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

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Supartz injections in both knees. The submitted documentation supports the medical necessity of the requested services. An exhaustive review of the current medical literature pertaining to viscosupplementation reveals mixed results. Evidence from eight systematic reviews and six randomized controlled trials indicates that although viscosupplementation may relieve knee pain in some individuals with osteoarthritis, it is not known as to which individuals will benefit. Different studies have tried mixing hyaluronic acid with corticosteroids, platelet-rich plasma, and other agents to make it more effective. 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, there is a history of lasting benefit from prior injections of Supartz in both knees. Therefore, the requested Supartz injections in both knees are 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

The parent of an enrollee has requested authorization and coverage for the medication Uceris 9 mg. Budesonide MMX (Uceris) is a steroid formulation which has much lower systemic absorption than prednisone, and concomitantly fewer side effects. Prolonged systemic exposure to steroids is particularly problematic in the pediatric age group, as they suppress linear growth and prevent achievement of maximal bone density. For that reason, in a child who is unable to taper off of prednisone, budesonide MMX is an appropriate alternative. According to the guidelines of the European Society of Pediatric Gastroenterology, Hepatology, and Nutrition (ESPGHAN), budesonide MMX is the appropriate treatment in the setting of colitis (with left sided disease) when there has been an incomplete response to mesalamine at maximum dose. The ESPGHAN paper also points out that most children with mild to moderate ulcerative colitis will not achieve remission with mesalamine monotherapy alone. In this case, the patient has had incomplete response to mesalamine at maximal dose, and has been unable to discontinue prednisone. Furthermore, a sequential trial of salicylates, such as a trial of balsalazide in place of mesalamine is not indicated in the pediatric age group. For these reasons, initiation of budesonide MMX for induction of remission with minimization of steroid side effects is appropriate. Accordingly, Uceris 9 mg is medically necessary for treatment of the patients medical condition.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 pediatrics, with subspecialty certification in pediatric gastroenterology, and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

A 54-year-old female enrollee has requested a third series of Synvisc injections in the left and right knees for treatment of her osteoarthritis.  Findings:  The physician reviewer found that the hyaluronan viscosupplements (Hyalgan, Synvisc or Synvisc One, Euflexxa, Supartz, and Orthovisc) have been approved by the Food and Drug Administration to treat the pain associated with osteoarthritis of the knee. Hyaluronan is a major component of synovial fluid. The goal of hyaluronan viscosupplementation is to restore the visco-elasticity of synovial hyaluronan. Viscosupplementation has been approved for patients who have failed to respond to conservative non-pharmacologic therapy and simple analgesics. There is medical justification for viscosupplementation treatment and even one-time retreatment if specific criteria are met. However, there is insufficient scientific evidence in the peer-reviewed medical literature demonstrating the long-term safety and efficacy of multiple retreatments with viscosupplementation for osteoarthritic knees. Given the lack of prospective, multi-center, randomized clinical trial data documenting the benefits of multiple retreatments (more than two courses) of viscosupplementation, the medical necessity of the requested Synvisc injections for this patient has not been established.
Appeal type: Medical Necessity
Decision: Upheld

A 37-year-old male enrollee has requested residential treatment services for treatment of his alcohol dependence.  Findings:  The physician reviewer found the patient was no longer showing signs of acute withdrawal or post alcohol withdrawal. The records indicate that he had no comorbid psychiatric conditions, other than his fractured tibia, and he had no comorbid medical conditions. He did not attest to suicidal or homicidal ideation and he was not a threat to others. He demonstrated a willingness to change as evidenced by attendance and participation in groups and 12 step meetings, as well as working on his steps. Although he had difficulties with impulse control and coping skills, these are issues that can be addressed at a lower level of care. The patient indicates that residing alone is an obstacle towards remaining sober. Applying the American Society of Addiction Medicine (ASAM) criteria, this patients risk for relapse was relatively low, thus a structured environment such as intensive outpatient would have been an appropriate level of care. All told, the patient did not require 24-hour supervision in a residential setting, and any medication changes could have safely been managed at a lower level of care. Therefore, the residential treatment services was not medically necessary for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld

