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

Nature of Statutory Criteria/Case Summary: An enrollee has requested computed tomography (CT) of the cervical spine for evaluation of his neck pain and other radicular symptoms in the upper extremities. Findings: The physician reviewer found that this patient is at risk for significant cervical spine pathology based upon the mechanism of injury; however, the submitted record does not indicate that a CT scan is medically necessary in this clinical setting. While there is a reference in the providers letter that conservative therapy had been tried, there is no record to show that conservative therapy had been initiated; there is only a reference to an x-ray showing degenerative changes but no formal report is included in the records provided. Also, not present in the records is documentation to indicate that a spinal stimulator or other contraindication to an MRI of the cervical spine is present in this case. The patient's surgery was performed several months ago and there should be no artifact created by hardware in the lumbar spine, an area well out of the field of view. It would be unusual, being post-op for several months, that the patient would have any contraindication due to the prior procedure unless there is something about the hardware making it ferromagnetically incompatible; a situation very unusual in current practice. In sum, cross sectional imaging may be necessary following a trial of conservative management or if there is neurological deterioration in the interim. For these reasons, the requested CT scan is not medically necessary for evaluation of this patients neck pain and other radicular symptoms in the upper extremities.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 radiology 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 Hyperbaric Oxygen Therapy for treatment of pyoderma gangrenosum. The scientific literature indicates there is still no general agreement on the medical and surgical treatment of this condition. Data are insufficient to recommend the routine use of this therapy. Further studies are needed for this diagnosis.  Most studies have been small.  For these reasons, hyperbaric oxygen therapy is not likely to be more beneficial than any available standard therapy.Final Result: Three of the three reviewers determined that the requested service is 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: Three reviewers are board certified in Dermatology 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: Upheld

A 51-year-old female enrollee has requested additional physical therapy for treatment of her wrist pain. Findings:  The physician reviewer found that the patient sustained an intra-articular distal radial fracture with an ulnar styloid avulsion fracture due to a fall while skating.  She underwent conservative management with immobilization followed by extensive physical therapy.  She has not apparently undergone formal physical therapy since the date indicated.  The last documented comprehensive therapy update was on the date indicated when she had no pain at rest and 2 out of 10 pain with activities.  There were some ongoing functional limitations at that time, with mild to moderate range of motion loss and weakness.  She reportedly has been performing a home exercise program, but continues to have symptoms of stiffness, weakness and pain at the right wrist. Although this patient continues to have symptoms and functional loss in relation to her right wrist injury, this is not unexpected given the nature of her injuries.  Intra-articular involvement, in particular, is associated with range of motion loss.  The associated ulnar styloid fracture is also a negative prognostic factor.  In this patients case, there are no marginally significant benefits with respect to health or functional outcomes expected with further formal physical therapy beyond what would be expected to transpire with ongoing home exercise and the passage of time.  All told, the requested additional physical therapy is not medically indicated in this patients case.
Appeal type: Medical Necessity
Decision: Overturned

The patient is a medically-complex six-year-old female diagnosed with failure to thrive whose oral intake is not sufficient to meet her daily nutritional requirements.  With the benefit of occupational therapy she can feed orally, but is still gastrostomy tube (G-tube) dependent for the majority of her calories.  Her last noted feeding regimen consisted of two jars of baby food, 21 ounces of Neocate Jr. formula, and 14 ounces of a specially-mixed high calorie formula.  The patients mother reports an effort to gradually replace the specially mixed formula with Neocate Jr. based on the patients tolerance of the change.  The patients parents dispute the Health Plans denial of coverage due to a lack of medical necessity.Although the patients diagnosis and course of treatment are not clearly determined, she is likely to require G-tube feedings for some time into the future. The patient is making progress in transitioning from G-tube feeding to oral intake and from specially mixed formula to a readily available pediatric formula, but for now her current feeding regimen is necessary to meet her nutritional needs. The patient should receive another year of nutritional supplementation and then the need for nutritional supplements should be reviewed again after a gastroenterologist has reviewed the patients progress.Based upon the information set forth above, I have determined the requested nutritional supplements are medically necessary for treatment of the patients medical condition. The Health Plans denial should be overturned.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for prostate artery embolization (PAE) procedures. The first-line therapy for management of benign prostatic hyperplasia (BPH) includes medical therapy. This includes alpha-blockers, 5 alpha reductase inhibitors, phosphodiesterase inhibitors and anticholinergic medications. The standard of care for management of patients with BPH not responding to medical therapy is transurethral resection of the prostate (TURP). In patients with glands over 100 cc, as this patient, holmium laser enucleation of the prostate (HoLEP) and prostatectomy are recommended. Prostate artery embolization (PAE) is a novel approach for treatment of patients with BPH. Current medical literature on PAE is limited to case series and retrospective comparisons. There is a lack of randomized controlled clinical trials demonstrating the improved efficacy of PAE over TURP, HoLEP or simple prostatectomy. The medical literature does not support use of PAE over standard treatments. All told, the requested PAE procedures are not 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 PAE procedures, CPT code 37243 (vascular embolization and occlusion), 36247 (insertion of catheter/abdominal/L-external artery 3rd), and 36248 (insertion of catheter abdominal/L-external artery additional) are not likely to be more beneficial for treatment of the patients 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 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: Medical Necessity
Decision: Upheld

