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 endovascular stenting.Nutcracker syndrome is a condition that is relatively rare, with few providers having significant hands-on experience. Medical literature on the subject of nutcracker syndrome is mainly based on case reports and small case series. Due to this limited experience, there are no established guidelines regarding this condition. There are, however, generally accepted indications and treatment options. Generally accepted indications for treatment include flank pain, particularly on the left side, hematuria either gross or microscopic (not absolutely required), evidence of renal vein compression by imaging studies including CT scan, and evidence of vascular engorgement. Typically, treatment is reserved as a last resort after conservative efforts, including attempts at weight gain, are not feasible or are exhausted. Symptoms typically should be severe enough that they are impacting a patients quality of life. Once intervention is determined to be necessary, both endovascular (left renal vein stenting) and open repair options are reasonable and accepted. Endovascular treatment is not without significant risks as stent migration, in-stent stenosis, and stent compression are all known complications. The incidence of stent migration, considering the small number of total patients treated, is a particular concern. For the procedure to be considered reasonable and medically necessary, there must be medical record documentation of a comprehensive evaluation by an experienced provider in which failure of conservative treatment is documented, and documentation of a plan for intervention, whether endovascular or open surgical, with rationale.In this case, the submitted documentation reflects that the patient has symptoms that could be reasonably attributed to left renal vein compression and that are impacting her quality of life. There is also documented evidence of left renal vein compression and evidence of venous engorgement. The submitted documentation does not reflect, however, that the patient has been re-evaluated by an experienced provider to assess her response to conservative treatments or that a clear plan of intervention, with rationale, has been documented in the medical record. Under these circumstances, endovascular stenting is not medically necessary for treatment of the patients medical condition.Final Result: The reviewer determined that the requested services are not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is board certified in surgery, with primary specialty certification in vascular 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 female enrollee requested Fiorinal (butalbital-aspirin-caffeine for medical treatment of her migraine. Findings:  The physician reviewer found that the use of Fiorinal in migraine has gradually diminished over the past two decades due to the high frequency of medication overuse headache. Recent recommendations from the American Headache Society, Canadian Headache Society, and a meta-analysis of acute therapy all indicate that the risks with Fiorinal far outweigh benefits for patients with headache. Fiorinal has been shown to cause physical and psychological dependence due to its sedative properties. Continued use of Fiorinal would be the counterproductive in the long-term as headaches typically become more frequent and patients require increasing doses. All told, the requested Fiorinal (butalbital-aspirin-caffeine) is not medically necessary for treatment of this patients medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary:   An enrollee has requested low field magnetic resonance imaging (MRI) for evaluation of her medical condition. Findings:  Three physician reviewers found that the current medical evidence supports the services at issue in this patients case.  MRI of the wrist has been a valuable tool in the assessment of the various ligaments of the wrist for at least two decades.  This technique allows for detailed analysis of the bones of the wrist not possible with plain x-rays, as well as detailed analysis of key soft tissue elements such as the triangular fibrocartilage complex and the various ligaments of the wrist which is not possible with other imaging techniques.  MRI of the wrist is a mainstay of imaging evaluation for patients with wrist injuries.  Ejbjerg and colleagues noted that there was essentially no change in the detection of pathology comparing high field and low field magnets.  The advantage of the low field magnets is increased patient tolerance due to positioning, and the use of low field magnets for hand/wrist evaluation has been in place for well over a decade.  In sum, low field MRI was likely to have been of greater benefit than other methods of evaluating this patient. Final Result: Three reviewers determined that the services at issue were 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 reviewers are board certified in diagnostic radiology 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: Upheld

The patient is a 13-year-old male with autism, attention deficit disorder, and behavior problems. It has been suggested that the patient undergo a single-photon emission tomography (SPECT) scan to determine the cause of his neuropsychiatric problem. The Health Plan has denied coverage for the SPECT scan on the basis that it is not medically necessary for evaluation of the patients condition.Review of the medical literature reveals SPECT has not been useful in the evaluation and specific treatment of neuropsychiatric disorders. SPECT scans provide information regarding brain function by documenting changes from moment to moment as the patients brain function changes; however, SPECT scanning does not provide a more accurate diagnosis than clinical observation and testing. Further, there is no evidence that information gleaned from SPECT scanning would alter the recommended treatment. Therefore, I have determined that the requested SPECT scan is not medically necessary for evaluation of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement and authorization and coverage for inpatient post-acute neuro-rehabilitation.Methamphetamine use disorder is a major public health problem associated with high rates of attrition, crime, relapse, morbidity and mortality. Methamphetamine can be neurotoxic, and chronic abuse is associated with behavioral problems and cognitive deficits, particularly with respect to executive functions.In this case, the patient has a history of chronic methamphetamine abuse, substance abuse treatment, and recidivism. She also has a remote history of frontal lobe