A 64-year-old female enrollee has requested removal of saline breast implants for treatment of her ruptured implant.  Findings:  The physician reviewer found that this patients records and photographs demonstrate that although the right breast implant was deflated and the skin wrinkled, there were no abnormalities affecting the right breast itself. Even if the breast with the ruptured implant was considered an abnormal structure of the body, the etiology of the abnormality was not due to congenital defect, developmental abnormality, trauma, infection, tumor or disease. Rather, the condition was secondary to an elective cosmetic procedure. The contention that the abnormality was made more severe due to weight loss associated with the patients colitis is not persuasive. Excess breast tissue due to weight loss is not considered an indication for reconstructive breast surgery by the American Society of Plastic Surgeons. Further, even if the patients condition was in fact exacerbated by weight loss due to colitis, removal of the implants would not create a normal appearance to the extent possible or improve function. As such, the patient does not meet criteria for reconstructive surgery as defined by California law. With regard to whether removal of the ruptured implant was medically necessary, the records document that the ruptured implant was a saline implant. Whereas removal of ruptured gel implants is necessary because the free gel can cause medical problems, a ruptured saline implant does not carry such risk. Moreover, there is no evidence the patient had experienced a Baker class IV contracture. All told, I find that the removal of the patients breast implants was a cosmetic procedure and not reconstructive or medically necessary.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Orthovisc injections for treatment of the enrollees bilateral knee pain. Findings:  The physician reviewer found that as evidenced by this patients history of significant benefit from prior injections, the current literature supports the use of viscosupplementation as treatment for osteoarthritis of the knees in this clinical setting. There is good evidence that these injections reduce pain and increase function in knee osteoarthritis and the benefits are long-lasting as compared with intra-articular corticosteroids. One study reported on a systematic review of overlapping meta-analyses comparing hyaluronic acid with other non-operative treatment modalities for knee osteoarthritis. The authors found that the current highest level of evidence suggests that intra-articular hyaluronic acid is a viable option for knee osteoarthritis. Furthermore, intra-articular hyaluronic acid has a good safety profile, and its use should be considered in patients with osteoarthritis of the knee. Final Result: The reviewer determined that the requested service 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

Nature of Statutory Criteria/Case Summary:  An enrollee has requested authorization and coverage for arthroscopy right knee, debridement/shaving of articular cartilage and meniscectomy. Findings:  The physician reviewer found that clinical trials have shown that arthroscopy of the knee is not an effective treatment for osteoarthritis. However, patients who have displaced meniscal tears or loose bodies in a knee with pre-existing arthritis can benefit from this procedure. Arthroscopy can have a role in arthritic knees if there is clinical and imaging evidence of symptomatic meniscal tear causing mechanical symptoms such as painful, disabling catching, locking and popping. Karpinski and colleagues conclude that results of randomized controlled trials comparing arthroscopic treatment of arthritic knees with other treatment options are inconsistent; however, there is evidence that a subgroup of arthritic patients with meniscal flap tears can benefit from arthroscopy. In this case, the MRI of the right knee showed a significant tear with a folded, displaced meniscal fragment posterior horn lateral meniscus. Two of the knee compartments were relatively healthy. The patient ran five to seven miles a day and is not considering total knee replacement. Therefore, the requested arthroscopy right knee, debridement/shaving of articular cartilage and meniscectomy is medically necessary for treatment of the patients medical condition.Final Result: The reviewer determined that the requested service 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: Upheld

