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

A 62-year-old male enrollee has requested a mandibular repositioning device and oral appliance for treatment of his sleep apnea.  Findings:  The physician reviewer found that based on review of the submitted clinical evidence, this patient has not undergone follow-up with a sleep medicine specialist. The patient reported he had problems adapting to CPAP. A sleep medicine specialist can assist with acclimatization therapy with CPAP. Additionally, based on the records provided, the patients original sleep study was performed over four years ago. There is no evidence in the submitted documentation of a repeat polysomnography prior to the implementation of any alternative therapies. It should also be noted that the sleep study as of the said date was notable for severe sleep apnea during REM sleep; it is well-documented in the literature that oral devices should only be considered for patients with mild to moderate sleep apnea. In light of the above, the medical necessity of a mandibular repositioning device and oral appliance has not been established.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for back surgery, cervical posterior decompression and fusion at C4-7. This patient presents with neck pain and stiffness, with numbness and tingling of trapezius. She denies radicular and myelopathy symptoms. In addition, there are no signs of myotomal findings compatible with a diagnosis of cervical radiculopathy or cervical myelopathy. The patients medication list does not document that she has exhausted an adequate trial of analgesics or non-steroidal anti-inflammatory drugs (NSAIDs). Further, there is no documentation of manipulation, home exercise program, epidural steroid injections, or nerve root blocks. There is documentation of only two physical therapy visits and a two-level facet block. She is employed full time, yet there is no documentation of pain affecting her activities of daily living or causing functional limitations. Except for diminished range of motion in her neck, she has maintained normal motor and sensory examinations. The physical examinations did not include neck lymph node or axillary examinations or Tinels sign. Thus, all pain generators have not been adequately defined or treated. She is status post ACDF and left C6 laminotomy. Her imaging shows adjacent segment abnormal findings. However, there is no correlation of her imaging with her clinical examination and there is no history of progressive neurologic deficits. Given these findings, the patient does not meet the current criteria for the requested surgical intervention. The patients records do not establish a diagnosis of cervical radiculopathy, cervical myelopathy, or progressive neurological deficit. Imaging does reveal evidence of nerve root compression, but this has not been correlated with the patients clinical examination. Moreover, the patient has not failed at least six weeks of conservative management and her pain has not been reported to affect her ability to perform activities of daily living or cause other functional limitations. Overall, the patients pain generators have not been adequately defined and treated. Thus, she fails to fulfill the criteria for ACDF and posterior spinal fusion. The proposed ACDF and posterior spinal fusion is not medically necessary since it is not in accordance with generally accepted standards of medical standards and is not consistent with the patients symptoms and diagnosis. Accordingly, the requested back surgery, cervical posterior decompression and fusion at C4-7 is not medically necessary for treatment of this patients cervicalgia. 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 reviewer is board certified in neurological surgery and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

A 62-year-old male has requested Intravenous Immune Globulin (IVIG) therapy for treatment of the degenerative cerebellar disorder.  Findings:  The physician reviewer found that at this time, there is no large scale placebo controlled trial to support the use of IVIG therapy for this patients symptoms. While individual reports exist regarding IVIGs benefit in paraneoplastic cerebellar diseases, it is not clear that this patient carries this diagnosis. The presence of autonomic symptoms is more suggestive of the alternative diagnosis of MSA (a non-IVIG responsive disorder). The presence of a positive ANA is a non-specific finding, and in isolation does not justify treatment. In addition, IVIG is not without side effects. Patients may experience headaches, aseptic meningitis, or life-threatening thrombosis. For these reasons, the use of IVIG in this patient is not justified at this time. If a malignancy is detected or if the patient is later found to have anti-Purkinje cell antibodies (anti-yo), then a trial of IVIG would be warranted. Until this time, the Health Plans denial is reasonable.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for intraoperative radiation therapy (IORT). This patient has a new primary lower quadrant invasive lobular carcinoma that is estrogen receptor (ER) positive, progesterone receptor (PR) positive, and human epidermal growth factor receptor 2 (HER2) negative. The patient previously underwent a course of IORT, and her provider has recommended IORT with partial mastectomy in light of the new imaging findings. Whole breast irradiation is within the standard care for breast cancer patients following surgery since it lowers the risk of recurrence and prolongs survival. IORT is a form of accelerated partial breast radiation therapy (APBI). The current National Comprehensive Cancer Network (NCCN) guidelines suggest that the use of APBI should only be performed within the confines of a high quality, prospective clinical trial. The ASTRO guidelines note that APBI may be appropriate for certain patients that meet specific criteria (Kirby, et al.). However, the follow-up is limited, and studies are ongoing. Based on the current medical evidence, the requested IORT is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Findings:  Three of the three physician reviewers found the IORT 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 radiation oncology and is actively practicing. Physician reviewer 2 is board certified in medical oncology and is actively practicing. Physician reviewer 3 is board certified in radiation oncology 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: Upheld

