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

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for anesthesia services performed during her colonoscopy. The American Society for Gastrointestinal Endoscopy (ASGE) Standards of Practice Committee noted that the combination of an opioid and benzodiazepine is a safe and effective regimen for achieving minimal to moderate sedation for upper endoscopy and colonoscopy in patients without risk factors for sedation-related adverse events. The authors recommended that anesthesia provideradministered sedation be considered for complex endoscopic procedures or patients with multiple medical comorbidities or at risk for airway compromise. The guidelines also noted, Minimal and/or moderate sedation can be delivered safely by endoscopists to patients who are ASA Class I, II, or III. Other candidates for minimal or moderate sedation include those with a history of previously successful procedures with moderate sedation and an expectation for moderate sedation as well as those undergoing a procedure that is expected to be uncomplicated or routine. In this case, the patient underwent a routine colonoscopy. She did not have any significant heart, lung, kidney, or liver disease. There was no documentation of a history of alcohol or substance abuse. There was no detailed documentation of a previous history of difficulties with anesthesia or sedation with past colonoscopies. The patient had an ASA classification score of 2 and had a Mallampati airway grade of 2. The literature does not support the use of monitored anesthesia care in a patient who does not have significant health conditions or airway concerns. Rather, the guidelines suggest there is high quality evidence to support the use of mild to moderate sedation in healthy uncomplicated endoscopy procedures, such as in this case. Based on the current medical evidence, the services at issue were not medically indicated. Therefore, anesthesia services performed during the patients colonoscopy were not medically necessary for the treatment of this patient.Final Result: The reviewer determined that the services at issue are not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is board certified in anesthesiology 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 patient has been diagnosed with a helicobacter pylori infection. The patient reported epigastric pain. The patient had been taking meloxicam for neck pain. The treatment plan included starting pantoprazole and performing Helicobacter pylori testing. The patient underwent stool antigen testing for Helicobacter pylori infection, and the results were positive. The patient has requested reimbursement for Pylera (120 capsule blister pack) received. The Health Plan denied the request and reported the medication at issue was not medically necessary for the treatment of this patient. At issue in this case is whether Pylera (120 capsule blister pack) received was medically necessary for the treatment of the patients medical condition. Researchers reported, Helicobacter pylori (H. pylori) infection is a common worldwide infection that is an important cause of peptic ulcer disease and gastric cancer. H. pylori may also have a role in uninvestigated and functional dyspepsia, ulcer risk in patients taking low-dose aspirin or starting therapy with a non-steroidal anti-inflammatory medication, unexplained iron deficiency anemia, and idiopathic thrombocytopenic purpura. The authors also noted, For first-line treatment, clarithromycin triple therapy should be confined to patients with no previous history of macrolide exposure who reside in areas where clarithromycin resistance amongst H. pylori isolates is known to be low. Most patients will be better served by first-line treatment with bismuth quadruple therapy or concomitant therapy consisting of a proton pump inhibitor, clarithromycin, amoxicillin, and metronidazole. In this case, the patient has not tried and failed treatment with the preferred antibiotics in addition to acid suppression therapy (i.e., proton pump inhibitor, H2 receptor blocker or bismuth). The medical evidence does not support the medication at issue in this clinical setting. Therefore, Pylera (120 capsule blister pack) received was not medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested medication was 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 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: Medical Necessity
Decision: Overturned

The patient is a 41-year-old female who has multiple reasons for severe intractable lymphedema, most significantly, ovarian cancer and severe infection. She has an active life and has been severely impaired by lymphedema. The patient indicates her condition has greatly limited her ability to perform her daily activities. The submitted evidence indicates the patient tried compression stockings without success. She has requested coverage for a Flexitouch pump. The Health Plan has denied this request indicating that the requested equipment is not medically necessary for treatment of the patients lymphedema. Severe intractable lymphedema can be a very difficult problem to treat. This patient has tried manual lymphatic drainage, which was successful, but she is unable to self-treat because of carpal tunnel and Raynauds syndrome. The patient has experienced a well-documented, dramatic reduction in her lymphedema over six months using the Flexitouch pump. Continued use of the Flexitouch pump is likely to reduce infections and the frequency of doctor visits. Given that the patient and her treating specialists have documented significant benefit from use of the Flexitouch pump, I have determined the requested equipment is medically necessary for treatment of the patients medical condition. The Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for intrathecal baclofen pump trial for treatment of the enrollees medical condition. Findings:  The physician reviewer found that the patient has a history of cervical myelopathy. The patient underwent resection of a hemangioblastoma as described above. The patient does not have physical examination findings of spasticity. The patient has normal reflexes without upper motor neuron signs and with no reported increase in muscle tone using established scales such as the Ashworth or modified Ashworth Scale. However, the patient has complaints of spasms which affect the upper extremities. Spasms are not the same as spasticity and, in this case, the patient's spasms may represent the residual sequela of his cervical myelopathy. The patient has undergone extensive conservative treatments and remains symptomatic more than 2.5 years after surgery. Final Result: The reviewer determined that the requested procedure is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.  Credentials/Qualifications: Physician reviewer number one is board certified in physical medicine and rehabilitation 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

