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

Nature of Statutory Criteria/ Case Summary:  The enrollee requested coverage for the medication Lupron Depot injections. The patient has been diagnosed with premenstrual dysphoric disorder. She was seen by her gynecologist for reported symptoms of depression, anxiety, anger, compulsive behavior, and difficulty concentrating. It was noted she is followed by a psychiatrist and a therapist. The patient has tracked her menstruation cycle and reports that the change in behavior, mood, and cognition happens the week before she gets her period. She has been treated with oral contraceptive pills in the past, but developed psychiatric symptoms and the contraceptive pills were discontinued. She has also tried antidepressant medications, which she reports did not help. Lupron Depot injections were prescribed and her gynecologist has recommended the Lupron Depot be given monthly. In women with severe symptoms who have not responded to or cannot tolerate Selective Serotonin Reuptake Inhibitors (SSRIs) or oral contraceptives, gonadotropin-releasing hormone agonist therapy (GnRH) is the next step. A review of the current literature shows the first demonstration of benefit of medical oophorectomy with a GnRH agonist in the treatment of premenstrual syndrome was made in a crossover study of eight patients. This finding has subsequently been replicated by several other investigators. Due to the severity of this patient's symptoms, and as supported by current medical literature, treatment with Lupron Depot is medically necessary to treat the patients medical condition. Result: The reviewer determined that the Lupron Depot injections are medically necessary for the treatment of the enrollees medical condition.Credentials/Qualifications: The physician reviewer is board certified in obstetrics and gynecology as well as reproductive endocrinology 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 similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for a treatment plan which includes Le Fort I osteotomy multi-segment with bone grafting, bilateral sagittal osteotomy with bone grafting, hardware removal and debridement, chin repositioning (revision with hardware removal), and HA Md (hydroxyapatite Avitene) length/body (possible). The Health Plan has denied this request indicating that the requested services are not medically necessary for treatment of the enrollee, who has a reported history of sleep apnea, and are not reconstructive in nature. The Le Fort 1 osteotomy multi-segment with bone grafting, bilateral sagittal osteotomy with bone grafting, and hardware removal and debridement are not medically necessary for the treatment of this patient. This patients complaints appear to be cosmetic concerns, and it is unclear if repeat surgery will satisfy the patients concerns. The records do not include a recent repeat sleep study demonstrating the patients sleep apnea. Thus, the medical necessity of the requested Le Fort 1 osteotomy multi-segment with bone grafting, bilateral sagittal osteotomy with bone grafting, and hardware removal and debridement has not been established.With regards to chin repositioning (revision with hardware removal), and HA Md (hydroxyapatite Avitene) length/body (possible), the records do not support the medical necessity of these requested services. However, this patients condition constitutes an abnormal structure of the body. The patient has been diagnosed with mandibular hypoplasia. The etiology of maxillofacial skeletal deformities may be either congenital or acquired. This condition may be evident at birth or may manifest during subsequent growth and development. The requested surgery will be performed to create a normal appearance to the extent possible. Additionally, the proposed surgery is likely to result in more than a minimal improvement in the appearance of the patient. Therefore, the requested chin repositioning (revision with hardware removal), and HA Md (hydroxyapatite Avitene) length/body (possible) is reconstructive in nature.  Final Result: The reviewer determined that a portion of the requested services is reconstructive in nature for treatment of the patients medical condition. Therefore, the Health Plans denial should be partially overturned.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:  The enrollee requested authorization and coverage for Genetic Tests for Common Hereditary Cancers Panel, Renal/ Urinary Tract Cancers Panel, and Add-On Panel. The scientific literature indicates risks for identifying variants of uncertain significance, possibility to receive unexpected results and potential results that do not have medical management guidelines. The literature does not endorse multiplex testing outside of a research setting For these reasons, Genetic Tests for Common Hereditary Cancers Panel, Renal/ Urinary Tract Cancers Panel, and Add-On Panel are not likely to be more beneficial than any available standard therapy.Final Result: Three of the three reviewers determined that the requested services are not likely to be more beneficial than any available standard therapy for treatment of the enrollees medical condition. Therefore, the health plans denial is upheld.Credentials/Qualifications: Two reviewers are board certified in Oncology and Hematology and are actively practicing. One reviewer is board certified in Oncology 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

A 57-year-old female enrollee has requested bilateral vein radiofrequency ablation for the treatment of her incompetent perforating veins. Findings:  Three physician reviewers found that this patient has varicose veins without ulceration and the standard of care is ablation of superficial veins and assessment and waiting. Simultaneous perforation surgery without ulceration is not widely used in this setting as discussed in the literature. There are insufficient level 1 or level 2 studies in the literature to demonstrate that radiofrequency ablation of perforators is appropriate and no evidence to support perforator surgery in the absence of stage 5 and 6 chronic venous disease.
Appeal type: Experimental/Investigational
Decision: Upheld

