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

Nature of Statutory Criteria/Case Summary:The enrollee has requested authorization and coverage for 15830 excision, excessive skin and subcutaneous tissue (includes lipectomy), abdomen, infraumbilical panniculectomy; 15847 excision, excessive skin and subcutaneous tissue (includes lipectomy), abdomen (eg, abdominoplasty) (includes umbilical transposition and fascial plication); 15834, lipectomy, hip; 15835 lipectomy, buttock; 15832 lipectomy, thigh; 15836 lipectomy arm; and 19316 mastopexy for treatment of the enrollees hidradenitis suppurativa.  Findings:  The physician reviewer found that based on the medical documentation provided for review, the functional aspect of this case involves the condition of chronic hidradenitis of focal areas of the breasts, axilla and pubic area. However, the requested procedures are more consistent with typical body contouring procedures. The documentation does not demonstrate that the patients skin overlap is contributing to her functional deficit, which is most likely related to her focal areas of hidradenitis. The photographs show focal areas of the breasts and thighs that are consistent with possible hidradenitis as well as evidence of redundant skin of the breasts, arms and lower abdomen. Final Result: The reviewer determined that the requested surgery is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The physician 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: The parent of an enrollee has requested authorization and coverage for occupational and physical therapy at a frequency of once per week.  Findings:  The physician reviewer found that the medical records support the medical necessity of the requested services.  A child with attention deficit/hyperactivity disorder may experience difficulties in many aspects of life, including processing of sensory information, motor planning, executive functions, and fine motor coordination. This patient been diagnosed with attention deficit/hyperactivity disorder, seizures, and cerebral palsy.  He has a number of functional deficits which are negatively impacting his ability to perform and participate in activities of daily living.  Further, he has difficulty with ambulation and balance because of asymmetric increased lower extremity tone and frequent falling.  Occupational therapy, with its focus on fine motor skills, self-regulation, visual perceptual skills, and self-help skills, is ideally suited to help this patient optimize his functional capacity and ability to care for himself.  Physical therapy is ideally suited to facilitate improvement in lower extremity tone and gait, optimizing his independence.  Both of these rehabilitative interventions are medically necessary for this patient to maximize his functional abilities.  Thus, the requested occupational and physical therapy at a frequency of once per week is medically indicated for the treatment of this patient. 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 physician reviewer is board certified in pediatrics 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 transcranial magnetic stimulation for treatment of her major depressive disorder.   Findings:  The physician reviewer found that the submitted documentation supports the services at issue in this clinical setting.  Transcranial magnetic stimulation is a non-invasive brain stimulating procedure utilized in the treatment of major depressive disorder.  The American Psychiatric Association has endorsed transcranial magnetic stimulation for the acute phase treatment of major depressive disorder after failure of at least one antidepressant trial.  The peer-reviewed medical literature does not support a contraindication for the use of transcranial magnetic stimulation in a depressed individual with a co-occurring diagnosis of posttraumatic stress disorder.  Considering the medical records and expanding peer-reviewed literature base, transcranial magnetic stimulation was a safe and appropriate treatment consistent with good medical practice.  The services at issue were reasonably expected to improve the patients condition and prevent a more serious episode of illness.  All told, transcranial magnetic stimulation was medically indicated for the treatment of this patient. Final Result: The reviewer determined that the services at issue 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 psychiatry and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for percutaneous tibial nerve stimulation (PTNS) services. The procedure for PTNS consists of the insertion of a needle above the medial malleolus into the posterior tibial nerve followed by the application of low-voltage electrical stimulation that produces sensory and motor responses. There is evidence in the peer-reviewed medical literature from randomized trials and prospective observational trials supporting the clinical utility and impact on patient management of PTNS in patients with urinary urgency and frequency. However, most trials have a small number of patients with short-term follow-up. For this reason, the role of PTNS in patients with overactive bladder remains unknown. Furthermore, this patients records do not include an urodynamic study to help determine whether the patients overactive bladder is secondary to bladder outlet obstruction from benign prostatic hyperplasia (BPH). Given the lack of support in the clinical studies and available guidelines, the requested PTNS services are not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Findings:  Three physician reviewers found the requested PTNS services are 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 PTNS services are not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.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: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary:    An enrollee has requested breast tomosynthesis for evaluation of her medical condition.   Findings:  Two physician reviewers found that peer reviewed literature supports the use of tomosynthesis in this clinical setting. Per Skaane and colleagues, the use of mammography plus tomosynthesis in a screening environment resulted in a significantly higher cancer detection rate and enabled the detection of more invasive cancers. Ciatto and colleagues state that integrated two dimensional and three dimensional mammography improves breast cancer detection and has the potential to reduce false positive recalls. For these reasons, tomosynthesis was likely to be more beneficial than any available standard modalities.   Final Result: Two reviewers determined that the services at issue were likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned.  Credentials/Qualifications:  All three reviewers are board certified in diagnostic radiology and are actively practicing. All three reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned

A 52-year-old male enrollee has requested facet joint rhizotomy for treatment of his neck pain.  Findings:  Two physician reviewers found that there is sufficient support for the services at issue in this patients case.  This patient had chronic neck pain following anterior cervical discectomy with fusion.  Per the medical records, he experienced significant pain relief following facet blocks.  As noted by Manchikanti and colleagues, the cervical facet is a clinically important pain generator in the post surgical neck patient.  Due to the pseudarthrosis and documented successful facet injections helping this patients pain while localizing the pain levels to the level of non-union post fusion surgery, facet joint rhizotomy was likely to have been superior over other available treatment options.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for 100 Freestyle Lite Strips per month for treatment of the enrollees diabetes.  Findings:  The physician reviewer found that the prevalence of diabetes is increasing worldwide and there is great concern regarding long term diabetic complications. Poorly treated diabetes can lead to microvascular complications such as retinopathy, nephropathy, and neuropathy as well as macrovascular complications such as cardiovascular disease, cerebrovascular accidents, and peripheral vascular disease. Recent studies have demonstrated that long term rates of microvascular complications are greatly decreased through close monitoring of blood glucose levels. Therefore, it is important that patients with diabetes are able to adequately test their blood glucose levels at home. It is important that this patient check fingersticks regularly in order to optimize glycemic control. This will help to prevent long-term diabetic complications and help prevent short-term complications of glycemic variability. The requested quantity of 100 test strips is medically necessary for proper management of this patients diabetes. Therefore, the request for 100 Freestyle Lite Strips per month is medically necessary for treatment of the patients medical condition. 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 internal medicine with sub-specialty certification in endocrinology, diabetes and metabolism 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

An enrollee has requested authorization and coverage for a globin blood test. The U.S. Preventive Services Task Force (USPSTF) guidelines for colorectal cancer screening recommend colonoscopy for colorectal cancer screening, or recommend stool fecal occult blood testing annually, but do not recommend a combination of these tests. Guidelines from the American Society for Gastrointestinal Endoscopy (ASGE) caution that there is an increase in the risk of harm from excessive screening. For patients with a family history of colorectal cancer in a first-degree relative with early-onset colorectal cancer or multiple first-degree relatives with the disease, the guidelines recommend screening more frequently starting at a younger age. However, this type of family history of colorectal cancer is not documented in this case. For patients who have had a tubular adenoma in the past, the most recent applicable guideline is the U.S. Multi-Society Task Force (USMSTF), which recommends colonoscopy for surveillance. The guidelines note that patients should not have interval fecal blood testing if colonoscopy is planned and the guidelines do not support interval fecal testing within the first five years after colonoscopy. The available data reports a high likelihood of false-positive test results, which results in unnecessary early colonoscopies. All told, the requested globin blood test is not supported as medically necessary for the evaluation of this patient. Final Result: The reviewer determined that the requested services are not medically necessary for evaluation 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 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: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: This patient presents with persistent right knee pain with mechanical symptoms of swelling, popping and catching. She has failed to achieve adequate symptom relief with activity modification, non-steroidal anti-inflammatory drugs (NSAIDs), physical therapy and a corticosteroid injectionFindings:  Two out of three physician reviewers found that evidence-based medical guidelines and literature do not support the use of hyaluronic acid injections in this patients mild osteoarthritis or for treatment of her medial meniscal pain. Therefore, the Synvisc One injection is not likely to be more beneficial for the treatment of the patients medical condition than any standard therapy.Final Result: The reviewers determined that the requested service is 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: 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: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary:  An enrollee has requested a gene test for evaluation of his thyroid nodule.   Findings:  Three physician reviewers found that the testing at issue was likely to be more effective for this patient than other available treatment options. Typically, fine-needle aspiration (FNA) biopsy of a suspicious thyroid nodule is an accurate means of assessing whether the nodule is benign or malignant, with approximately 15% of FNA biopsy results considered to be indeterminate. Until recently, the only way to establish whether the nodule was in fact thyroid cancer was via surgical excision even though the majority of the cases turn out to be benign. The Afirma gene test utilizes a gene expression classifier in order to help determine the likelihood of malignancy of nodules with indeterminate cytology on FNA biopsy, thereby decreasing the need for unnecessary surgeries.  Because it is very sensitive and has a high negative predictive value, a negative Afirma result is rather suggestive of a benign nodule and can therefore preclude such surgical procedures. Therefore, the testing at issue was likely to be more beneficial for evaluation and treatment of the patients medical condition than any available standard therapy.   Final Result: Three reviewers determined that the testing at issue was likely to be more beneficial for evaluation and treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned.  Credentials/Qualifications: Two reviewers are board certified in endocrinology and metabolism and are actively practicing. One reviewer is board certified in medical oncology and metabolism 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: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for loop recorder implant for evaluation of the enrollees atrial fibrillation and atrial flutter. Findings:  The physician reviewers found that there is a lack of medical evidence to support the superior efficacy of the services at issue in this clinical setting. In this circumstance, periodic monitoring for recurrent atrial fibrillation/flutter is usually initially assessed with serial 24-48 hour Holter monitoring and patient activated or auto rate change activated event recorders. The documentation provided does not indicate these have been tried or that the patient is not able to manage these external devices. Routine placement of implantable loop recorders after atrial fibrillation ablation is not recommended in either atrial fibrillation or ablation guidelines. Therefore, the loop recorder implant  was not likely to be superior over the other standard methods of evaluating this patients medical condition. Final Result: All three reviewers determined that the  services at issue were 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: Physician reviewers number one, two, and three are board certified in internal medicine with sub-specialty certification in cardiovascular disease and 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

