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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Euflexxa injections in both knees. The current medical evidence supports the requested services in this clinical setting. Studies show that intra-articular hyaluronic acid provides a significant benefit in knee osteoarthritis. Studies show hyaluronic acid injections can reduce pain and increase function in patients with knee osteoarthritis. Studies show a systematic review of overlapping meta-analyses comparing viscosupplementation with other nonoperative treatment modalities for knee osteoarthritis. Studies show that intra-articular hyaluronic acid is a viable option for knee osteoarthritis. There is sufficient support for the requested services in this patients case. Therefore, Euflexxa injections, in both knees is medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested services are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in orthopedic surgery and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

A 35-year-old female enrollee has requested hospital services at a facility that can meet the immediate needs of her unborn child for the treatment of her highrisk pregnancy. Findings:  The physician reviewer found that this fetus has a significant congenital cardiac anomaly which will require intervention immediately after birth. A fetal echocardiogram is done prenatally to allow for the provider to plan the delivery at a tertiary center which can best deal with the defects and reduce mortality. Double outlet right ventricle (DORV) can have a mortality rate as high as 50% when combined with other cardiac anomalies. Transporting a sick newborn even for a short distance can add to that mortality rate. Additionally, it is not in the best interest of this patient to deliver in one hospital and immediately be separated from her baby. The baby may have to go to surgery before the mother can be medically discharged from the hospital, and it will also interfere with the bonding process. If the mother is in the same hospital as the child, she may be able to hold and nurse the child up to the time of surgery.
Appeal type: Experimental/Investigational
Decision: Upheld

A female enrollee requested a sinus endoscopy with balloon dilation for medical treatment of her medical condition.  Findings:  Two physician reviewers found that at this point, medical therapy and work-up have not been sufficient to plan surgical therapy.  All told, the requested sinus endoscopy with balloon dilation is not likely to be of greater benefit than other treatment options.
Appeal type: Medical Necessity
Decision: Upheld

A 34-year-old female enrollee has requested for wedge resection or bisection of the ovaries (CPT 58920) for treatment of her polycystic ovaries. Findings:  The physician reviewer found that ovarian wedge resection or bisection of the ovaries is performed in the treatment of infertility, not for dysfunctional uterine bleeding. The submitted documentation does not include any documentation regarding the patients infertility from the time of her office visit in August 2004 until the date of surgery. If there is objective clinical evidence regarding the patients fertility issues, the patients request for reimbursement should be reconsidered.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a three-year-old male enrollee has requested  speech and language therapy for treatment of the enrollee's autism.  Findings:  The physician reviewer found that patients need to engage in imitation and play to improve social and language development. Therefore, consistent with the medical literature and available scientific data, this patient should receive speech and language therapy to maximize his ability to function and communicate. As such, the requested service is medically necessary.
Appeal type: Experimental/Investigational
Decision: Overturned

A 44-year-old female enrollee has requested bronchial thermoplasty for treatment of her severe persistent asthma.  Findings:  Three physician reviewers found that the records indicate this patient has severe persistent asthma and has failed treatment with numerous medical therapies. In the peer-reviewed medical literature, bronchial thermoplasty results in fewer exacerbations and improved quality of life as well as reduced hospitalizations and need for rescue inhalers. The available data has shown that results do not diminish after five years. This patient is a good candidate and would likely benefit from bronchial thermoplasty. All told, the requested procedure is likely to be more beneficial for treatment of the patients medical condition than any standard therapy.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An female enrollee has requested authorization and coverage for body contour surgery (bilateral thighplasty with liposuction) for treatment of the enrollees rashes and are not reconstructive in nature. Findings: The physician reviewer found that the submitted documentation supports the medical necessity of a portion of the requested services. The records document evidence of functional impairment related to moderate to severe excess skin of the bilateral medial thighs, following significant weight loss.  The patient is noted to have chronic rashes and irritation associated with the excess skin of the medial thighs which has been treated with over-the-counter powders and prescription medication. Medial thighplasty is likely to provide functional improvement in her chronic rashes. No other conservative management would likely be beneficial. Her photographs are supportive of her documented functional impairment, which show significant excess skin of the medial thighs. Thus, medial thighplasty is medically necessary for the treatment of this patient. However, the records do not establish the medical necessity of the requested liposuction. Based on the submitted photographs, there is minimal excess subcutaneous tissue.  The requested liposuction is not likely to affect her functional deficit of chronic rashes. The patients excess skin of the medial thighs constitutes an abnormal structure of the body.  However, the excess subcutaneous tissue does not constitute an abnormal structure of the body, as there is no evidence of an abnormal collection of subcutaneous tissue.  Thus, the requested liposuction is not reconstructive in nature. Final Result: The reviewer determined that a portion of the requested services is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be partially overturned. Final Result: The reviewer determined that a portion of the requested services is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be partially overturned.
Appeal type: Medical Necessity
Decision: Overturned