A 47-year-old female has requested transforaminal selective nerve root block (SNRB) right L5 (CPT code 64483) for treatment of her complex regional pain syndrome of the lower limb.  Findings:  The physician reviewer found that the submitted documentation fails to establish the medical necessity of the requested transforaminal (SNRB) right L5. It appears SNRB of the right L5 nerve root has been proposed to confirm that the pain sensation is being transmitted by the L5 nerve root; if so, a radiofrequency procedure will then be performed to modulate the L5 nerve roots ability to transmit pain signals. There is a lack of documentation within the current medical literature of the prognostic value of selective nerve root block (SNRB) followed by radiofrequency ablation of the dorsal root ganglion in complex regional pain syndrome. Its place in the treatment algorithm for this clinical condition does not yet rise to meet generally accepted standards of care. Further studies are needed in order to establish the prognostic benefit of SNRB in this clinical setting. Moreover, there is a lack of evidence to support the therapeutic use of SNRB in this case, as the submitted clinical documentation does not provide confirmatory evidence of radiculopathy based on clinical exam, MRI or CT imaging of the lumbar spine, or electrodiagnostic studies. In conclusion, the medical necessity of SNRB for treatment of this patients condition has not been established.
Appeal type: Medical Necessity
Decision: Upheld

The patient is a 33-year-old female with a BMI of 37. Though she has some obesity related comorbidities, she does not have any severe comorbidities such as diabetes or intractable hypertension. She wishes to undergo gastric bypass surgery. The Health Plan has determined that the requested procedure is not medically necessary for treatment of the patients medical condition.The Health Plans denial is correct. This patient does not meet nationally accepted medically necessary criteria for weight loss surgery. With a BMI of 37 and no severe comorbidities such as diabetes or hypertension, weight loss surgery is not medically indicated or necessary for this patient. The patient should make further attempts at conservative weight loss and behavior modification prior to considering surgery. Therefore, I have determined that the requested procedure is not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Experimental/Investigational
Decision: Upheld

A 59-year-old male enrollee has requested computed tomography (CT) angiography (CPT code 75574) for evaluation of his abnormal cardiac study and an iliac artery aneurysm.  Findings:  Three physician reviewers found that performance of coronary CT angiography in this patient is not consistent with current standard medical practice or likely to be more beneficial than any available therapy. An exercise stress test with imaging is considered the first-line diagnostic study given this patients history and the time that has elapsed since the previous study (Miller, et al). According to the Health Quality Ontario review on the utility of CT angiography, the diagnostic procedure is almost as good as coronary angiography in detecting true positives but poorer in the rate of false positives, which may lead to further unnecessary testing. Consistent with the available data, the requested CT angiography (CPT code 75574) is not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.
Appeal type: Experimental/Investigational
Decision: Overturned

A 43-year-old male enrollee has requested radioembolization using 90-Yttrium spheres for the treatment of his metastatic neuroendocrine tumor to the liver. Findings:  Two physician reviewers found that the National Comprehensive Cancer Network recommend management of recurrent or unresected disease for patients who are deemed unresectable include a number of options. These include clinical trials, local ablative therapy (radiofrequency ablation, microwave and cryotherapy) and hepatic regional therapy (arterial embolization, chemoembolization and radioembolization). Therefore, local ablative therapy, including radiofrequency ablation, is listed as an option for patients such as this.  Radioembolization using 90-Yttrium spheres is medically appropriate and indicated for treatment of this patient.
Appeal type: Experimental/Investigational
Decision: Upheld

A 51-year-old female enrollee has requested the human papillomavirus (HPV) vaccine, Gardasil for the treatment of nasal papillomas.  Findings:  Three physician reviewers found that this vaccine is not a cure for papillomas, but a preventative measure. As such, it is not indicated for the treatment of existing papillomatous disease. There is no literature to support the use of Gardasil in patients with nasal papillomas.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for hypoglossal nerve stimulation (Inspire Upper Airway Stimulation system).Findings:  Three physician reviewers found that there is sufficient support for the requested services in this patients case. Although traditional upper airway surgical procedures target the anatomic component of obstruction, upper airway stimulation tackles the twin goals of improving anatomic and neuromuscular pathology. The STAR trial demonstrated that hypoglossal nerve stimulation led to significant improvements in objective and subjective measurements of the severity of obstructive sleep apnea. This trial has demonstrated the hypoglossal nerve stimulator to be safe and effective in a small subset of patients with obstructive sleep apnea who have failed CPAP, have nonconcentric airway collapse, an AHI between 20 and 50, and a body mass index less than 32. With a body mass index of 23, AHI of 44 and nonconcentric airway collapse, this patient meets the criteria. She has failed CPAP, which is the gold standard treatment for OSA. Therefore, hypoglossal nerve stimulation (Inspire Upper Airway Stimulation system) is likely to be more effective than other available treatment options. Final Result: The reviewers determined that the requested services are likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: Physician reviewers 1, 2 and 3 are board certified in otolaryngology 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

