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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for radiofrequency ablation of right and left first and second perforator veins (CPT 36475 and 36476). The American Venous Forum (AVF) supports ablation of superficial and perforator veins in a patient with a venous leg ulcer (C6) and incompetent superficial veins that have reflux to the ulcer bed in addition to pathologic perforating veins with an outward flow of more than 500 millisecond duration, with a diameter of more than 3.5 mm, located beneath or associated with the ulcer bed. For these patients, the AVF suggests ablation of both the incompetent superficial veins and perforator veins in addition to standard compressive therapy to aid in ulcer healing and to prevent recurrence. This patient has a two-year history of chronic venous stasis disease with symptomatology consisting of lower extremity pain, discomfort, edema and skin changes quite consistent with venous disease. He has failed compression therapy, which was started when duplex scanning of the veins of both lower extremities indicated bilateral greater and lower saphenous vein reflux and Cocketts vein reflux. Measurement and duration of reflux at that time were sufficient to justify vein ablations. The patient returned two years later for evaluation of complaints consisting of bilateral lower extremity edema, discomfort, and non-healing wound at the gaiter area of the right leg. Physical examination revealed a venous ulcer above the ankle on the right and lipodermatosclerosis on the left. Duplex scan in March 2020 documented bilateral greater and lower saphenous vein, and Cocketts vein reflux. CEAP classification makes the right leg a C6 lesion and the left leg C4. Based on these findings, the requested radiofrequency ablation of right first and second perforator veins (CPT 36475 and 36476) is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Findings:  Two of the three physician reviewers found the requested radiofrequency ablation of right first and second perforator veins (CPT 36475 and 36476) is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that a portion of the requested services is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be partially overturned. Credentials/Qualifications: Physician reviewers 1, 2, and 3 are board certified in surgery with subspecialty certification in vascular 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: Overturned

A 56-year-old female enrollee has requested Forteo for treatment of her osteoporosis. Findings:  The physician reviewer found that osteoporosis is a skeletal disorder characterized by a loss of bone osteoid that reduces bone integrity, resulting in an increased risk for fracture.  Treatment of osteoporosis involves general measures such as increased calcium in the diet, Vitamin D supplementation, and high impact physical activity.  Medical therapy involves the use of oral and intravenous bisphosphonates, sex hormones, selective estrogen receptor modulators, RANK ligand inhibitors, and Forteo.  Forteo stimulates the production of new collagenous bone matrix that must be mineralized.  This medication can dramatically increase bone density in most bones except the distal radius.  This patient has a documented history of osteoporosis and is status post two non-traumatic fractures.  Her bone density measurements have declined despite oral and intravenous bisphosphonate therapy.   The current medical evidence supports Forteo in this clinical setting.  All told, Forteo is medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld

A 30-year-old female enrollee has requested a panniculectomy for the treatment of her redundant skin condition. Findings:  The physician reviewer found that the colored photographs reveal an overweight female with hypertrophic scars and stretch marks on the lower abdomen. The panniculus covers the upper portion of the mons pubis but does not extend below the inguinal ligament. There is some erythema in the suprapubic area and erythema of the umbilicus, but no skin ulcerations. The plastic surgery consultation note indicates low healed scar from cesarean sectionsskin quality is moderatemultiple stretch marksfat distribution copious... mild rectus diastasis. The provider also noted excoriation of the waistline and a little bit of redness of the umbilicus, but no intertriginous rash. The stated diagnosis was lipodystrophy. Although the patient was seen on several occasions for skin rash, the rash seems to be intermittent based on the records and medications for dermatitis, fungal infection or intertrigo were not prescribed on an on-going basis. It does not appear there has been a comprehensive skin care program for at least six months to control the intertrigo. The panniculus has not been demonstrated to interfere with activities of daily living.
Appeal type: Experimental/Investigational
Decision: Overturned

A 64-year-old male enrollee has requested NeuroStar transcranial magnetic stimulation (TMS) therapy for the treatment of his intractable major depression and strong anxiety. Findings:  Two physician reviewers found that TMS is a noninvasive method of brain stimulation. The technique involves placement of a small coil over the scalp, then a rapidly alternative current is passed through the coil wire producing a magnetic field that passes through the brain. In contrast to electroconvulsive therapy (ECT), TMS does not require anesthesia and does not include convulsions. While some scientific data suggests that ECT is more effective than TMS, the studies also report a much higher incidence of side effects. Some emerging studies have concluded that TMS is more effective than ECT in treating patients with depression (Rosa, et al). The Food and Drug Administration (FDA) granted approval for the NeuroStar TMS system for the treatment of major depressive disorder (MDD) in adults who have failed to achieve results with antidepressant medication. It should be noted that FDA clearance for NeuroStar TMS device was approved for the patients who failed to benefit from one antidepressant and had not yet tried and failed a second. This patient has been treated with a litany of antidepressants without significant benefit but has responded positively to prior treatment with TMS. It is therefore reasonable to give him a trial of therapy with the NeuroStar TMS.
Appeal type: Experimental/Investigational
Decision: Upheld