A 60-year-old female enrollee has requested Xibrom for the  treatment of her uveitis and cataracts. Findings:  The physician reviewer found that the patient has either episcleritis or scleritis. The best and most effective anti-inflammatory in cases such as this would be a steroid. However, if the patient has early cataracts, a steroid will hasten the need for cataract surgery, and possibly produce glaucoma. Although there has not been a long series confirming benefit, non-steroid anti-inflammatory (NSAIDs) are often used in this clinical setting in an attempt to avoid the complications associated with steroid use. A trial of the Health Plan formulary medications (Acular or Ocufen) is medically reasonable and appropriate in this case. The only benefit of Xibrom over the formulary NSAIDs is that it only requires twice daily dosage. As such, the use of Xibrom is not medically warranted in this case.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for DecisionDx-Melanoma gene testing. Findings:  The physician reviewer found that The DecisionDx-Melanoma has shown some accuracy determining risk of metastasis in thin melanomas, however treatment of this patient would not change based on the results of the examination. The testing at issue is not considered routine standard of care. There is a lack of peer-reviewed literature to support its use in patients with thin melanomas to effect health outcomes. Therefore, the DecisionDx-Melanoma gene testing performed was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Final Result: All three of 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: Physician reviewers 1, 2, & 3 are  board certified in dermatology and are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for stellate ganglion block and warm water therapy. In this case, the patient has a history of major depression disorder, anxiety, fibromyalgia, autism spectrum disorder, severe obesity and chronic pain syndrome. The patient is requesting a stellate ganglion block. However, there is a lack of support in the medical literature for treatment with stellate ganglion block in this patients clinical setting. A review by Lipov and colleagues evaluated the stellate ganglion block treatment for patients with post-traumatic stress disorder (PTSD). The authors concluded that, there have not yet been randomized controlled studies which demonstrate efficacy, although the authors and others have been advocating for these trials. Li and Loshak evaluated the stellate ganglion block for the treatment of patients with PTSD, depression, and anxiety. The authors found that, No relevant literature or evidence-based guidelines regarding the clinical effectiveness or use of stellate ganglion block for the treatment of depression or anxiety were identified. Furthermore, the authors noted that, The identified literature revealed mixed conclusions regarding the clinical effectiveness of stellate ganglion block for the treatment of PTSD. Thus, the requested stellate ganglion block is not medically necessary for treatment of this patient. Bidonde and colleagues compared the effectiveness of aqua therapy for the treatment of patients with fibromyalgia. The authors noted that, Low to moderate quality evidence relative to control suggests that aquatic training is beneficial for improving wellness, symptoms, and fitness in adults with fibromyalgia. The authors concluded that, Very low to low quality evidence suggests that there are benefits of aquatic and land-based exercise, except in muscle strength (very low quality evidence favoring land). Thus, regarding aquatic therapy there is also low quality evidence to support this treatment modality in lieu of conventional treatment modalities for management of this patients medical conditions. Accordingly, the requested warm water therapy is not medically necessary for treatment of this patient. Therefore, the requested stellate ganglion block and warm water therapy are not medically necessary for treatment of this patient. Final Result: The reviewer determined that the requested services are not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in anesthesiology with subspecialty 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: Upheld

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested authorization and coverage for braces for treatment of the enrollees dental condition and are not reconstructive in nature. Findings:  The physician reviewer found that the medical records provided show the patient to have had a congenital cleft of the soft palate which was successfully repaired at a young age.  The records show this repair to have been primarily affecting the soft tissues of the palate and do not demonstrate any issues at that time with the bones of the maxilla.  The submitted documentation included a note from a provider stating the patient needs braces, with no orthodontic records showing the extent of the issues or whether the congenital cleft palate could have been causative to the patients current dental condition. Therefore, while the patient has a history of the congenital abnormality of cleft palate, there is no evidence that the requested dental braces are treatment for or an integral part of the reconstruction of the patients congenital cleft palate. While most orthodontic treatment would be expected to provide some extent of improvement in function and aesthetics, there are no orthodontic records provided which would indicate the requested services will either improve function or create a normal appearance correcting any defects remaining from the patients congenital condition of cleft palate. The submitted records do not show compromise in the patients appearance caused by the cleft of the soft palate. Therefore, the requested services are not shown to provide more than a minimal improvement in the appearance of the patient. In sum, the requested braces are not medically necessary for the treatment of this patient and are not reconstructive in nature. Final Result: The reviewer determined that the requested services are not medically necessary for treatment of the patients medical condition and are not reconstructive in nature. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in dentistry and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

