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

Nature of Statutory Criteria/Case Summary: The enrollee has requested reimbursement for the radiofrequency denervation for treatment of the enrollees chronic severe left intercostal chest wall ribs pain and left thoracic costovertebral junction syndrome status post left thoracotomy.  Findings:  The physician reviewer found that In the documentation available for review, the provider does not document a pain diary for the intercostal block done prior to the radiofrequency ablation. The literature is clear how a diagnostic blocks are supposed to be done prior to radiofrequency ablation with use of a pain diary for the day to verify when the local anesthetic wore off, using only local anesthetic, and not using sedation (Derby, et al; Falco, et al). In this case, the blocks lasted longer than the duration of the local anesthetic, steroids and sedation were also used. Furthermore, there is no discussion regarding the specific types of conservative care for intercostal neuralgia. There are different types of medications being used to successfully treat neuropathic pain and intercostal neuralgia after thoracotomy (Mendlik and Uritsky). In addition, no physical examination was performed to confirm the diagnosis at the treated levels, and the procedure performed exceeds the number of levels done on the prior nerve block. Finally, there is limited evidence in the form of a few case studies and one small randomized control trial to support the procedure as safe and effective in this clinical setting (Engel). Therefore, the radiofrequency denervation provided was not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Final Result: Two of three reviewers determined that the service at issue was 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 reviewer number one is board certified in anesthesiology with sub-specialty certification in pain 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.Physician reviewer number two is board certified in anesthesiology with sub-specialty certification in pain 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.Physician reviewer number three is board certified in anesthesiology with sub-specialty certification in pain 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: Overturned

The parent of a three-year-old male enrollee has requested physical therapy, occupational therapy and speech therapy. for treatment of the enrollees autism.  Findings:  The physician reviewer found that the standard of care adopted by the medical community as set forth by evidence based guidelines for autism by the American Academy of Neurology (AAN) and Child Neurology Society (CNS) recommends speech therapy for children with autism. These organizations state that the goal of early identification of speech and language problems is to initiate early intervention, which has been shown to improve outcomes for children who have autism spectrum disorders. They further indicate that immediate and long-term evaluation and monitoring of autistic individuals requires a comprehensive multidisciplinary approach.In addition, to speech and language deficits, the prevalence of impairments in fine and gross motor skills appears to be relatively high in autistic patients, based on the studies that have been performed to date. In practice, occupational and physical therapists work as part of a team that includes parents, teachers, and other professionals to help set specific goals for patients with autism. These goals often involve social interaction, behavior, and classroom performance. In support of the need for occupational and physical therapy, studies have shown benefits that prevent deterioration and provide significant improvements in activities of daily living (Case-Smith and Arbesman, and Shoener). Thus, speech therapy, PT, and OT are standard of care modalities for patients with autism. Given this patients deficits associated with his diagnosis of autism, it is medically necessary for this patient to receive the requested services as there is a reasonable expectation that he will achieve significant improvement in mobility and/or activities of daily living with the requested modalities.
Appeal type: Experimental/Investigational
Decision: Overturned

A 42-year-old female enrollee has requested magnetic resonance-guided focused ultrasound (MRgFUS) for treatment of her uterine fibroids. Findings:  Two physician reviewers found that the use of non-invasive alternatives for fibroid management is well established in the medical literature. The recent developments in research support the use of MRgFUS in patients with symptomatic uterine fibroids. In addition, the efficacy of MRgFUS has been shown to be comparable in terms of safety and efficacy to uterine artery embolization. Hesley and colleagues concluded that as more long-term follow-up data are published, the efficacy of this technique can be compared to more invasive surgical and minimally invasive catheter treatments. Given this support, the requested MRgFUS is likely to provide this patient with greater health benefits than any available standard therapy.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for revision top surgery. Chest surgery in transgender male minors is a common treatment for gender dysphoria. The World Professional Association for Transgender Health (WPATH) states, Chest surgery in female-to-male patients could be carried out earlier, preferably after ample time of living in the desired gender role and after one year of testosterone treatment. Medical literature reported that chest surgery in transgender youth and males is a safe and effective treatment for gender dysphoria, noting, Chest dysphoria was high among presurgical transmasculine youth, and surgical intervention positively affected both minors and young adults. Given these findings, professional guidelines and clinical practice should consider patients for chest surgery based on individual need rather than chronologic age. In this case, the patient has a diagnosis of gender dysphoria whose provider has recommended revision surgery following a mastectomy. In this patients case, revision top surgery is in accordance with the generally accepted standards of mental health and substance use disorder care. Additionally, the requested service is clinically appropriate in terms of type, frequency, extent, site, and duration. The requested service is not primarily for the economic benefit of the health care service plan and subscribers or for the convenience of the patient, treating physician, or other health care provider. Therefore, the requested revision top surgery is medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested service is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board 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: Medical Necessity
Decision: Upheld