A female enrollee requested posterior tibial nerve stimulation (PTNS) for medical treatment of her urinary incontinence. Findings:  Three physician reviewers found that the records provided for review indicate that this patient has nocturia and nocturnal incontinence. Based on the current peer-reviewed medical literature, PTNS is not indicated and unlikely to be effective for this patients symptoms. Thus, the requested PTNS is not likely to provide this patient with an improved health outcome when compared to standard available therapies.
Appeal type: Medical Necessity
Decision: Upheld

The patient is a 47-year-old woman who has been diagnosed with rheumatoid arthritis, osteoarthritis, lumbar spinal stenosis, and fibromyalgia. The submitted information indicates the patient has a standard wheelchair. The patient reports she does not have sufficient strength in her hands and shoulders to operate a manual wheelchair. She has requested authorization for a POV. The Health Plan has denied the request on the basis that a POV is not medically necessary for the patients mobility.Review of the submitted medical records demonstrates the patient had normal strength, sensation, and reflexes in her upper extremities upon examination on 2/19/04. The exam notes from 2/19/04 and 4/26/04 reveal no evidence of any deformities, swelling, joint effusions or impairment in range of motion in the arms. Thus, the provided documentation does not demonstrate the patient is precluded from operating a manual wheelchair. Furthermore, there is no indication in the submitted information as to the extent to which the patients gait is limited. As such, the medical necessity of a POV has not been established. Therefore, I have determined that the requested equipment is not medically necessary for the patients mobility. The Health Plans denial should be upheld.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: A 59-year-old female enrollee has requested reimbursement for the blood test (Guardant360 biopsy-free tumor sequencing test). According to the National Comprehensive Cancer Network (NCCN), prospective randomized clinical trials are needed that compare the strategy of targeted treatment based on panel results with standard of care to support an indication for the Guardant360 testing in this clinical setting. The available literature consists of a small number of uncontrolled studies, and non-randomized controlled trials that use imperfect comparators. Given the peer-reviewed medical literature and current guidelines, this patient is eligible for ALK, EGFR, ROS1 and BRAF testing. Thus, the ALK, EGFR, ROS1 and BRAF portions of the blood test (Guardant360 biopsy-free tumor sequencing test) was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy, while the remainder of the Guardant360 testing was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.One reviewer found that the EGFR, ALK, ROS1, BRAF, MET, RET and HER 2 neu portions of blood test (Guardant360 biopsy-free tumor sequencing test) was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy, while the remainder of the Guardant360 assay was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. One reviewer found that the Guardant360 testing was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Final Result: Two of the three reviewers determined that a portion of the testing at issue was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be partially overturned.Credentials/Qualifications:  One reviewer is board certified in internal medicine with sub-specialty certification in medical oncology and is actively practicing. One Reviewer is board certified in internal medicine with sub-specialty certification in medical oncology and is actively practicing.  One Reviewer is board certified in internal medicine with sub-specialty certification in medical oncology 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: Overturned

The patient has requested authorization and coverage for Noxafil DR 100 mg. Coccidioidomycosis, more commonly referred to as Valley fever, can cause severe symptoms including fever, night sweats and weight loss to fatigue, chest pain and cough. Pneumonia and disseminated disease can also occur. In the medical literature, colleagues noted that Valley fever remains difficult to treat, especially when patients have not responded to therapy with drugs that were recommended in treatment guidelines. The authors found that the success rate suggests that oral posaconazole should be considered as an important agent for the treatment of refractory coccidioidomycosis. This patients persistent right lower lung mass not reportedly improved despite treatment with Diflucan. Given this support, the requested Noxafil DR 100 mg is supported as medically necessary. Final Result: The reviewer determined that the requested medication is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in internal medicine with subspecialty certification in pulmonary disease and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for ultrasound guided trigger point injections. Within the documentation provided for review, there is report that this patient underwent treatment for myofascial pain status post fusion. The patient has a history of Ewing sarcoma at T3. The medical records note that the patient has tried and failed conservative treatments including physical therapy and medications. In a progress note, the provider recommended an ultrasound guided trigger point injection. The peer-reviewed medical literature suggests that trigger point injections are an appropriate treatment option in the management of myofascial pain syndrome where trigger points are present. The current medical literature supports use of ultrasound guided trigger point injections for the treatment of patients with acute and chronic pain in the context myofascial pain syndromes. Appasamy and colleagues noted that, Trigger point injections can be performed with or without imaging guidance such as fluoroscopy and ultrasound; however, the use of imaging in years past has been recommended to improve patient outcome and safety. Furthermore, there is support for this treatment modality in cancer patients with myofascial pain syndrome. Lee and colleagues found that, Trigger point injection is an alternative and effective pain control modality for advanced cancer patients with myofascial pain syndrome. Given these findings, the ultrasound guided trigger point injections were 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 services at issue were likely to be more beneficial for treatment 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 treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: Physician reviewer 1 is board certified in physical medicine and rehabilitation with subspecialty certification in pain medicine and is actively practicing. Physician reviewer 2 is board certified in anesthesiology with subspecialty certification in pain medicine and is actively practicing. Physician reviewer 3 is board certified in physical medicine and rehabilitation with subspecialty certification in pain medicine 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: Medical Necessity
Decision: Overturned