The enrollee is requesting authorization and coverage for Euflexxa injections to both knees. An x-ray showed degenerative/arthritic changes in both knees, markedly severe in the left knee and moderate in the right knee. The enrollee has been treated with cortisone injections, non-steroidal anti-inflammatory drugs, knee braces, viscosupplementation injections every six months, and arthroscopy of the left knee. Office notes indicate the enrollees symptoms have been well controlled with steroid and viscosupplementation injections and non-steroidal anti-inflammatory drugs. The enrollee was due for viscosupplementation injections. The treatment plan includes Euflexxa injections in both knees, as well as rest, ice, and non-steroidal anti-inflammatory drugs. The enrollee indicates injections provide significant relief from the chronic pain in her knees. The treatment helps cushion and protect her knees from the hard exercise in which she engages. She believes the Euflexxa treatment is relatively mild and less risky for her than a total knee replacement. Review of the record indicates viscosupplementation has been successful in controlling this patient's bilateral knee pain and temporarily increasing function. Repeat injection therapy is indicated. The enrollee has failed bracing, oral NSAID therapy, ice, and steroid injections. The medical literature describes osteoarthritis as a common condition that can cause pain, reduced mobility, and decreased function. Those with more severe radiographic change often had a better response with the second course of IA-HA, specifically Euflexxa, in this study.Final Result: The reviewer determined that the requested service is medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The physician reviewer is board certified in orthopedic surgery and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or similar medical condition.
Appeal type: Urgent Care
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for emergency medical services. Findings:  The physician reviewer found that the medical services provided on the first day were necessary for treatment of an emergency medical condition. The patient presented on the first day with increased back pain, paresthesias and weakness of her legs after a fall. The imaging and evaluation performed on the first day were emergent for evaluation of the patients medical condition. However, the medical services provided for 3 days after were not necessary for treatment of an emergency medical condition. The patients surgery was performed on the second day, 24 hours after the patient presented to the hospital. The surgery at issue did not warrant emergency surgery. The records do not demonstrate that the patient had cauda equina syndrome or other findings supporting emergency surgery. Based on the clinical documentation submitted for review, the services day 2-4 were not emergency medical services.  Final Result: The reviewer determined that the patient received emergency medical services on a portion of the dates of service at issue. Therefore, the Health Plans denial should be partially overturned. 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: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Hizentra 8 gm subcutaneously every week for one year. Selective antibody deficiency with normal serum immunoglobulin concentrations is a deficiency of specific antibody response to polysaccharide antigens with intact response to protein antigens and normal serum level of IgG and IgG subclass. Immunoglobulin replacement therapy with intravenous immunoglobulin (IVIG) or subcutaneous immunoglobulin preparations is a treatment option for this group of patients with recurrent infections that persist after immunizing and antibiotic treatment. Wasserman reports that immunoglobulin replacement therapy is the cornerstone of management for most primary immunodeficiency disease patients, and that immunoglobulin replacement therapy leads to significant decreases in the number of infections. In this case, the patient has normal levels of IgG and abnormal post-vaccination pneumococcal titers constituting an immunodeficiency with only a 57% response to vaccination, or 13 out of 23 serotypes showing protection. In this case, given that the patient meets the diagnostic criteria for specific antibody deficiency disorder based on a history of recurrent infections such as sinusitis and bronchitis, and poor antibody response to pneumococcal antibody, the requested services are medically indicated. Therefore, Hizentra 8 gm subcutaneously every week for one year is medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested services are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in allergy and immunology 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 56-year-old female who is requesting relief for a number of symptoms that she relates to excess skin following her weight loss after gastric bypass surgery. A significant problem is irritation from the folding skin in the abdomen (the pannus), particularly in the region of psoriatic plaques. The patient has been followed over the years by dermatology for treatment of psoriasis. Treatment has consisted of primarily topical medications. Her psoriasis is assuredly a chronic illness, with no cure available. However, the patients examinations have consistently revealed significantly more inflammation on the psoriatic plaques in the infra-pannus region. This is also demonstrated in the photographs provided. The patient consulted a plastic surgeon who discussed a panniculectomy, abdominoplasty and brachioplasty with the patient. The Health Plan has determined that the requested surgery is cosmetic in nature and not medically necessary for treatment of the patients medical condition. The submitted records and photographs demonstrate an obvious need for more aggressive treatment of the patients pannus, which is a super-inflamed area of psoriasis. This patient meets medical necessity criteria for a panniculectomy. The complicated region of psoriasis in the skin fold area of the pannus represents as uncontrolled intertriginous dermatitis and thus, constitutes a medical indication for panniculectomy. However, based upon the evidence provided, an abdominoplasty and brachioplasty are not medically indicated. As such, I have determined that although a panniculectomy is medically necessary for treatment of the patients medical condition, an abdominoplasty and brachioplasty are not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be partially overturned.
Appeal type: Medical Necessity
Decision: Overturned

