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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Percocet. The Centers for Disease Control and Prevention (CDC) states that when starting opioid therapy for chronic pain, providers should prescribe immediate-release opioids instead of extended-release/long-acting (ER/LA) opioids. The CDC also states when opioids are started, providers should prescribe the lowest effective dosage, use caution when prescribing opioids at any dosage, and carefully reassess evidence of individual benefits and risks when considering increasing dosage to 50 or more morphine milligram equivalents (MME) per day. However, in the documentation available for review, no objective treatment goals for pain and function are noted for the requested medication. Thus, the need to use this medical therapy as the primary treatment strategy for pain has not been established. In addition, there is no mention that behavior therapy has been completed despite much research to support its use. Moreover, not all non-opioid medications classes have been optimized or tried. All told, the requested Percocet is not supported as medically necessary for treatment of this patients chronic pain. Final Result: The reviewer determined that the requested medication is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in 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: Medical Necessity
Decision: Upheld

A 42-year-old female enrollee has requested a bariatric consultation for bariatric surgery for treatment of her morbid obesity.  Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested services in this patients case.  Current guidelines do not support the requested services in this clinical setting.  The submitted medical records do not document prior failed weight loss efforts.  A behavioral clearance was obtained.  However, a thorough multidisciplinary evaluation also includes a dietary evaluation, and there was no record of a dietary evaluation.  All told, the requested bariatric consultation for bariatric surgery is not medically indicated for the treatment of this patient.
Appeal type: Experimental/Investigational
Decision: Upheld

A 59-year-old female enrollee has requested a wound vacuum for treatment of her wound. Findings:  Three physician reviewers found that in this patients case, use of wound vacuum was not and is not likely to be of greater benefit than other treatment options.  She has been treated with wound vacuum in the past, with unclear results.  There is a lack of support for the services at issue in this case, as the medical literature has not demonstrated consistent improvement of wound healing over standard therapy in this clinical setting.  Therefore, the services at issue were not and are not likely to be more effective than other treatment modalities.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for parathyroid planar imaging single-photon emission computed tomography/computed tomography fusion imaging for evaluation of the enrollees hypercalcemia and elevated parathyroid hormone levels.Findings: All three physician reviewers found that this patient presents with classic laboratory evidence of primary hyperparathyroidism.  While laboratory values can be transiently or inaccurately high on occasion, there have been repeated assays, and the laboratory findings appear to be legitimate and reproducible.  Primary hyperparathyroidism is usually caused by a solitary benign adenoma (80 to 85 percent), but can also be due to double adenomata (2 to 5 percent), diffuse or nodular hyperplasia (10 to 15 percent), or parathyroid carcinoma (less than 1 percent). In the past, the next step would have been to perform a full exploration of the neck and to interrogate all four parathyroid glands.  Currently, a more focused, minimally invasive approach to parathyroid surgery is being adopted at many centers.  The goal has been to localize the suspected tumor prior to surgery.  Typically, a sonogram of the neck is performed, but it is generally difficult to distinguish a thyroid nodule from a parathyroid nodule.  A routine enhanced computed tomography (CT) scan is often insufficient, as these nodules are generally small, and are again masked by the thyroid gland which may, in itself, have intrinsic nodules. Over the years, nuclear medicine has become the standard means to diagnose a parathyroid nodule.  However, there are still limitations to a routine sestamibi technetium parathyroid scan, mainly related to the potentially small size of the adenoma.  In recent years, SPECT/CT scans have become the state of the art.  By fusing the nuclear medicine SPECT scans with the CT images, one can best localize the offending adenoma, and provide guidance for the minimally invasive surgery.  Per the medical evidence, the requested services are likely to be superior over other methods of evaluating this patient.Final Result: All three reviewers determined that the requested services are 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 physician reviewers are board certified in diagnostic radiology 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

