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

A 58-year-old male enrollee has requested Qualaquin for the treatment of his leg cramps. Findings:  The physician reviewer found that the FDA issued a statement of concern about the use of Qualaquin (quinine), for the off-label treatment of leg cramps due to the risk of serious side effects such as arrhythmias. There are other medications that are useful for the treatment of leg cramps which are not documented in the records submitted as having been tried and failed. Alternative medications include verapamil and gabapentin which have been shown to be effective in studies by Baltodano and colleagues and Serrao and colleagues respectively.  A trial of one of these drugs for treatment of this patients leg cramps would be more medically appropriate than Qualaquin, given its safety risks.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for percutaneous tibial nerve stimulation (PTNS) treatments for treatment of the enrollees overactive bladder. Findings:  2/3 of the physician reviewers found that the PTNS treatments in dispute were likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. There is sufficient support in the peer-reviewed literature for the services at issue in this clinical setting. PTNS is considered to be an appropriate salvage therapy for patient with intractable irritative lower urinary tract symptoms including urgency and incomplete emptying. According to the documentation submitted for review, the patient is symptomatic with overactive bladder symptoms including urgency. The patient has failed multimodal therapy. The patient responded well to PTNS treatments. Therefore, the PTNS treatments received have been established as likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Final Result: 2/3 of the reviewers determined that the services at issue were 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 reviewer number one is board certified in urology 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 urology 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 urology 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 parent of an enrollee has requested authorization and coverage for oral surgery under general anesthesia performed in a surgical setting.  The submitted documentation supports the medical necessity of the requested services. Tooth number is in need of extraction. This impacted tooth with an anomalous position and shape is preventing eruption of his adjacent permanent teeth and normal development of his anterior maxilla. Given the anatomic position of this tooth and the nature of the procedure, general anesthesia is indicated. Due to the patients age and the invasive nature of the procedure, it is not likely that he will be capable of cooperating during surgery. General anesthesia with the presence of an anesthesiologist is indicated for the safety of this patient. All told, oral surgery under general anesthesia performed in a surgical setting 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 oral and maxillofacial 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 a 17-year-old male enrollee has requested for chemical dependency partial hospital/day treatment for treatment of the enrollees polysubstance abuse. Findings:  The physician reviewer found that the patient does have a significant chemical dependency issue and requires treatment. He has not had any substantive outpatient treatment in the recent past. The evidence does not demonstrate that the patients overall functioning is overtly impaired; he was able to attend school prior to entering detoxification. However, there is valid concern over the substances the patient has been using and the danger in which he has placed himself by the use of intravenous OxyContin and heroin.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested reimbursement for continuous passive motion (CPM) machine for ten days. Findings:  The physician reviewer found that although continuous passive motion (CPM) is not routinely used after ACL reconstruction, a review of the literature reveals advantages to using postoperative continuous passive motion. The evidence indicates that CPM enhances tendon to bone healing, reduces arthrofibrosis and also reduces the incidence of patellofemoral arthritis after anterior cruciate ligament disruption. The literature indicates that postoperative CPM therapy significantly enhanced tendon-bone healing, as evidenced by increased amount of fibrocartilage, elevated ultimate load to failure levels, and up-regulated gene expressions of Collagen I, alkaline phosphatase, osteopontin, Tenascin C and tenomodulin at the tendon-bone junction. In this case, the ACL reconstruction was performed using the hamstring autograft. As such, tendon to bone healing is likely improved with the use of CPM. CPM contributes to improved knee health by preventing joint stiffness, preserving normal articular tissue with better histologic and biologic properties, and improving range of motion as compared with joint immobilization and intermittent active motion.  In light of the foregoing, the CPM provided was medically necessary for treatment of this enrollee's medical condition. Final Result: The reviewer determined that the device at issue was 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: The patient has requested authorization and coverage for suction assisted protein lipectomy (SAPL) (CPT 28999 and 76499). The SAPL approach discussed by researchers is optimal to address the fluid portion of lymphedema swelling, which predominates during the early stages of the disease process. SAPL removes the otherwise permanent solid component of the swelling, usually found in chronic cases. In this case, the patients left leg does not reduce in size to match the right leg, even with maximum lymphedema therapy. Thus, her condition is likely due to solid, rather than fluid swelling. In this clinical setting, SAPL is indicated to provide significant volume reduction. Moreover, the patient has tried and failed a properly planned and administered lymphedema therapy regimen with manual lymphatic drainage, fitted compression garment use, and bandaging. She has significant disability from chronic lymphedema of her left leg. Physical examination reports chronic, non-compressible, solid predominant, stage 2 congenital lymphedema of her left leg. All told, the requested SAPL (CPT 28999 and 76499) is medically necessary for treatment of this patient. The California reconstructive surgery statute requires health insurers to cover reconstructive surgeries, defined as surgery performed to correct or repair abnormal structures of the body caused by congenital defects, developmental abnormalities, trauma, infection, tumors, or disease to do either of the following: (1) to improve function; (2) to create a normal appearance, to the extent possible. The patients lymphedema is a congenital and developmental abnormality. The purpose of SAPL is both to improve function and to create a normal appearance, to the extent possible. Given these findings, the requested SAPL (CPT 28999 and 76499) is reconstructive in nature for treatment of this patient. Final Result: The reviewer determined that the requested services are medically necessary and reconstructive in nature for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in plastic 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 59-year-old male enrollee has requested Actiq for the treatment of his condition. Findings:  The physician reviewer found that it is unclear if the prescribed medications are indeed helping the patients pain. Actiq has been used off-label for the management of non-malignant pain. Clear documentation is needed regarding the dose and frequency of the prescribed medication. Absent this information, the medical necessity of the requested medication cannot be established.
Appeal type: Medical Necessity
Decision: Upheld