A 58-year-old male enrollee has requested selective internal radiation therapy (SIRT) for treatment of his colon cancer with metastases to the liver. Findings:  Three physician reviewers found that this patient has multiple liver metastases; it is not possible to treat all of these lesions with the proposed radioembolization with Yttrium-90 microspheres (SIRT). In addition, it is too early to assess the patients response to his chemotherapy regimen, and whether or not he is refractory to such treatment. Finally, in this case, there is possible evidence of progressive disease outside of the liver as there is some increase in the size of his para-aortic lymph nodes (which would not be treated by the proposed SIRT procedure). In light of these factors, the medical literature at this time does not support the use of SIRT in this patients particular clinical situation. Vente and colleagues noted that although the clinical results of SIRT are promising, overall response and survival are not yet known and the impact on patient survival will not be established until the results of phase III studies are published.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for a hysterectomy for treatment of the enrollees uterine prolapse. Findings:  The physician reviewer found that the services at issue were medically necessary in this clinical setting. The patient had a complete workup for the etiology of her symptoms. The provider recommended surgical management for treatment of this patients uterine prolapse after the workup was completed and the physiologic/pathologic changes that were contributing to her symptoms were more clearly defined. Based on the records, the degree of rectoenterocele prolapse at the time of this patients surgery would not have been resolved with medical management or pelvic floor physical therapy. The use of a pessary may have helped alleviate some of her symptoms temporarily, but it would not have resolved all of her symptoms completely. The American College of Obstetrics and Gynecology (ACOG) supports a hysterectomy in patients who decline the use of a pessary or in patients whose pelvic organ prolapse would not have reached a resolution of their symptoms through conservative management. This patient is postmenopausal, hypoestrogenic state, and not currently sexually active. This patients uterine prolapse would have likely continued beyond the current stage 1. Repair of the cystocele and rectoenterocele without addressing the uterus would have progressively prolapsed further. Addressing her pelvic organ prolapse in totality was clinically indicated for this specific patient. Final Result: The reviewer determined that the services at issue were 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 obstetrics and gynecology 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 63-year-old female enrollee has requested authorization and coverage for a standing aid frame. The Health Plan has denied this request indicating that the requested equipment is considered investigational for treatment of the enrollee, who is status post spinal stabilization revision surgery.  Findings:  Three physician reviewers found that the patient has a history of muscular dystrophy, scoliosis, and spinal stenosis. She is status post lumbar decompression with fusion. She has subsequent paraparesis and requires a power wheelchair for mobility. She has been receiving physical therapy, but requires assistance with transfers. The patient has requested coverage for a standing aid frame for use at home.  The Health Plan has denied coverage for the requested standing aid frame and reported that the requested equipment is investigational in this patients case.  The patient is appealing this denial.  In this patients case, the current medical evidence has not demonstrated that the requested standing aid frame is likely to be more effective than other treatment options.  There are few studies which examine the efficacy of standing frames for improving strength, function and bone density in paraparetic patients.  There may be benefits in endurance and strength, but there is a lack of definitive evidence in the literature that justifies making a standing aid frame standard of care in this clinical situation. There is a lack of evidence of functional benefit from a standing aid frame.  Thus, the requested standing aid frame is not likely to be more beneficial than other available treatment alternatives.