A 47-year-old female enrollee has requested for a CT scan and MRI for evaluation of her pain. Findings:  The physician reviewer found that it has been shown in multiple studies and is well-documented in clinical guidelines that uncomplicated back pain is best treated with conservative therapy. Uncomplicated back pain is described as back pain with no associated red flags. According to the American College of Radiology guidelines, indications of a more complicated status include recent significant trauma, or milder trauma, age greater than 50, unexplained weight loss, unexplained fever, immunosuppression, history of cancer, intravenous drug use, prolonged use of corticosteroids, osteoporosis, age greater than 70 and focal neurologic deficit with progressive or disabling symptoms. Per an article by Kinkade, in the absence of red flag findings, four to six weeks of conservative care is safe and appropriate, and imaging is not indicated. The author also noted diagnostic imaging of the spine has a high rate of abnormal findings in asymptomatic persons. Therefore, imaging should be used in carefully selected patients and interpreted with appropriate clinical correlation.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested modafinil for treatment of her medical condition.  Findings:  The physician reviewer found that modafinil is medically necessary for treatment of the patients medical condition. Modafinil is widely used in the treatment of MS related fatigue as well as excessive daytime somnolence. In this case, the patient has taken modafinil with reported benefit. She indicates that when she takes a lower dose or misses medication, she becomes much less functional. Although the medical literature on the use of modafinil in MS is mixed, there are many case series that strongly suggest a significant benefit in some patients. Rammohan and colleagues assessed the efficacy and safety of modafinil for the treatment of fatigue in MS. The authors concluded that modafinil improves fatigue and is well tolerated. All told, modafinil is medically necessary for the treatment of this patients MS related fatigue.  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 neurology 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: An enrollee has requested reimbursement for left first metatarsophalangeal joint interposition arthroplasty with Cartiva implant. Findings:  The physician reviewer found that The Cartiva implant is a novel polyvinyl alcohol (PVA) hydrogel implant with recent Food and Drug Administration (FDA) approval. Anderson and colleagues have noted that while early and midterm results comparing the PVA hydrogel implant to arthrodesis are encouraging, long-term studies are lacking. Emmons and colleagues have noted that a prospective, randomized, noninferiority trial was conducted to assess the efficacy of polyvinyl alcohol hydrogel implant in the setting of a side-by-side comparison with arthrodesis. They stated that a subset of the hydrogel implant group has now reached minimum 5-year follow-up, and the implant has demonstrated high rates of survival (96.3%) at midterm. They state, nevertheless, that whether these success rates will be reproduced in studies born from third-party investigators is unknown. Therefore, the hydrogel implant has moderate early results with a significant emphasis being placed on the lack of high-quality studies comparing it to the gold standard, which is noted to be arthrodesis. Thus, the left first metatarsophalangeal joint interposition arthroplasty with Cartiva implant in issue was not likely to have been more beneficial than any other available standard treatments for the patients medical condition.Findings: Three out of three physician reviewers found that the services at issue were not likely to have been more beneficial than any other available standard treatments for the patients medical condition.Final Result: The reviewers determined that the services at issue were not likely to be more beneficial than any other available standard treatments for the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: Physician reviewers 1, 2 and 3 are board certified in orthopaedic surgery and are actively practicing. All three reviewers are experts in the treatment of the enrollees medical condition and are 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 actigraphy testing. Findings:  Three of the three physician reviewers determined that the requested services are not likely to be more beneficial than any available standard therapy for treatment of the enrollees medical condition.  The enrollee is diagnosed with non-24-hour circadian rhythm disorder. He was evaluated at a sleep center and results showed an Epworth sleepiness score of 0, insomnia scale of 18, fatigue scale of 29, sleep paralysis frequency score of 5, and the reduced Morningness-Eveningness questionnaire (rMEQ) score is 14. His bedtime and wake time is delayed by one hour each day and sleep-onset latency is less than 20 minutes. His reported sleep time is eight hours. He is unrefreshed upon wakening and has excessive daytime sleepiness. The sleep center physician ordered polysomnography with seizure montage and actigraphy to objectively assess the enrollees circadian rhythm. Actigraphy devices have FDA 510(K) clearance for use as a medical device. However, contribution of actigraphy to diagnoses of circadian rhythm sleep disorders (CRSD) is limited. Practice parameters from the medical literature have determined that recommendations for this procedure are low-level, as their benefit for the evaluation of circadian rhythms has yet to be determined nor has this technique been demonstrated to provide more benefit than other methods of evaluation, such as sleep diaries. The limited credible literature for CRSD precludes the ability to make conclusions on the efficacy of actigraphy when compared to (patient completed) sleep logs/sleep diaries.  Current literature supports that gold standards for measurement of sleep and wake cycles are polysomnography and the multiple sleep latency test. Actigraphy is a useful alternative if a polysomnogram cannot be completed and is particularly useful when recording of sleep and wake cannot be determined by sleep diaries or observation. In the clinical records submitted for review, there is insufficient evidence of inability to record sleep and wake cycles or obtain information needed for treatment using more traditional methods. The utility of actigraphy to assess circadian rhythm disorders has not been proven. Thus, there are few data to support its use and given the limitations of actigraphy it is not likely the results of actigraphy would impact the enrollees treatment plan. Final Result: Three of the three reviewers determined that the requested services are not likely to be more beneficial than any available standard therapy for treatment of the enrollees medical condition. Credentials/Qualifications: Three reviewers are board certified in sleep medicine 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: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for a Synvisc-One injection in both knees. Per the medical literature, although viscosupplementation may relieve knee pain in some individuals with osteoarthritis, it is not known as to which individuals will benefit. The current evidence is limited, and guidelines from organizations such as the American Academy of Orthopedic Surgeons indicate that the evidence is not conclusive. In light of the foregoing, viscosupplementation can only be recommended in individuals with a history of lasting benefit from prior injections, and in carefully selected cases where everything else has been tried, and the options are limited. In this case, the patient tried and failed other conservative treatments, with the alternative being a total knee arthroplasty. Given the patients limited options and based on the current medical literature, the requested services are medically indicated. Therefore,  Synvisc-One injection 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: Upheld