A 37-year-old female enrollee has requested Duac CS for treatment of her acne. Findings:  The physician reviewer found that the prescription ingredient in Duac is a combination of benzoyl peroxide 5% and clindamycin 1% in a gel. The Duac CS kit also contains a face wash that is available over-the-counter.  The formulary medication BenzaClin also contains benzoyl peroxide 5% and clindamycin 1%.  These products are known to be effective in controlling acne flares.  There is no indication that the patient has failed treatment with this medication.  The over-the-counter face wash in the Duac CS kit is available without a prescription.  The submitted documentation does not demonstrate that the patients acne would be better controlled using the non-formulary option.  In this patients case, Duac CS is not medically indicated.
Appeal type: Experimental/Investigational
Decision: Upheld

A 61-year-old male enrollee has requested radiofrequency neurolysis of the sacroiliac joint (CPT 64623) for treatment of his chronic back pain.   Findings:  Three physician reviewers found that the majority of peer-reviewed literature supports the efficacy of radiofrequency neurolysis in the treatment of chronic spinal pain due to facet pathology, as long as the patients are appropriately selected.  This patient had a spinal fusion in the area to be treated with radiofrequency ablation. The medical literature does not support the efficacy of radiofrequency ablation at levels in which the medial/lateral branches are already disrupted, which may occur in spinal fusions.  Cohen and colleagues proposed that cervical facet denervation was less likely to be beneficial due to poor selection criteria. This study may also be applied in the patients case, as he is a poor candidate for radiofrequency neurolysis due to his history of spinal fusion. Dreyfuss and colleagues performed a prospective audit to establish the efficacy of lumbar medial branch neurotomy under optimal conditions. They determined that lumbar medial branch neurotomy is an effective means of reducing pain in patients carefully selected on the basis of controlled diagnostic blocks. They also determined that adequate coagulation of the target nerves could be achieved by carefully placing the electrode in correct position as judged radiologically. If the anatomy were disrupted, as possible in spinal fusion, it would be difficult to adequately coagulate targeted nerves if they are still present.  Therefore, the requested radiofrequency neurolysis of the sacroiliac joint is not likely to be more beneficial than other available methods of treating this patient.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for a knee scooter 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 equipment.  There are very limited high-quality data published with respect to the rehabilitation of ankle fractures outside of basic interventions such as weight-bearing restrictions.  In this case, the patient sustained an ankle fracture and has non-weight-bearing restrictions on the affected limb.  Per the medical records, there are no other significant impairments.  This patients mobility-related activities of daily living can be met with the approved durable medical equipment.  Final Result: The reviewer determined that the requested equipment 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 physical medicine and rehabilitation 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 62-year-old male enrollee has requested coverage for past quantitative sensory testing for evaluation of his foot pain.  Findings:  Two physician reviewers found that the patient reported pain in the bottom of his feet.  The patients diagnoses included mild predominantly axonal length-dependent sensorimotor peripheral neuropathy and left L5 radiculopathy.  Quantitative sensory testing was recommended to further evaluate the patients symptoms.  Although ongoing research is being conducted regarding quantitative sensory testing, it has not been definitely demonstrated via clinical trial to change patient management.  In this patients case, he already carried a diagnosis of axonal polyneuropathy by electromyography/nerve conduction study.  In this clinical setting, quantitative sensory testing would not have changed this diagnosis or altered patient management.  The current medical evidence has not demonstrated the superior effectiveness of the services at issue in this patients case.
Appeal type: Medical Necessity
Decision: Overturned

A 45-year-old female enrollee has requested Orthovisc injections for treatment of the enrollees osteoarthritis of the left knee. Findings:  The physician reviewer found that Orthovisc injections are medically necessary for this patient.  She has failed conservative management and has confirmed localized inflammatory pain with osteoarthritis on MRI and radiographs.  The patient has failed treatment with NSAIDs, Tylenol, physical therapy and steroid injections.  The medical records noted that she is at an ideal weight.  The use of Orthovisc is an appropriate conservative modality before a surgical solution is considered.  The current medical literature supports the use of viscosupplementation in this clinical scenario. All told, in this patients case, the requested Orthovisc injections are medically indicated.
Appeal type: Medical Necessity
Decision: Upheld