The mother of a 19-year-old female enrollee requested authorization and coverage of residential treatment for treatment of the enrollee's medical condition.  The Health Plan denied the request indicating that the requested services are not medically necessary for treatment of the enrollee's medical condition.One physician reviewer performed a medical necessity Independent Medical Review.  The physician reviewer upheld the Health Plan's denial on the basis that the requested services are not medically necessary.
Appeal type: Experimental/Investigational
Decision: Upheld

A 54-year-old male enrollee has requested temperature gradient studies and surface electromyography for an evaluation of his back and leg pain. Findings:  Three physician reviewers found that temperature gradient studies and surface EMG are not recognized or generally accepted by the medical community as diagnostic technologies for this type of case. There are no objective studies demonstrating their effectiveness in evaluating this patients condition. The patient could have received an appropriate evaluation through standard tests and physical examination.
Appeal type: Medical Necessity
Decision: Upheld

A 50-year-old male enrollee has requested for Cyberknife therapy or in the alternative, proton beam therapy for treatment of his astrocytoma. Findings:  The physician reviewer found that the current National Comprehensive Cancer Network (NCCN) guidelines for central nervous system (CNS) tumors indicate that stereotactic radiosurgery (SRS) (of which Cyberknife is one method of delivery) is a standard treatment for meningiomas, brain metastases and spine metastasis. However, SRS is not a standard upfront treatment option for newly diagnosed primary brain tumors. It is often considered in the management of recurrent, unresectable astrocytomas, and can be considered in the case of small residual tumors after resection. The NCCN guidelines regarding low-grade gliomas state that Enthusiasm for SRS in low-grade gliomas has waned due to insufficient evidence for therapeutic advantage (Roberge, et al.). The published data to date has been primarily from small case series from single institutions and has involved patients described as highly selected. In this patients case, the submitted documentation reveals no clinical indication for the use of SRS with Cyberknife versus conformal radiation therapy or intensity-modulated radiation therapy (IMRT). Standard radiation is delivered with a linear accelerator (LINAC), which delivers photon therapy (akin to high energy light), while protons (and other charged particles) are generated from a cyclotron. The difference between proton and photon irradiation is that the protons (or charged particles) stop abruptly in the tissue (Bragg peak) so there is less exit dose through normal tissue. Whether proton beam therapy (in general) affords any benefit over conventional radiation therapy remains the subject of debate. The general consensus in the medical community is that proton beam therapy has a role in the treatment of some cancer patients. Proton beam therapy is an accepted, safe and effective treatment modality for CNS tumors. However, there are no data that describes proton beam therapy as superior to photon therapy for astrocytomas.  In fact, as astrocytomas are infiltrative tumors, there may be a benefit to a less sharp dose fall-off, as the lower dose surrounding the target may provide some therapeutic benefit.  The current NCCN guidelines for CNS tumors do not address proton beam therapy at all. All told, there is insufficient scientific data that either Cyberknife therapy or proton beam therapy are medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for periodontal care, gum recession surgery, extractions, and orthognathic surgery nature for treatment of the enrollee who is status post repair of a cleft palate. Findings:  The physician reviewer found that there is a lack of support for the medical necessity of the requested services in this clinical setting. The patient does have periodontitis that will require dental treatment but that is not related to the patients cleft palate. The risk factors for periodontitis include amongst others poor oral hygiene. Treatment with scaling and root planning would be appropriate for the patient. Grafting the patients gingiva to augment her gingiva is also appropriate given the patients periodontal findings. However, the documentation provided indicates that the treatment of her periodontal condition is not related to the patients cleft palate. There is no documentation to support the need for orthognathic surgery. Per the notes provided, there are no issues with the patients repaired cleft palate. As such, periodontal care, gum recession surgery, extractions, and orthognathic surgery will not improve function. There is no documentation of any functional deficit from the patients malocclusion and no documentation to indicate any issues with the patients repaired cleft palate. This patients periodontal gum care are dental in nature and not a direct result of the patients cleft palate. Therefore, periodontal care, gum recession surgery, extractions, and orthognathic surgery are not medically necessary and are not reconstructive in nature for treatment of this patients medical condition. Final Result: The reviewer determined that the requested services are not medically necessary and are not reconstructive in nature for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in oral and maxillofacial 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 Intracept procedure (CPT 22899) with HCPCS C9752. While the clinical evidence does support the utility of the Intracept procedure in the setting of chronic low back pain, there are data suggesting that radiculopathy is an exclusion criteria for the use of this procedure. This patients records document a diagnosis of radiculopathy reported by his treating provider. The finding of radiculopathy was substantiated by the documented 80% relief with a selective nerve root block, which anesthetized a nerve outside of the spinal canal indicating that the patients pain is largely from radiculopathy. Therefore, the requested Intracept procedure (CPT 22899) with HCPCS C9752 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 Intracept procedure (CPT 22899) with HCPCS C9752 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 reviewer 1 is board certified in orthopedic surgery and is actively practicing. Physician reviewer 2 is board certified in orthopedic surgery and is actively practicing. Physician reviewer 3 is board certified in orthopedic surgery and is 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 reimbursement for Guardant360 diagnostic laboratory testing. Findings:  Two of the three physician reviewers found that molecular diagnostic studies in non-small cell lung cancer are considered a standard of care. Numerous gene alterations have been identified that impact therapy selection. The National Comprehensive Cancer Network (NCCN) strongly advises broader molecular profiling with the goal of identifying rare driver mutations for which effective drugs may already be available, or to appropriately counsel patients regarding the availability of clinical trials. Broad molecular profiling is a key component of the improvement of care of patients with non-small cell lung cancer. Testing of lung cancer specimens for these alterations is important for identification of potentially efficacious targeted therapies, as well as avoidance of therapies unlikely to provide clinical benefit. Therefore, Guardant360 diagnostic laboratory testing was likely to have been of greater benefit than other methods of evaluating this patient. Final Result: The 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: Physician 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: Upheld