A 65-year-old male enrollee has requested for electronic-controlled thermal therapy (cooling device) post-operative use for treatment of his condition. Findings:  The physician reviewer found that there is a lack of medical evidence to support this manual therapy for the treatment of abdominal or pelvic adhesions.  The only studies in this area are uncontrolled pilot studies which do not provide sufficient evidence of efficacy to justify physical therapy for this patients condition.
Appeal type: Medical Necessity
Decision: Upheld

A 41-year-old male enrollee has requested intensive post acute neurological rehabilitation services for treatment of his anoxic encephalopathy secondary to massive hemorrhage during heart transplant surgery.  Findings:  The physician reviewer found that the records indicate this patients medical and functional rehabilitation needs can be addressed in a skilled nursing facility (SNF). He needs some rehabilitation as well as careful attention to his daily care needs as he continues to experience neurological recovery. There is a substantial body of evidence suggesting that SNF based rehabilitation is an appropriate treatment setting to achieve these goals. All told, the requested intensive post acute neurological rehabilitation services are not medically necessary for treatment of this patients medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for multi-parametric magnetic resonance imaging (MRI) of the prostate (MRI pelvis with and without contrast - RX should specify: mpMR prostate with & without contrast) for evaluation of the enrollees elevated prostate specific antigen (PSA). Findings:  Three physician reviewers found that the patient presented with signs and symptoms consistent with prostate infection.  The patient presented with elevated prostate specific antigen (PSA). He was treated with ciprofloxacin. The patient has requested multi-parametric magnetic resonance imaging (MRI) of the prostate (-MRI pelvis with and without contrast - RX should specify: mpMR prostate with & without contrast for evaluation of his medical condition). The Health Plan considers the requested services as investigational for the evaluation of the patients medical condition. This patient presented with a symptoms consistent with prostate infection. He was found to have an elevated PSA. Elevated PSAs are commonly found to be elevated with prostate infections. The patient was treated appropriately with ciprofloxacin to treat the infection. There was no evidence in the submitted records to suggest that this patient had prostate cancer other than the elevated PSA. Once the patient is treated for his prostate infection, the patient should be rechecked. If the patients PSA is still elevated, an ultrasound of the prostate and biopsy would be indicated at that time. Multi-parametric magnetic resonance imaging (mpMR) of the prostate is used to establish clinically significant information (i.e. staging and grading) that may influence a treatment approach after prostate cancer has been established through traditional means. However, the standard steps in diagnosing prostate cancer is by performing an ultrasound and a biopsy.  MpMR of the prostate has not replaced that step in diagnosing prostate cancer. As such, the requested services are not likely to be more effective than the available standard options for evaluation of this patient for prostate cancer. Final Result: The reviewers determined that the requested services are 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 physician reviewers 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: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for facial feminization surgeries to include the following specific surgeries: CPT 21139 (reduction forehead), CPT 14041 (adjacent tissue transfer or rearrangement, forehead, cheeks, chin, mouth, neck, axillae, genitalia, hands and/or feet), CPT 67900 (repair (brow ptosis, blepharoptosis, lid retraction, ectropion, entropion), procedures of the eyelids), CPT 30420 (rhinoplasty, primary), CPT 21209 (osteoplasty, facial bones), and CPT 64611 (somatic nerve).Ainsworth and Spiegel demonstrated that facial feminization surgery, like genital surgery, improved mental health-related quality of life. The World Professional Association for Transgender Healths (WPATH) Position Statement on Medical Necessity of Treatment noted that non-genital surgical procedures, including facial feminization surgery, are often of greater practical significance in the patients daily life than reconstruction of the genitals. WPATH noted, These reconstructive procedures are not optional in any meaningful sense, but are understood to be medically necessary for the treatment of the diagnosed condition. In this case, the patient has been diagnosed with gender dysphoria and has symptoms caused by her facial features. Therefore, the requested facial feminization surgeries: CPT 21139 (reduction forehead), CPT 14041 (adjacent tissue transfer or rearrangement, forehead, cheeks, chin, mouth, neck, axillae, genitalia, hands and/or feet), CPT 67900 (repair (brow ptosis, blepharoptosis, lid retraction, ectropion, entropion), procedures of the eyelids), CPT 30420 (rhinoplasty, primary), CPT 21209 (osteoplasty, facial bones), and CPT 64611 (somatic nerve), are medically necessary for the treatment of the patients medical condition.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 psychiatry with expertise in transgender 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.