A 32-year-old female has requested coverage for acute inpatient psychiatric treatment provided for treatment of her pain disorder with psychological factors and medical conditions.  Findings:  The physician reviewer found that based on review of the available records, acute inpatient psychiatric treatment provided on the dates at issue was medically necessary for treatment of this patients medical issues. This patient has a complex presentation and history that requires treatment of multiple chronic medical problems, all of which are inter-related and must be treated together. The medical record indicates that this patient was labile and not in control of her own behavior for more than a few hours per day. Whenever she perceived any type of stress or was not able to have her own way, she began to decompensate. The complex interplay among her problems could not be handled in an outpatient setting. She also needed the supervision of a large staff with careful coordination of her care. She was intolerant of dealing with any stress. She required continued observation over a period of weeks in order to clarify her complex situation and develop a treatment plan that had some chance of succeeding in helping her improve her functioning. All told, the acute inpatient psychiatric services provided to this patient on the dates at issue is supported as medically necessary for treatment of her medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary:  An enrollee has requested intensity modulated radiation therapy for treatment of his medical condition.   Findings:  Three physician reviewers found that the patients history supports the use of intensity modulated radiation therapy.  Long-term complications from Hodgkins disease survivors include cardiac and pulmonary toxicity from radiation therapy.  Newer techniques, such as intensity modulated radiation therapy, can reduce the radiation dose to the lungs and heart, especially in patients with large anterior mediastinal masses.  The current medical evidence supports the requested services in this clinical setting.  All told, the requested intensity modulated radiation therapy is likely to be superior over other treatment options.  Final Result: Three 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:  All three reviewers are board certified in radiation oncology 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 authorization and coverage for panniculectomy for treatment of the enrollee who has a history of massive weight loss. Findings:  The physician reviewer found that The submitted documentation supports the medical necessity for the requested procedure in this clinical setting. The patient is noted to have a significant lower abdominal pannus secondary to weight loss following bariatric surgery. In this patients case, there is sufficient detail in the medical documentation to support functional impairment related to chronic infection associated with her overlapping lower abdominal skin and pannus. The clinical documentation, including a review of the photographs, support that the likely primary source for this functional deficit is the lower abdominal pannus. Based on the medical documentation and photographs, the abdomen is well supported to be the source of functional problems. With respect to the Health Plans denial that the patients weight has not been stable for six months, the last two office notes do not show an appreciable change in this patients weight (218-221 pounds).  Additionally, although prior to any body contouring procedure a stable weight is recommended, this should not be considered an absolute contraindication to performing surgery.  This patient has evidence of chronic infection that is directly related to the overlapping lower abdominal pannus that would directly be addressed with a panniculectomy.  Therefore, panniculectomy is medically necessary for the treatment of this patients medical condition. Final Result: The reviewer determined that the requested procedure is medically necessary and is reconstructive in nature for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in plastic surgery and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: A 55-year-old male enrollee has requested authorization and coverage for Orthovisc injections.  Findings:  The physician reviewer found that there is adequate evidence that intraarticular hyaluronic acid injections reduce pain and increase function in knee osteoarthritis, and the benefits are long-lasting as compared with intraarticular corticosteroids. Maheu and colleagues conducted a systematic review of overlapping meta-analyses comparing viscosupplementation with other non-operative treatment modalities for knee osteoarthritis. The authors reported that the current highest level of evidence suggests that intraarticular hyaluronic acid is a viable option for patients with knee osteoarthritis which results in improvements in knee pain and function that can persist for up to 26 weeks. Viscosupplementation has a good safety profile, and its use should be considered in patients with knee osteoarthritis. Thus, the requested Orthovisc injections are supported as medically necessary for treatment of this patients bilateral knee osteoarthritis. 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 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

The parent of a two-year-old female enrollee has requested a second cochlear implant for treatment of sensorineural hearing loss.  Findings:  The physician reviewer found that many patients continue to benefit from unilateral hearing aids. With regard to cochlear implantation, a second cochlear implant for any patient involves a small but real surgical risk. Rare complications of cochlear implants include meningitis and other risks implied in a delicate surgical procedure in this area. No implants have been approved by the Food and Drug Administration for binaural use.