The enrollees parent is requesting authorization and coverage, and reimbursement, for intensive outpatient program (IOP) level of care services. The Child and Adolescent Level of Care Utilization System (CALOCUS), developed as a collaboration between the American Academy of Child and Adolescent Psychiatry and the American Association of Community Psychiatrists, is a level of care assessment tool used by behavioral health managers and clinicians to support accurate level of care recommendations. This enrollee did not display a serious risk of harm or serious functional impairment. His family is willing and able to assist in his recovery. The enrollee has shown progress with recovery and is collaborating on his treatment plan. His composite CALOCUS score correlates with Level 1, Recovery Maintenance and Health Management, which is a lower level of care than intensive outpatient program (IOP).Final Result: The reviewer determined that the requested services were not, and are not, medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The physician reviewer is board certified in child and adolescent psychiatry and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary:  An enrollee has requested a referral to a gastroenterologist for evaluation of the enrollees constipation.  The physician reviewer found that the submitted documentation establishes the medical necessity of the requested referral. According to the documentation submitted for review, the patient presents with gastrointestinal (GI) symptoms that warrant further evaluation. Care provided by gastroenterologists for GI bleeding and diverticulitis resulted in significantly shorter length of hospital stay. Gastroenterologists diagnosed celiac disease more accurately than generalists, and more adequately diagnosed colorectal cancer and prescribed antimicrobials for peptic ulcer disease. Gastroenterologists were more likely to test and treat for Helicobacter pylori in patients with peptic ulcer disease, and were more likely recommended for medical versus surgical therapy. Gastroenterologists had a lower threshold for ordering [endoscopic retrograde cholangiopancreatography] ERCP before cholecystectomy than surgeons, but had similar responses regarding indications for surgery in inflammatory bowel disease. Finally, primary care physicians were less likely to associate symptoms of profuse watery diarrhea with cryptosporidium infection compared with gastroenterologists and infectious disease specialists. Based on the clinical documentation submitted and the medical literature a gastroenterology specialty evaluation is medically necessary for evaluation of the patients unexplained weight loss, bloody stool, and persistent abdominal distress. Final Result: The reviewer determined that the requested referral is medically necessary for evaluation of the patients medical condition. Therefore, the Health Plans denial should be overturned.  Credentials/Qualifications: The reviewer is board certified 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: Overturned

A 64-year-old female enrollee has requested a magnetic resonance imaging (MRI) of the breast for evaluation of the enrollees medical condition. Findings:  Two physician reviewers found that review of the submitted documentation and relevant literature supports the requested diagnostic procedure in this clinical setting. The medical literature demonstrates that MRI is more sensitive than mammography in detecting tumors in women with an inherited susceptibility to breast cancer. According to the patients history, she has one first-degree relative (mother) and two second-degree relatives (aunt and grandmother) with diagnosed breast cancer. Thus, this patient meets criteria as having a high familial risk for breast cancer and the patient qualifies for annual screening MRI of the breast. All told, the request for MRI of the breast is likely to be more beneficial than other modalities for the evaluation of the patients medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for suction-assisted lipectomy procedure of bilateral hips and legs. The patient has congenital lymphedema with Aegenes syndrome. This condition is complicated due to severe obesity with a body mass index (BMI) of just under 54. Weight loss may improve lymphatic dysfunction, but might not reverse the condition. He has massive bilateral leg and foot swelling, which is non-pitting. Conservative therapy has not been successful. Classical liposuction for the treatment of lower extremity lymphedema has not been shown to be beneficial in the long-term. The literature states that the approach outlined by researchers is different. Researchers reported that suction-assisted protein lipectomy (SAPL) has been shown to reduce large amounts of volume excess with a one-year average reported reductions in volume excess in the legs of 86%. The authors reported that the SAPL is effective in reducing limb volume in patients with lower extremity lymphedema who have used maximal conservative therapy preoperatively and postoperatively. The key differentiation is whether the lymphedema is pitting or non-pitting. Pitting lymphedema is an early stage, is not pathognomonic of protein accumulation, and is not appropriate for SAPL. Non-pitting edema is protein containing, will not be responsive to conservative therapy, and is appropriate to consider for SAPL. This patient has non-pitting edema, which has been resistant to standard conservative therapy. Based on peer-reviewed medical literature and the medical information available for review, the requested suction-assisted lipectomy procedure of the bilateral hips and legs is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Final Result: Two of the three 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:  One reviewer is board certified in plastic surgery and is actively practicing. One Reviewer is board certified in plastic surgery and is actively practicing.  One Reviewer is board certified in plastic surgery and is 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.