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for surgical repair of facial lesions and removal of facial cysts. Findings:  The physician reviewer found that Gallagher and colleagues note that in the dermatological use of intralesional triamcinolone in the treatment of acne, that observed skin atrophy rates are extremely low, but they are long lasting when it occurred. Min and colleagues report that while surgical excision is the treatment of choice for epidermal cysts, the cyst wall may be ruptured during operation, especially when the cyst wall is relatively thin, and that the incomplete excision of the cyst sometimes occurs because of a rupture of the cyst and may cause recurrence. In this case, given that the patient has a wound from a ruptured cyst secondary to a steroid injection in the glabella region, the requested service is medically indicated. Therefore, surgical repair of facial lesions and removal of facial cysts is medically necessary for the treatment of this patient.The California reconstructive surgery statute requires health insurers to cover reconstructive surgeries, defined as surgery performed to correct or repair abnormal structures of the body caused by congenital defects, developmental abnormalities, trauma, infection, tumors, or disease to do either of the following: (1) to improve function; (2) to create a normal appearance, to the extent possible. In this case, the lesion is an abnormal structure of the body that is the result of the disease of acne and treatment of the acne cyst. The requested surgery is to create a normal appearance to the extent possible and will provide more than a minimal improvement as the patient currently has an obvious deformity of the skin, with a crater in the glabella region. For these reasons, surgical repair of facial lesions and removal of facial cysts is reconstructive in nature for this patient. Final Result: The reviewer determined that the requested services are medically necessary for treatment of the patients medical condition and are reconstructive in nature. 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: Experimental/Investigational
Decision: Overturned

A 50-year-old female enrollee has requested reimbursement for transcranial magnetic stimulation (TMS) provided over a five-week period for treatment of the enrollees major depressive disorder.  Findings:  Two physician reviewers found that the patient has major depressive disorder and has requested reimbursement for TMS treatment. She presented with depressed mood, tearfulness, helplessness, anhedonia, cognitive impairment, appetite change, sleep disturbance and isolativeness. She had impaired functioning socially and occupationally. She has been tried on and failed to achieve significant improvement or remission on multiple antidepressants and augmentation strategies, including: Prozac, Paxil, Effexor, Elavil, Deplin, Abilify and Topamax which have been either ineffective or produced intolerable side effects. Psychotherapeutic approaches have also yielded inadequate therapeutic effect.According to the records provided for review, this patients depression is treatment resistant since multiple antidepressants and augmentation strategies have not successfully brought on remission. In the peer-reviewed studies, Schutter reported that TMS had a moderate effect on patients with treatment resistant depression. Similarly, George and colleagues showed that TMS was significantly more likely than sham treatment to produce remission in patients with treatment resistant depression. With regard to this patients diagnosis, Avery and colleagues demonstrated that TMS is a safe and effective treatment for major depressive disorder (MDD). Moreover, the American Psychiatric Association (APA) practice guidelines for treatment of depression suggest that acute phase treatment may include TMS.Thus, although relatively new, TMS is an effective treatment supported by the evidence-based literature. Further, TMS is widely practiced throughout the U.S., has been granted a category I CPT code by the American Medical Association (AMA), and is FDA approved for patients with treatment-resistant MDD. Consistent with this support, the requested TMS therapy will likely be more beneficial for treatment of the patients medical condition than any available modality for her depression.
Appeal type: Medical Necessity
Decision: Upheld

An enrollee has requested authorization and coverage for an in-center polysomnography test. American Academy of Sleep Medicine (AASM) guidelines recommend that polysomnography, or home sleep apnea testing with a technically adequate device, be used for the diagnosis of obstructive sleep apnea (OSA) in uncomplicated adult patients who present with signs and symptoms that indicate an increased risk of moderate to severe OSA. These guidelines recommend that if a single home sleep apnea test is negative, inconclusive, or technically inadequate, polysomnography should then be performed for the diagnosis of OSA. The guidelines state that polysomnography, rather than home sleep apnea testing, is recommended for the diagnosis of OSA in patients with significant cardiorespiratory disease, potential respiratory muscle weakness due to neuromuscular condition, awake hypoventilation or suspicion of sleep related hypoventilation, chronic opioid medication use, history of stroke, or severe insomnia.In this case, while the submitted documentation reflects that the patient experienced palpitations, shortness of breath and irregular heart rate, these symptoms do not establish that the patient has significant cardiorespiratory disease. Similarly, the patients elevated coronary artery calcium scores do not constitute significant cardiorespiratory disease that would warrant in-center polysomnography testing. Consistent with AASM guidelines, the patient may proceed with a home sleep study first, and in the event that the home sleep apnea test is negative, inconclusive, or technically inadequate, polysomnography could then be performed for the diagnosis of OSA. Accordingly, an in-center polysomnography test is not medically necessary to treat the patients medical condition at this time.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 internal 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