The patient is a 53-year-old female requesting reduction mammaplasty.  There is photographic evidence of large breasts and shoulder grooving along with the typical symptoms of macromastia.  Her symptoms have been treated with physical therapy and chiropractic therapy without relief.  Additionally, the patient has lost 40 pounds.  The patients provider has requested authorization for bilateral reduction mammaplasty to treat the patients symptoms. The Health Plan has denied authorization based upon a determination that the procedure is not medically necessary.This patient has symptoms consistent with macromastia.  Her complaints of shoulder and back pain, bra strap grooving, headaches, arm numbness and paresthesias are typical for this diagnosis.  The photographs confirm large breasts and deep bra strap grooves.  Her symptoms have not improved with chiropractic treatment, which is not surprising, as symptomatic macromastia is a mechanical problem and conservative treatments have been shown to be ineffective for this condition. The medical literature provides no evidence that weight loss or conservative treatments of any type can alleviate the symptoms of macromastia.  Non-operative treatments are unlikely to improve the patients pain and surgery provides the only real chance for symptomatic relief.  The medical literature supports the concept that patients who present with the typical symptoms of macromastia and who have a confirmatory exam will benefit greatly from breast reduction surgery. The Kerrigan study identified seven physical symptoms predictive of successful surgery.  These symptoms include back pain, rashes, bra strap grooves, neck pain, shoulder pain, upper extremity numbness and arm pain.  The patient has five of these seven symptoms, suggesting she will be significantly improved with breast reduction surgery.  Kerrigan also noted that weight loss and conservative therapy do not improve symptoms of macromastia. This patients symptoms are very unlikely to improve unless she has a breast reduction.  The anticipated resection of 400 to 500 grams is greater than the amount recommended in the literature for a medically necessary reduction. The peer-reviewed literature strongly supports the concept that the requested procedure 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 viscosupplementation injection for treatment of the enrollees osteoarthritis of knees. Findings:  The physician reviewer found that evidence based medical peer-reviewed literature supports the use of repeat series of viscosupplementation injections for the treatment of pain in patients with osteoarthritis of the knee. Viscosupplementation has been found to be safe and effective. More importantly, viscosupplementation has delayed total knee replacements for patients diagnosed with osteoarthritis. The studies have also shown that viscosupplementation is  more effective than corticosteroid injections. This patient was diagnosed with severe left knee osteoarthritis. He had been treated with corticosteroid injections, medications, and activity modification without sustained relief. He had undergone more than two series of viscosupplementation injections with reported significant sustained relief of his chronic osteoarthritis pain. Therefore, the requested coverage for viscosupplementation injection is medically necessary for treatment of this patients medical condition. Final Result: The reviewer determined that the requested injection 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 orthopedic surgery and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

A 41-year-old female has requested transcranial magnetic stimulation (TMS) therapy for treatment of her major depressive disorder.   Findings:  The physician reviewer found that the records indicate that this patients depression is treatment resistant since multiple antidepressants and augmentation strategies had not successfully brought on remission. In the medical literature, Schutter reported that TMS had a moderate effect of TMS on treatment resistant depression. In addition, George and colleagues showed that TMS was significantly more likely than sham treatment to produce remission in patients with treatment resistant depression. Further, Avery and colleagues provide evidence that TMS is a safe and effective treatment for major depressive disorder. Moreover, the American Psychiatric Association (APA) practice guidelines endorse TMS for treatment of depression in the acute phase of therapy. Thus, although relatively new, TMS is an effective treatment, has been granted a category I CPT code by the American Medical Association (AMA) and is FDA approved for the treatment of patients with treatment resistant major depressive disorder.
Appeal type: Medical Necessity
Decision: Overturned

Standard Review An enrollee has requested authorization and coverage for Vemlidy 25 mg, one tablet every day for one year. The Health Plan has denied this request indicating that the requested medication is not medically necessary for treatment of the enrollees hepatitis B virus. Nature of Statutory Criteria/Case Summary: Guidelines for the treatment of hepatitis B from the American Association for the Study of Liver Diseases (AASLD) recommend entecavir and tenofovir compared with alternatives for the treatment of chronic hepatitis B (Terrault, et al). In comparison with tenofovir disoproxil fumarate (Viread), which the patient had been taking, the medical literature indicates that the Vemlidy formulation of tenofovir is effective for hepatitis B, and is associated with lower incidence of side effects such as osteopenia and renal disease.  For this reason, Vemlidy 25 mg, one tablet every day for one year is medically necessary for the treatment of this patients chronic hepatitis B. Final Result: The reviewer determined that the requested medication is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in internal medicine with 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: Experimental/Investigational
Decision: Upheld

The parent of an eight-year-old female enrollee has requested cognitive skills development therapy for treatment of the enrollees attention deficit/hyperactivity disorder. Findings:  Three physician reviewers found that cognitive skills therapy was not and is not likely to be more beneficial for the treatment of attention deficit/hyperactivity disorder than standard therapy.  In the report by Antshel and Barkley, limited efficacy for cognitive therapy was noted.  The American Academy of Child and Adolescent Psychiatry practice parameters note that formal skills training for children with attention deficit/hyperactivity disorder has not been shown to be effective.  All told, cognitive skills development therapy was not and is not likely to be the most beneficial treatment alternative.