The patient is a 35-year-old obese woman who had gained 30 pounds over a one-year period. She was able to lose most of it while on a trial of Byetta. She now seeks authorization for coverage for Byetta from her Health Plan for further weight loss. She has sleep apnea and dyslipidemia by history and is worried about the possibility of developing diabetes. The Health Plan indicates Byetta is not approved for weight loss or for treatment of a metabolic syndrome or prediabetes.Based on the evidence provided, this patient does not have diabetes. Her physician raised the possibility of metabolic syndrome because of her obesity, unspecified dyslipidemia and one glucose reading (presumably fasting) greater than 100 mg/dl, which would be consistent with impaired fasting glucose or prediabetes, if persistent.Although the patient is concerned about developing diabetes there are several scientific peer-reviewed alternatives to diabetes prevention in susceptible populations including diet and exercise, metformin or acerbose. Given the availability of other alternatives, the use of Byetta is not medically warranted. Therefore, I have determined the requested medication is not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned

A 37-year-old female enrollee has requested for a panniculectomy for treatment of her excess skin. Findings:  The physician reviewer found that the photographs confirm a moderate overhanging abdominal pannus. This patient has functional issues related to the overlapping skin, and a panniculectomy is likely to resolve these issues. The submitted medical records document a chronic skin problem unresponsive to treatment. All told, the requested panniculectomy is medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld

A 57-year-old female enrollee has requested bunionectomy  foot surgery (correction hallux valgus 28296, with Osteotomy 28308, and correction hammertoe 28285) for treatment of her right foot hammertoe.  Findings:  The physician reviewer found that surgical correction of painful bunion and hammertoe deformities are appropriate in patients that have a severe structural deformity and have not responded to conservative care. In this patients case, the provider has not clearly documented the clinical findings to support the medical necessity for surgical correction. In addition, there is no description of clinical inflammation, associated skin irritation, or the inability to wear closed shoes. Further, there are no x-ray findings demonstrating bony deformities. All told, the requested correction hallux valgus (28296), with Osteotomy (28308), and correction hammertoe (28285) are not medically necessary for treatment of this patients medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary:  An enrollee has requested Afirma Gene Expression Classifier testing for evaluation of his medical condition.  Findings:  Three physician reviewers found that there is sufficient support for the Afirma gene test in this clinical setting. This patients biopsy revealed follicular lesion of undetermined significance. The genetic testing noted that the left thyroid was benign, and the right thyroid was suspicious. The Afirma test was a determining factor in delineating the further course of action to assess whether a surgical procedure was warranted with its resultant possible concomitant co-morbidity. Afirma testing is considered standard protocol on fine needle aspirations performed on thyroid nodules. In sum, the testing at issue was likely to be more beneficial for evaluation 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 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 internal medicine with sub-specialty certification in endocrinology and metabolism 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: Upheld

Nature of Statutory Criteria/ Case Summary:  The enrollee has requested reimbursement for residential treatment center (RTC) services. Findings:  The physician reviewer found that the requested service is not medically necessary for the treatment of the enrollees medical condition. He was admitted to a RTC due to the social consequences of his addictions; legal charges, unemployment and homelessness. He has a history of substance and alcohol abuse. He initially received detoxification services at the facility and then transitioned to the regular residential program. The enrollee was very motivated for treatment. His goals included improving his communication and interpersonal skills, receiving education regarding substance abuse, improving his health, and preventing relapse. He participated in individual and group therapy and received medication management.  He stepped down to a partial hospitalization program (PHP) level of care. Review of the record indicates the enrollee felt satisfied with his life but not with his relationships. He denied ever been diagnosed with mental health disorders or taking any psychotropic medications. He reports feeling anxious and hopeless because of his substance use. He was very motivated to recover. His alcohol and substance abuse withdrawal score remained low throughout his stay. The enrollees composite score is 19, which correlates with community outpatient services. This enrollee does not meet the RTC level of care requirements.Final Result: The reviewer determined that the requested service is not medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The physician 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 similar medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned

At issue is whether the prosthetic implant that the patient received was likely to have been more beneficial for the treatment of the patients condition than any available standard therapy. The patient complained of ongoing increasing low back pain associated with numbness, weakness, and left foot drop. Previous treatments included physical therapy, epidural steroid injections, and left lower extremity strength exercises. The patients diagnosis included lumbar degenerative disc disease with herniated nucleus pulposus at L4-5. The concern was for a neurological deficit due to an acute disc herniation.Findings:  Two out of three physician reviewers found that there is adequate data in the peer-reviewed medical literature demonstrating the benefits of an artificial disc replacement in this clinical setting. Reviewed studies comparing total disc replacement with a lumbar fusion. The authors conclude that total disc replacement is significantly better in terms of reduced clinical symptoms, improved physical function, and preserved range of motion for the treatment of lumbar degenerative disc disease compared to anterior lumbar interbody fusion. The operative report documented insertion of the ProDisc-L artificial disc to the L4-5 disc space. The ProDisc-L total disc replacement is approved by the U.S. Food and Drug Administration (FDA). The FDA states that this device is indicated for patients who are skeletally mature, have degenerative disc disease at one level in the lumbar spine, have no more than grade 1 spondylolisthesis at the involved level, and have had no pain relief after at least six months of non-surgical treatment. Colleagues concluded that patients undergoing ProDisc-L total disc replacement maintained significant improvement during the five-year follow-up.Final Result: The reviewers determined that the requested prosthetic implant 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 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: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for array-based evaluation of multiple molecular probes test and the advanced lipoprotein testing for evaluation of the enrollee who has a history of coronary heart disease.  Findings:  The physician reviewers found that The American College of Cardiology/American Heart Association Task Force on Practice ACC/AHA guidelines do not support the use of the advanced lipoprotein analysis over standard lipid measurements. Despite some researchers advocating for use of the advanced lipoprotein analysis, ACC guidelines do not support the use of advanced lipid testing. Rather, their guidelines recommend use of standard risk factors and standard lipid profile to make decisions about lipid management. Accordingly, the array-based evaluation of multiple molecular probes test and the advanced lipoprotein testing  were not likely to be superior to the available standard lipid profile for evaluating this patients medical condition.  Final Result: All three reviewers have determined 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:  All three reviewers are board certified in in internal medicine with sub-specialty certification in cardiovascular disease 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: Upheld

A 52-year-old male has requested coverage for past bovine insulin and future coverage for porcine and bovine insulin for treatment of his type 1 diabetes.   Findings:  The physician reviewer found that in this patients case, the submitted documentation fails to establish the medical necessity of the medication at issue at this time.  Additional details regarding the patients prior medical history are required in order to establish the medical necessity of porcine and bovine insulin.  The submitted medical records do not describe why the patient was unable to tolerate synthetic insulin and do not indicate details regarding prior regimens of synthetic insulin.  Patients who switch from animal insulin to synthetic or human insulin typically require additional insulin injections.  However, they are generally able to regulate their blood sugars with the newer insulin.  Of note, this usually takes time, as the duration of action of the synthetic insulin is different, given the immunogenic properties of the animal insulin.  In some cases, patients have rare insulin allergies.  However, the documentation does not indicate that this patient has an insulin allergy.  In order to demonstrate the medical necessity of the requested porcine and bovine insulin, medical records evidencing suboptimal results despite adequate dosing, blood glucose monitoring, and medical follow-up are needed.  Absent this information, the medical necessity of the medication at issue cannot be established at this time.
Appeal type: Medical Necessity
Decision: Upheld

A 32-year-old female enrollee has requested  a discography (procedure codes 72295 and 62290) to prepare for a platelet-rich plasma treatment for evaluation of her medical condition.  Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested services.  The records indicate that the patient reported lumbar spine pain.  She described it as constant, severe, and caused her to have trouble walking, eating and sleeping.  The current medical evidence does not support the requested discography in this clinical setting.  Carragee and colleagues reported that In all graded or measured parameters, discs that had been exposed to puncture and injection had greater progression of degenerative findings compared to control (non-injected) discs.  There is a lack of a recent clinical notes submitted for review.  In this patients case, the records do not provide an adequate description of the intended level(s) for the proposed discogram.  In addition, given the annular tear at L4-5, the discogram would be non-diagnostic at that level.  All told, the medical necessity of the requested discography has not been demonstrated in this patients case.
Appeal type: Medical Necessity
Decision: Upheld

The parent of a 17-year-old female enrollee has requested for chemical dependency intensive outpatient program services for treatment of the enrollees polysubstance dependence and major depression. Findings:  The physician reviewer found that the patient has had prior intensive outpatient treatment, residential treatment, and inpatient level of care treatment.  These all had the goals of adherence to treatment, abstinence from substance abuse and improvement in psychological and social functioning.  This patient has failed to benefit from services provided.  Repeating these services is not likely to result in an improvement in the patients condition.Polysubstance users tend to have a higher prevalence of comorbid psychiatric conditions which may enhance dysfunctional coping motives and interfere with treatment participation.  Agonist therapies and cognitive therapies provide for better long-term outcomes.
Appeal type: Medical Necessity
Decision: Upheld

A male enrollee requested monitored anesthesia care (MAC) services for medical evaluation of his risk for colon cancer.  Findings:  The physician reviewer found that this patient did not present with a significant history that would require MAC. Colonoscopy may be safely and effectively performed with conscious sedation of a benzodiazepine alone or with a narcotic in an office based setting and without the need of MAC services with propofol, as required per American Society of Anesthesiologist (ASA) guidelines. For these reasons, MAC services were not medically necessary for evaluation of this patients medical condition.