A 65-year-old male enrollee has requested two-level cervical disc replacement surgery (artificial cervical discectomy) for the treatment of his cervical stenosis. Findings:  Two physician reviewers found that the search for a technique to relieve the problems associated with cervical disc disease and its related conditions, and, at the same time, avoiding the loss of motion from fusion, has led to the great interest in cervical disc replacement. Although many questions and problems have been encountered, some success has been achieved. However, the long-term safety and efficacy of the procedure remains an open question at this time (Murrey and colleagues). Although there are some favorable case reports of multiple level cervical disc replacement in the literature (Pimenta and colleagues), there is a lack of peer-reviewed evidence to support disc replacement at more than one level as safe and efficacious. Even favorable studies have pointed to the need for larger patient series and longer follow-up periods to determine the rate of adjacent segment degeneration and preservation of motion (Ozturk and colleagues) and to validate earlier studies. In the present case, the concerns regarding the problems associated with a long fusion mass over five segments are understandable. However, based on the lack of literature regarding multiple level cervical disc replacement, the proposed procedure is not likely to be any more efficacious for this patient than the alternative of fusion.
Appeal type: Medical Necessity
Decision: Upheld

A 57-year-old female enrollee has requested coverage for partial hospitalization program services for treatment of her  alcohol dependency.  Findings:  The physician reviewer found that based on review of the available records, the patient was authorized for PHP care through a specific date, by which time she was medically stable, cooperative with the treatment and her clinical institute withdrawal assessment (CIWA) was zero. Patients with her low degree of severity and vast experience with sobriety and recovery can be safely and effectively managed on an outpatient basis, typically in an intensive outpatient program (IOP). Applying the treatment guidelines from the American Psychiatric Association (APA), PHP or residential care is generally reserved for patients who require a significant degree of medical or psychiatric monitoring or supervision and consultation, which was not demonstrated in this case. Therefore, the additional PHP services provided this patient were not medically necessary for management of her medical condition.
Appeal type: Medical Necessity
Decision: Overturned

The patient has been diagnosed with bilateral knee osteoarthritis. The provider noted the patient received a series of Synvisc-One injections to bilateral knees, which provided an improvement in symptoms. Physical examination findings included tenderness to palpation over the medial joint line, lateral joint line, and patellar tendons in bilateral knees, right greater than left. A month after the injections, the patient reported bilateral knee pain. Synvisc-One injections were administered again. In an undated letter, the patient reported corticosteroid injections result in an elevation of her blood glucose. The patient has requested reimbursement for Synvisc-One injections that were received in both knees for the second time. The Health Plan denied the request and reported the services at issue were not medically necessary for the treatment of this patient. At issue in this case is whether Synvisc-One injections that were received in both knees the second time were 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, the patient has a history of lasting benefit from prior Synvisc-One injections. As such, the patients options are limited. The patient has tried and failed other conservative treatments with the alternative being a total knee arthroplasty. The medical evidence supports the services at issue in this clinical setting. Therefore, Synvisc-One injections that were received in both knees the second time were medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested services were medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in 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: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for cervical traction equipment (CPT E0855). Findings:  Two of the three physician reviewers found cervical traction, which involves the manual or mechanical distraction of vertebral bodies and facet joints to reduce pain from nerve irritation, is frequently prescribed in the setting of neck pain, cervical radiculitis and cervical radiculopathy. However, the quality of evidence in support of this practice is not strong. The evidence supporting this practice is largely anecdotal in nature. This treatment has not been shown objectively in rigorously designed studies to improve health or functional outcomes.  It is not proven to be an effective adjunct or substitute for standard conservative care, including exercise, stretching, topical thermal modalities, rest and analgesics. Therefore, the requested cervical traction equipment (CPT E0855) is not likely to be of greater benefit than other treatment options. Final Result: The reviewers determined that the requested equipment 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: Physician reviewers 1, 2 and 3 are board certified in physical medicine and rehabilitation 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: Experimental/Investigational
Decision: Overturned