The patient is a 56-year-old male with low back pain who has failed conservative treatments. He is requesting coverage for VAX-D therapy for treatment of his low back pain. The Health Plan has denied reimbursement of the therapy at issue indicating the therapy at issue was not medically necessary.The Health Plans denial should be upheld. VAX-D therapy is considered an unproven modality in the treatment of low back pain. There are no peer-reviewed, controlled trials demonstrating the efficacy of VAX-D therapy for low back pain. Furthermore, VAX-D therapy is not considered an acceptable, indicated intervention for low back pain by medical community standards. Therefore, I have determined that the therapy at issue was not medically necessary for treatment of the patients medical condition. Accordingly, the Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested reimbursement for general anesthesia services provided during wisdom teeth extraction.  Findings:  The physician reviewer found that The submitted documentation does not support that the services at issue were medically necessary. The American Academy of Pediatric Dentistry (AAPD) guidelines for general anesthesia outline four indications for general anesthesia (GA) in pediatric dentistry: 1) Patients exhibiting physical, intellectual, or medically compromising conditions, for which dental treatment under local anesthesia cannot be expected to provide a humane and successful result; 2) Patients demonstrating dental treatment needs for which local anesthesia is indicated, but is ineffective because of acute infection, anatomic variation or allergy; 3) An extremely uncooperative, fearful, anxious or uncommunicative patient with dental needs of such magnitude or clinically apparent and functionally threatening to the well-being of the individual that treatment should not be postponed or deferred; or 4) Patients who have sustained extensive oral-facial and/or dental trauma, for which treatment under local anesthesia would be ineffective or compromised.In this case, the necessity for general anesthesia is not substantiated in the records available for review. Wisdom teeth are typically extracted under local anesthesia or with moderate sedation. There is no rationale presented to justify the use of general anesthesia in this case. There is no documentation that indicates that the patient has a physical, intellectual, or medically compromising condition. There is no documentation that the patient had an acute infection, anatomic variation or allergy that would make local anesthesia ineffective. There is also no documentation that general anesthesia was required either due to the patient being extremely uncooperative, fearful, anxious or uncommunicative, or due to patient having sustained extensive oral-facial and/or dental trauma. Therefore, the general anesthesia services provided during wisdom teeth extraction were not medically necessary for treatment of the patients medical condition.Final Result: The reviewer determined that the services at issue were not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is board certified in anesthesiology, with subspecialty 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: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for a circumferential body lift (upper), thigh lift with custom garment, arm lift with custom garment, and breast lift/augmentation. Findings:  The physician reviewer found that based on the medical documentation provided, there is insufficient documentation to fully define a functional deficit related to this patients soft tissue excess following weight loss. The patient states that she has some functional compromise associated with the lower abdominal excess, but this is not clearly supported by the records provided for review. The body contouring procedures requested are generally considered cosmetic intervention, as supported by the reference from the American Society of Plastic Surgeons (ASPS) except in rare circumstances for the arms, thighs and breasts. To satisfy the criteria for medical necessity, there should be documentation of chronic rashes unresponsive to typical dermatologic treatment or other functional issues unresponsive to conservative management. This is not present in the medical records provided for review. A study noted that massive weight loss leads to functional and aesthetic deformity that can be corrected with body contouring surgery. However, based on the medical records provided, there is not a clear functional deficit related to the massive weight loss in the areas of concern that has failed specific dermatologic treatment. The documentation provided for review does not include evidence of recurrent rashes or detail specific dermatologic medications. As there is not a well-supported functional deficit detailed in the medical records that the patient has failed specific dermatologic treatment, brachioplasty, augmentation/mastopexy, bilateral thigh lift and abdominoplasty with lower body lift, are not medically necessary. In addition, the patients condition does not constitute an abnormal structure of the body. Although the patient has moderate soft tissue excess of the breasts, abdomen, thighs and arms, this should not be considered an abnormal structure of the body, but rather a normal consequence of significant weight loss. Thus, the procedures do not satisfy reconstructive principles which is supported by the peer-reviewed references. The patients condition should be considered one of an aesthetic problem and thus not medically necessary or reconstructive in nature. Moreover, the requested surgery will not provide a more than minimal improvement in the appearance of the patient. Final Result: The reviewer determined that the requested surgery is not reconstructive in nature and is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in 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 magnetic resonance angiogram (MRA) of the brain blood vessels for evaluation of the enrollees recurring brain tumor (craniopharyngioma). Findings:  The physician reviewer found that the standard of care in pediatrics is moving away from using computed tomography angiography due to the evidence that the overall lifetime radiation received by this modality has a very high potential to increase the risk of cancer in later years of life. After reviewing the data, repeated findings appear to suggest that MRA is an appropriate modality to image brain blood vessels, in this patients case. Furthermore, MRA appears to be a better modality for patients requiring repeated follow up because MRA does not expose the patient to iodizing radiation. The records show that MRA has been used to monitor this patient and has been an effective modality in monitoring the progression of his medical condition. One study pointed out, that a child who has an MRA performed every three months for surveillance MRA is a safe and appropriate modality. Final Result: The reviewer determined that the requested services are medically necessary for evaluation of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in pediatrics with sub-specialty certification in pediatric hematology-oncology 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.