (NCCN) have specific recommendations for medications in this clinical setting including tamoxifen, or other aromatase inhibitors such as Letrozole or exemestane. Therefore, Toremifene Citrate is not medically necessary for 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 subspecialty certifications in medical oncology and hematology 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 was diagnosed with positional plagiocephaly at the age of 3.5 months and underwent a course of DOC band therapy. The patient improved with this therapy and in September 2004 the provider noted the patients cranial measurements were within the norm for his age. The patients provider indicated some asymmetry remained. At the age of 15 months, the patient underwent a second course of DOC band therapy.Positional plagiocephaly is often a self-correcting condition, treated by meticulous head positioning and in selected cases by DOC banding. The patient underwent DOC band therapy for approximately 10 months with good results. There is no evidence or documentation to support retreatment with DOC banding. As such, there was no clinical indication for use of a second DOC band. Accordingly, I have determined the equipment at issue was not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.