Nature of Statutory Criteria/Case Summary:   The parent of an enrollee has requested two hours per week of occupational therapy for treatment of the enrollees medical condition.   Findings:  The physician reviewer found that review of the submitted documentation and medical literature demonstrates the medical necessity of the requested services. There is ample evidence in the peer-reviewed literature that demonstrates occupational therapy can be effective for addressing sensory processing issues for children with autism spectrum disorder (ASD). An overall sensory based intervention can help children with ASD develop coping strategies. In addition, there is sufficient evidence in the peer-reviewed literature that supports occupational therapy as helpful for patients with ASD with learning activities of daily living. According to the documentation submitted for review, the patient continues to require occupational therapy to address decreased sensory processing and difficulty with fine motor skills. Thus, the requested two hours per week of occupational therapy has been established as medically necessary in this clinical setting. Final Result: The reviewer determined that the requested two hours per week of occupational therapy 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 pediatrics with sub-specialty certification in developmental and behavioral 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: Upheld

A 58-year-old male enrollee has requested authorization and coverage for laser treatment for treatment of the enrollees growth on his scrotum.  Findings:  The physician reviewer found that angiokeratoma of the scrotum, also known as angiokeratoma of Fordyce, is a common benign cutaneous lesion of capillaries, resulting in small marks of red to blue color with a horny overgrowth. These vascular lesions may be single and discrete or arranged in clusters. New lesions are red, soft and compressible, while the older lesions may be firm and non-compressible, often keratotic. The lesions of angiokeratoma may be asymptomatic, while in some cases there may be itching. Associated fungal eczema of scrotum/groin may lead to trauma and chronic irritation causing changes in the vessel wall in susceptible individuals. Histologically, this vascular disorder occurs in the papillary dermis and characterized by dermal vascular ectasia with overlying hyperkeratosis of the epidermis (Pahwa, et al). Although angiokeratomas of Fordyce usually do not need to be treated, they can be treated because of cosmetic concerns or bleeding that causes anxiety to the patient. It can be challenging to treat when lesions occur in large numbers. Treatments include surgery or locally destructive treatment modalities. Surgical excision or locally destructive methods such as electrocoagulation or cryotherapy may be used. Excision is not practical if there are many lesions, and electrocoagulation and cryotherapy may not be suitable for diffuse patterns. These modalities can cause hypopigmentation, hyperpigmentation, and atrophic scarring. Several vascular lasers have been used successfully to treat angiokeratoma of Fordyce with minimal side effects. In addition, ablative lasers such as carbon dioxide and erbium-doped yttrium aluminum garnet lasers have been used to remove the hyperkeratotic epidermis before treatment with a vascular laser (Civas, et al). Based on review of the available records, the patients angiokeratomas represent a cosmetic problem. There are no documented complications such as frequent bleeding. Therefore, treatment does not appear to be medically necessary at this point in time. Because angiokeratomas are not tumors, these do not qualify for reconstructive surgery. Consistent with these findings, the requested services are not reconstructive in nature or medically necessary for treatment of the patients medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for an Intracept procedure (basivertebral nerve ablation). Current medical literature supports the requested services as safe and effective for relief of vertebrogenic pain. Medical literature notes that vertebrogenic pain is a frequently underestimated cause of chronic low back pain and that vertebral endplate degeneration, characterized by cortical bone damage and subchondral bone inflammatory reaction, is a significant source of low back pain transmitted by the basivertebral nerve. The authors further note that radiofrequency ablation of the nerve leads to a thermal injury of nerve tissue and relief of pain. In a study of 56 patients, the authors found that at three- and twelve-month follow-ups, Oswestry Disability Index (ODI) and Visual Analog Scale (VAS) scores decreased significantly compared to baseline, with 54 out of the 56 patients achieving clinical success for pain and disability. The authors noted that computed tomography assisted targeting of the ablation zone was successful in 100% of patients. In this clinical setting, the requested service has been shown to lead to improvement of pain and function. Therefore, the Intracept procedure (basivertebral nerve ablation)  is likely to be more beneficial for treatment of the patients condition than any available standard therapy.Findings:  Three of the three physician reviewers found the requested Intracept procedure (basivertebral nerve ablation) is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the requested service is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned. 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: Medical Necessity
Decision: Overturned

A 57-year-old female enrollee has requested a biliopancreatic diversion with duodenal switch for treatment of her obesity. Findings:  The physician reviewer found that the patients BMI was 40.4.  She has failed supervised weight loss and completed a thorough multidisciplinary evaluation.  Barriers to surgery were not noted by the patients provider.  This patient is requesting a standard procedure for treatment of morbid obesity.  The requested procedure is approved by the American Society for Metabolic and Bariatric Surgery and the American Medical Association based upon numerous published peer-reviewed articles documenting the safety, efficacy and durable long-term outcomes.  Current medical evidence supports the requested procedure in this clinical scenario.  All told, the requested biliopancreatic diversion with duodenal switch is medically indicated for this patient.