A 59-year-old female enrollee has requested a sacroiliac joint injection for the treatment of her back and hip pain. Findings:  Two physician reviewers found that although SI joint injection treatment remains the subject of debate, its use in this particular case was medically appropriate. SI joint injection has been in use for pain for several years as a diagnostic and therapeutic modality. Passar and colleagues in their educational guidelines for interventional spinal procedures recommend that consideration for SI joint injection be given to those patients with pain below the L5 spinal level who have failed to respond to conservative management and have had pain for at least 4 weeks. This patient meets those criteria. An article by McKenzie-Brown and colleagues which evaluated SI joint injection for diagnostic and therapeutic purposes concludes there is a moderate level of data to support the efficacy of SI joint injections. Furthermore a prospective comparative study comparing the effect of periarticular and intraarticular injection of the SI joint revealed that periarticular SI joint injections were effective in providing pain relief for all 25 patients (Murakami and colleagues).
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The enrollee has requested reimbursement for the FoundationOne test performed for evaluation of the enrollees pancreatic neuroendocrine cancer. Findings:  Two physician reviewers found that FoundationOne testing offers a comprehensive panel of molecular genetic markers on an individual patients tumor with the hopes of identifying markers than can help guide therapy decision making. Per the National Comprehensive Cancer Network (NCCN) guidelines it has not been determined if molecular markers are useful in treatment determination and prognosis other than KRAS, NRAS, and BRAF mutations. There is currently a phase II clinical trial underway that is evaluating the efficacy of genetic molecular testing to guide individual therapy. As FoundationOne provides genetic testing to guide therapy and this is the subject of an ongoing phase II trial, the FoundationOne test was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Final Result: The reviewers determined that the testing at issue was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: Reviewers 1, 2 and 3 are board certified in internal medicine with sub-specialty certification in medical oncology 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: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for varicocele vascular embolization procedure. Findings:  The physician reviewer found that Standard treatment of enlarged painful varicocele entails open surgery, laparoscopy, or embolization. Pain relief is anticipated in 50% of cases with classic symptomatology uncomplicated by prior surgeries. Given this patients prior vasectomy, procedures other than venous embolization place the patient at risk of testicular devascularization. Treatment with embolization is the preferred surgical approach to correct the patients clinically diagnosed varicocele Grade 3. Given this support, the requested varicocele vascular embolization procedure is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Findings: Two of the three physician reviewers found the requested varicocele vascular embolization procedure is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the requested services are likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: Physician reviewers 1, 2, and 3 are board certified in urology 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

The parents of a 33-year-old female enrollee have requested acute rehabilitation services for the treatment of her condition. Findings:  The physician reviewer found that the patients condition is chronic. It requires longitudinal management rather than a short acute stay. Her condition primarily indicates outpatient longitudinal management or chronic institutional stay with outpatient follow-up. The patient made little progress in acute rehabilitation. She had one psychiatric visit with oral medication adjustment. She was limited in her ability to participate in physical therapy, and this has continued.  The likelihood of benefit from acute management was low. Contracture and spasticity management is a long-term management challenge. It is not resolved with acute stays.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested inpatient level of care services for treatment of her behavioral health condition.  Findings: The physician reviewer found that inpatient level of care services is not medically necessary for treatment of the patients behavioral health conditions. The patient feels disconnected, and the hospital setting furthers this sense of disconnection.  Therapeutically, the patient needs harmonized parental relations, social support and community connection to re-establish a sense of meaning and consolidate her identity formation. This will likely be a long-term endeavor, but an intermediate setting such as residential, partial hospital or intensive outpatient appears to be most appropriate.  In the absence of clinical documentation evidencing active treatment that is reasonably expected to improve the patients condition or prevent a more serious episode of illness, the clinical situation improved to the point where transition to a less restrictive setting would have been appropriate. Thus, the services at issue were not and are not medically necessary.Final Result: The reviewer determined that the services at issue are not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The physician reviewer is certified in psychiatry and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned

A 62-year-old male enrollee requested LINX Anti-Reflux Management System for medical treatment of the enrollees gastroesophageal reflux disease (GERD).  Findings:  Two physician reviewers found that LINX is approved by the U.S. Food and Drug Administration (FDA) for the treatment of GERD and there is growing support in the medical literature demonstrating the efficacy and safety of the requested procedure (Lipham, et al; Reynolds, et al). In this case, LINX is clinically indicated as the patient has had partial relief of symptoms from proton pump inhibitors and does have documented objective evidence of GERD and Barretts esophagus. Based on the documentation submitted for review and the medical literature, the requested services are likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.
Appeal type: Medical Necessity
Decision: Upheld

The parent of an eight-month-old female enrollee has requested a cranial helmet for treatment of the enrollees cephalic index of 96.3 (+4 standard deviations above mean).  Findings:  The physician reviewer found that based upon a review of the information provided, the patient is documented to have a cranial vault diagonal diameter of 2 mm. The diameter of 2 mm falls into a category of mild plagiocephaly, according to the available medical literature. In 2011, the American Academy of Pediatrics (AAP) published a statement that mild positional cranial vault abnormalities could be treated with positioning and observation. Consistent with these recommendations, the requested cranial helmet is not medically necessary for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned

The patient has requested authorization and coverage for hysteroscopy to remove uterine septum under laparoscopic guidance. Anatomic correction can be effective treatment to restore normal anatomy. Hysteroscopic septum removal may improve fertility outcome while restoration of the patients normal anatomy is beneficial to her overall gynecologic and obstetric health. Clinical evidence supports that a uterine septum can cause recurrent pregnancy loss and dysmenorrhea. It is reasonable and appropriate for this patient to undergo septum removal of her uterus via hysteroscopy in order to restore normal anatomy and optimize her chances of carrying a healthy pregnancy to term. 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 obstetrics and gynecology 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.