Persius/imr-appeals huggingface dataset:
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for a tap water iontophoresis device. Findings:  Three physician reviewers found that there is sufficient support for the device at issue in this clinical setting. This patient has been diagnosed with primary focal hyperhidrosis. Researchers noted that iontophoresis is safe and effective for the treatment of palmar and plantar hyperhidrosis. The researchers also noted that this modality may be combined with other treatments, including Botox injections and topical antiperspirants. This patients condition has impacted her quality of life. Thus, the tap water iontophoresis device was likely to have been more effective than other treatment options. Final Result: The reviewers determined that the device at issue was likely to have been 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 internal medicine and are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: At issue is whether the stab phlebectomy of varicose veins procedure is likely to be more beneficial for the treatment of the patients condition than any available standard therapy. The patient presented with complaints of ongoing pain in the right leg, inability to stand, and associated itching. Prior treatments included greater than three months of compression stockings, elevation, exercise, and medication therapy. She was diagnosed with chronic venous hypertension with inflammation of the right lower extremity.Findings:  Two out of three physician reviewers found that there is evidence to support the requested the stab phlebectomy of varicose veins procedure. The Society for Vascular Surgery (SVS) and the American Venous Forum (AVF) have developed clinical practice guidelines for the care of patients with varicose veins of the lower limbs and pelvis. In this case, the rationale for not treating the great saphenous vein is that it is too small and that even with reflux, it is likely to have no clinical impact. With clinically-irrelevant reflux, only removing the branches is required. One out of three physician reviewers found that most data show that there are advantages of up to two years with either laser or radiofrequency ablation compared to standard stripping and there is a greater patient acceptance with shorter recovery time. Thus, the stab phlebectomy of varicose veins procedure is not likely to be more beneficial for the treatment of the patients condition than any available standard therapy.Final Result: Two out of three reviewers determined that the requested procedure is 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 vascular 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 advanced lipoprotein blood testing (CPT 83704, 82172, 83695 and 83698) performed by Quest Diagnostics. Harada and colleagues report that standard lipid testing, represented by total cholesterol, low-density lipoprotein cholesterol (LDL-C), high-density lipoprotein cholesterol (HDL-C), and triglycerides, is a well-established platform for cardiovascular disease (CVD) risk prediction and management. In this case, laboratory testing reported a total cholesterol level of 222 mg/dL, HDL-C of 72 mg/dL, LDL-C of 135 mg/dL, and triglyceride level of 61 mg/dL. Visit notes did not report a history of diabetes, hypertension, or tobacco use. While an advanced lipid profile may be used as adjunctive information in determining whether to start a patient with intermediate CVD risk on statin therapy, given this patients low overall CVD risk, current guidelines recommend continued lifestyle modifications and would not consider the patient a candidate for statin therapy. Therefore, advanced lipoprotein blood testing (CPT 83704, 82172, 83695 and 83698) that was performed by Quest Diagnostics was not likely to have been more beneficial for the evaluation of the patients medical condition than any available standard therapy.Findings:  Three of the three physician reviewers found the advanced lipoprotein blood testing (CPT 83704, 82172, 83695 and 83698) performed by Quest Diagnostics was not likely to have been more beneficial for the evaluation of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the service at issue not likely to be more beneficial for the evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: Physician reviewers 1, 2, and 3 are board certified in internal medicine with sub-specialty certification in cardiovascular disease 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 35-year-old female enrollee has requested for breast reduction surgery for treatment of her back pain and breast pain. Findings:  The physician reviewer found that breast reduction surgery is effective in relieving the symptoms related to large breasts such as back pain, neck pain, skin breakdown, etc. To further delineate the group of patients who are likely to benefit from breast reduction surgery, a Schnur scale was developed to relate the amount of breast tissue removed to preoperative body mass surface area as a means of differentiating cosmetic from reconstructive medically necessary breast reduction surgery. This also makes intuitive sense because if the surgeon removes a small amount of tissue (e.g., less than 75 gm) it is highly unlikely the surgery would have any effect on back pain. As the amount removed is increased, the procedure changes from a cosmetic procedure to a medically necessary procedure. The aforementioned scale accounts for this by relating the amount removed to body surface area (size of the person) rather than just weight or height. In this case, the removal of 900 gm from each breast meets these criteria. In sum, this patient is an appropriate candidate for medically necessary breast reduction surgery.