Nature of Statutory Criteria/Case Summary: An enrollee has requested radiofrequency neurolysis for treatment of her medical condition. Findings: Two physician reviewers found that the patient has chronic neck pain with successful past interventions including cervical facet injections and radiofrequency neurolysis of the nerves of the cervical spine. The patients last cervical radiofrequency neurolysis was noted with success for her pain at C3, C4, C5 bilaterally. Manchikanti and colleagues (2009) discuss the effectiveness of medial branch radiofrequency neurotomy in systematic reviews and randomized trials. However, in this case, the patient has not had repeat confirmation blocks after a significant amount of time post procedure. For these reasons, radiofrequency neurolysis is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.  Final Result: Two 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: All three reviewers are board certified in anesthesiology with sub-specialty certification in pain medicine and are actively practicing. All three reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary:   An enrollee has requested Sovaldi and Daklinza for 24 weeks for treatment of his chronic hepatitis C virus genotype 3.   Findings:  The physician reviewer found that according to 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 should be treated except those with life expectancy less than 12 months due to non-liver-related conditions. Per the guidelines, patients with cirrhosis are considered high priority for treatment. In cirrhotic treatment naive genotype 3 patients, therapy is recommended with Sovaldi and Daklinza for 24 weeks. This is based on the ALLY-3 and EUCUP trials, which demonstrated a higher cure rate with 24 weeks than with 12 weeks of therapy, and a cure rate of 88% in cirrhotic patients. The AASLD/IDSA guidelines state that the alternative regimen, which requires interferon, has similar efficacy in cirrhotic patients but increased adverse event rates and monitoring requirements. For these reasons, the requested treatment with Sovaldi and Daklinza for 24 weeks is supported as medically necessary for the treatment of this patients hepatitis C infection. Final Result: The reviewer determined that the requested medications 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 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: Experimental/Investigational
Decision: Upheld

The parent of a seven-year-old female enrollee has requested occupational therapy (OT) for the treatment of the enrollees autism.  Findings:  Three physician reviewers found that autism, or PDD-NOS, is defined in the DSM-IV as a disorder of communication, socialization and behavior. Standard treatment is psycho-educational and involves a team approach. This is usually carried out through the school system rather than independent therapy. The available records do not reflect any services the patient is currently receiving through the educational system. Sensory integration is a theory proposed about 40 years ago. Over the part 40 years, there has been a lack of scientific evidence accumulated to support it.