A 51-year-old male enrollee has requested Class 4 laser treatment sessions for treatment of his neck pain and stiffness. Findings:  Three physician reviewers found that in this clinical scenario, standard treatments include heat, electrical stimulation, massage and stretching.  There is a lack of scientific evidence in the medical literature demonstrating that Class 4 laser treatments are more beneficial for non-specific neck and shoulder pain than these standard treatments. Although some studies have shown a small effect on some types of pain, such as diabetic neuropathy, there is a lack of evidence showing that laser is more effective than conservative treatments. Thus, Class 4 laser treatments provided were not likely to have been superior over other available treatment alternatives.
Appeal type: Medical Necessity
Decision: Overturned

The patient is a 25-year-old woman who was seen by her physician on 4/23/04 and 7/29/04. At both visits, the patient indicated she had thickened, yellowed toenails. This was confirmed in the physicians physical examination. The patient reports that her toes are painful, making it difficult for her to walk. A fungus culture dated 8/27/04 reported Bipolaris species and Penicillium species. The patients provider recommended treatment with Lamisil. The Health Plan has determined the requested medication is not medically necessary for treatment of the patients medical condition.The patient has painful onychomycosis. Due to the pain, she experiences difficulty walking, which is a functional impairment. The fungus culture grew out Penicillium and Bipolaris species, two organisms that are opportunistic fungal contaminants probably secondary to the deterioration of the nails. Contaminants grow more rapidly in culture than pathogens and therefore, mark the presence of pathogens. Thus, though they may not be apparent, pathogens are present is this culture. As such, treatment with Lamisil is medically indicated for treatment of the patients medical condition.Based upon the information set forth above, I have determined the requested medication is medically necessary for treatment of the patients medical condition. The Health Plans denial should be overturned.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for fecal pancreatic elastase (EL-1) laboratory testing (CPT 82656). This patient presented with lower abdominal cramping and a provisional diagnosis of irritable bowel syndrome. The patient was assessed for infectious pathogens such as giardia and Clostridium difficile, which were ruled out. Her systemic inflammatory markers were low and celiac disease was excluded based on serology. Fecal elastase-1 is the most sensitive and specific indirect test of pancreatic function. Fecal elastase-1 is an enzymatic product of pancreatic secretion that remains relatively stable during transport through the gastrointestinal tract. There is a direct correlation in pancreatic elastase-1 concentrations in pancreatic fluid and stool. The sensitivity of fecal elastase-1 for mild, moderate, and severe exocrine pancreatic insufficiency in patients with chronic pancreatitis are 63, 100, and 100%, respectively. Fecal elastase has a specificity of 93% in patients with exocrine pancreatic insufficiency. All told, the fecal pancreatic elastase (EL-1) laboratory testing (CPT 82656) was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Findings:  Two of the three physician reviewers found the fecal pancreatic elastase (EL-1) laboratory testing (CPT 82656) was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the services at issue were likely to be more beneficial for evaluation 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 internal medicine with subspecialty certification in gastroenterology 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 31-year-old female enrollee has requested Molecular Pathology Procedure Level 5 testing (CPT code 81404) for evaluation of the enrollees medical condition.  Findings:  Two physician reviewers found that review of the submitted documentation and medical literature demonstrates that the procedure requested is likely to be more beneficial for evaluation of the patients medical condition than standard therapies. This patients diagnosis remains unclear. Obtaining the correct diagnosis allows for the proper counseling, estimate on prognosis, and most importantly, it guides treatment strategies. Mitochondrial and lipid storage diseases are treated very differently and have varying clinical courses. The patient has already received an appropriate work-up (muscle biopsy) without a clear determination of the disease process. Although genetic testing is not necessary in all cases, it would be appropriate in this particular case.  The literature above outlines cases of rhabdomyolysis and describes its association with select diseases and genetic influences. For the reasons set forth above, the requested diagnostic procedure is likely to be more beneficial for this patient than any available standard therapies.