Appeal type: Medical Necessity
Decision: Upheld

A 50-year-old male enrollee has requested a Donjoy cold therapy unit for treatment following rotator cuff surgery.  Findings:  The physician reviewer found that the peer reviewed literature does not support the use of a cold therapy unit following rotator cuff surgery. Available data has not demonstrated that cryotherapy is an essential element of postoperative recovery or that the use of this equipment is more effective than the application of ice packs. Additionally, there is no long-term data showing that the use of a cold therapy unit results in better clinical outcomes.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for digital breast tomosynthesis that was performed for evaluation of the enrollee, who presented for a breast screening mammogram. Findings:  2/3 of the physician reviewers found that the patient is a female who presented for a bilateral screening mammogram with breast tomosynthesis. There was no mammographic evidence of malignancy. The breast tissue was average in density. There were no suspicious abnormality reported. The impression was negative. The Health Plan has denied the request for reimbursement for digital breast tomosynthesis performed. Per the Health Plan, the service at issue was investigational for the evaluation of this patient.There is clinical support for the service at issue. According to colleagues, the use of mammography plus tomosynthesis in a screening environment resulted in a significantly higher cancer detection rate and enabled the detection of more invasive cancers. Colleagues noted that integrated two dimensional and three dimensional mammography improves breast cancer detection and has the potential to reduce false positive recalls. Thus, the literature supports the use of breast tomosynthesis over conventional mammogram due to improved cancer detection rate.  In sum, digital breast tomosynthesis performed was likely to have been more effective than other methods of evaluating this patient. Final Result: 2/3 of the reviewers determined that the service 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: Physician reviewer number one 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.Physician reviewer number two 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.Physician reviewer number three 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: Medical Necessity
Decision: Upheld

A 53-year-old female enrollee has requested an abdominal and pelvic computerized tomography (CT) with and without contrast for evaluation of her recurrent left lower quadrant pain.  Findings:  The physician reviewer found that at this time, the requested diagnostic procedure  is not indicated for evaluating this patient. On the date in question, it was noted that the patients symptoms had  resolved, and she was  showing no evidence of an ongoing inflammatory process. A colonoscopy is indicated, given this patients presentation. Based on the results of that examination, it may be necessary to perform imaging if a mass is found. However, if the colonoscopy only shows diverticulosis, and her symptoms are resolved, a CT scan is not warranted.  Based upon the submitted documentation, the medical necessity of the requested diagnostic procedure has not been established.  Thus, the requested abdominal and pelvic computerized tomography (CT) with and without contrast is not medically indicated for the evaluation of this patient at this time.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for a transoral incisionless fundoplication (TIF) procedure utilizing the EsophyX device (CPT code 43210). The Health Plan has denied the requested services as investigational for treatment of the enrollees gastroesophageal reflux disease (GERD). Findings:  Three physician reviewers found that guidelines from the American Society for Gastrointestinal Endoscopy (ASGE) report that the long-term follow-up data for TIF is limited. These conclusions are bolstered by recent reports of severe adverse events during the procedure and the need for surgery to revise ineffective TIF. As such, the requested TIF procedure utilizing the EsophyX device is not likely to be more beneficial for treatment of the patients medical condition than any other available standard therapy.Final Result: The reviewers determined that the requested procedure is not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: Physician reviewers 1, 2 and 3 are board certified in internal medicine with subspecialty certification in gastroenterology 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

Findings:  The physician reviewer found that The patient has requested reimbursement for ciprofloxacin 0.3% and dexamethasone 0.1% otic suspension (Ciprodex). Based on available clinical documentation, treatment with ciprofloxacin 0.3% and dexamethasone 0.1% otic suspension (Ciprodex) was medically necessary for treatment of this patients medical condition. The American Academy of Otolaryngology-Head and Neck Surgery (AAOHNS) clinical practice guideline on tympanostomy tubes in children states that tympanostomy tube otorrhea is usually a manifestation of acute otitis media and caused by Pseudomonas aeruginosa or common nasopharyngeal pathogens (Rosenfeld, et al.). In addition, the AAOHNS guideline stated that aminoglycoside-containing eardrops, often used to treat acute otitis externa, should be avoided in patients with tympanostomy tubes due to potential ototoxicity. The guidelines further recommend quinolone eardrops with or without steroids such as ciprofloxacin with dexamethasone to treat patients with middle ear infections. In this case, the patient had a tympanic membrane perforation, which is functionally similar to a having a tympanostomy tube since the membrane is not intact. In addition, the patients otorrhea culture demonstrated pseudomonas. In this clinical setting, the AAOHNS supports treatment with ciprofloxacin with dexamethasone otic suspension. Therefore, the ciprofloxacin 0.3% and dexamethasone 0.1% otic suspension (Ciprodex) was medically necessary for treatment of this patient. Final Result: The reviewer determined that the medication at issue was medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for midazolam, meperidine and moderate sedation services provided during epidural steroid injections. The submitted documentation fails to demonstrate the medical necessity of the requested medications and requested services. Midazolam and meperidine are used for conscious sedation for certain in-office procedures. Epidurals for pain management are an appropriate indication for conscious sedation in patients who have anxiety, extreme fear of needles or risk of moving during the procedure. Most patients can tolerate local anesthesia for these epidural injections. Conscious sedation is generally reserved for patients who have tried but are unable to tolerate local anesthetic for these injections. In this patients case, the records do not document that the patient requires conscious sedation for this procedure. The records do not document previous attempts with local anesthesia where the patient was unable to tolerate the procedure under local anesthesia. Therefore, midazolam, meperidine and moderate sedation services provided during epidural steroid injections are not medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested medication and 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 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: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for MyRisk genetic testing for evaluation of the enrollees risk of cancer. Findings:  Two physician reviewers found that if the patient tested negative for BRCA1 it could be possible that other non-tested affected family members harbored a different mutation or that a mutation came from the patients paternal side. A negative panel affects how the patient will be screened in the future. The patient would revert back to the same risk as the general population and no additional cancer screening would be necessary.  The recent introduction of multi-gene testing for hereditary forms of cancer has rapidly altered the clinical approach to testing at-risk patients and their families. Based on next-generation sequencing technology, these tests simultaneously analyze a set of genes that are associated with a specific family cancer phenotype or multiple phenotypes. When more than one gene can explain an inherited cancer syndrome, then multi-gene testing may be more efficient. Final Result: The 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: Reviewers 1, 2 and 3 are board certified in internal medicine with sub-specialty certification in medical oncology and are 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 consultation for gastric bypass surgery for treatment of the enrollees medical condition.  Findings: The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested services in this patients case.  The records do not indicate a known technical or anatomic problem with the gastric bypass which would result in weight regain and or be amenable to surgical repair/improvement.  There is a lack of documented follow-up notes and no updated psychological or dietary evaluation to support the requested services.  The current medical evidence does not support the requested services in this clinical setting.  All told, the requested consultation for gastric bypass surgery is not medically indicated for the 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 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

A 54-year-old male enrollee has requested rosacea laser treatment for his rosacea.   Findings:  Findings:  Three physician reviewers found that laser treatment of rosacea is considered to be investigational for the treatment of rosacea at this time. Standard treatment involves consistent therapy with topical metronidazole-containing creams, as well as the use of low-dose oral antibiotics to reduce inflammation (Odom, et al. and Del Rosso). This patient does not appear to have been optimized on these regimens. In the absence of evidence demonstrating lack of benefit from a multi-modal approach that includes oral antibiotics and topical metronidazole-containing medications, the superiority of laser therapy over standard therapy has not been established.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for serological antibody testing for Helicobacter pylori.Findings:  Two out of three physician reviewers found that this patient reported a history of Helicobacter pylori infection. Medical literatures noted Helicobacter pylori infection can be clinically challenging, given the numerous diagnostic and therapeutic options available. Consistent with standard of care, the researchers noted 13C urea breath test or the stool antigen test can be used for noninvasive screening for Helicobacter pylori in a test and treat strategy in younger patients presenting with dyspepsia without alarm symptoms and without the need for endoscopic prelude to therapy or re-treatment. The medical evidence does not support serologic testing for the evaluation of this patient. The Helicobacter pylori immunoglobulin G (IgG) antibody assayed in this patients case is not beneficial in distinguishing between active disease and previous exposure. Further, antibodies to Helicobacter pylori can remain elevated for a long time after treatment, potentially increasing the number of false-positive results. This patients records do not specify whether she received treatment upon Helicobacter pylori detection in previous years, or whether it was her desire to be retested to assess efficacy of past eradication efforts. Serologic testing for re-documentation of a previously positive Helicobacter pylori status was not likely to have been more beneficial in achieving a positive outcome than standard testing with detection of active infection with stool antigen or urea breath assays. In sum, serological testing for Helicobacter pylori was not likely to have been superior over other methods of evaluating this patient. Final Result: The reviewers determined that the services at issue were not likely to have been more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: Physician reviewers 1, 2 and 3 are board certified in internal medicine with sub-specialty certification in gastroenterology 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.