cerebral insult due to a hemorrhage, a condition well associated with acquired personality disturbances. These pathological processes have resulted in a chronic history of poor overall social function, with chronic cognitive deficits, behavioral problems and safety awareness impairments. The patients physical impairments are likewise chronic, but mildly impairing. Records reflect that prior to her stay at the residential facility, the patient was already physically independent for all of her self-care and community-level mobility. Her functional deficits were predominantly cognitive and behavioral in nature.The patient has been undergoing an extensive and intensive rehabilitation program. There are some reported improvements in some domains, but the patient largely remains significantly impaired with respect to her cognition, behavior and safety awareness. It is not anticipated that she will be able to return to the community without significant levels of supervision. It is not clear, moreover, whether the modest reported improvements in the various tests that have been employed in the formal therapy setting are likely to translate to practical, meaningful benefits in the community setting, or that these benefits would be sustained for a meaningful duration. Records reflect that the patient, overall, is at a custodial level of care. She is, and has been, physically independent for all of her self-care and basic mobility. She is receiving supervision for her safety. She is also receiving therapy services that can be provided on an outpatient basis if she elects to continue these services on an empiric basis on her own. Under these circumstances, the requested inpatient post-acute neuro-rehabilitation was not, and is not, medically necessary to treat the patients medical condition.Final Result: The reviewer determined that the services at issue and requested services were not, and are not, medically necessary to treat the patient's medical condition. Therefore, the Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary:   An enrollee has requested intravenous immune globulin for treatment of his medical condition.  Findings:  The physician reviewer found that there is a lack of support for the requested services in this patients case.  A recent review by Bayry and colleagues stated despite promising clinical trials, intravenous immunoglobulin (IVIG) therapy in relapsing-remitting multiple sclerosis (MS) has met with uncertainties that might be attributed to small patient cohorts, heterogeneity in the patients, dose of IVIG, or the duration and window of treatment. All told, the requested intravenous immune globulin treatment is not medically indicated for the treatment of this patient. Final Result: The reviewer determined that the requested services are not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.  Credentials/Qualifications: The reviewer is board certified in 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: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Euflexxa injection series in both knees.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. 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 has had good lasting relief from prior viscosupplementation on multiple occasions in the past. The patient has tried other conservative treatments, such as NSAIDs, with the alternative being bilateral total knee arthroplasties. Therefore, Euflexxa injection series in both knees 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 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 bilateral radiofrequency facet denervation of the sacroiliac joints for treatment of her chronic back pain. The physician reviewer found that the submitted documentation establishes the medical necessity for the requested services. According to the documentation submitted for review, this patient presents with SI joint pain and has had positive results with previous radiofrequency ablation of the SI joint. Additionally, there is medical literature supporting the utility of SI joint rhizotomy for pain due to sacroilitis. Ferrante and colleagues reported on the results of a consecutive series of 50 SI joint radiofrequency denervations performed in 33 patients with sacroiliac joint syndrome. The results of the study suggested that radiofrequency denervation of the SI joint can significantly reduce pain in selected patients with sacroiliac syndrome for a protracted period. Moreover, Yin and colleagues performed a retrospective audit to determine the effectiveness of sensory stimulation-guided radiofrequency neurotomy for the treatment of recalcitrant sacroiliac joint pain. The authors concluded that a sensory stimulation-guided approach toward the identification and subsequent radiofrequency thermocoagulation of symptomatic sacral lateral branch nerves appears to offer significant therapeutic advantages over existing therapies for the treatment of chronic sacroiliac joint complex pain. Based on the clinical documentation submitted for review and peer reviewed literature, the medical necessity of the requested services has been established in this clinical setting. 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 anesthesiology with sub-specialty certification in pain medicine and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary:  An enrollee has requested BART genetic testing for evaluation of her medical condition.  Findings:  Two physician reviewers found that at the present time, genetic testing is not applied universally but rather to patients who exhibit family histories that are suggestive of inherited predispositions (Frank et al). Genetic testing in this case was clearly indicated. BRCA 1 and BRCA 2 gene sequencing does not pick up all point mutations and gene rearrangement needs to be tested by other methods (Mazoyer). BRCA loss of function due to point mutation or rearrangement predisposes patients to increased risk for breast cancer and ovarian cancer. The detection methods are robust and are not experimental (Welcsh and King). Thus, testing for BRCA gene rearrangement (BART) was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Final Result: Two reviewers determined that the service at issue was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned.  Credentials/Qualifications:  One reviewer is board certified in in obstetrics and gynecology with sub-specialty certification in gynecological oncology and is actively practicing. Two reviewers are board certified in medical oncology and hematology 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: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for digital breast tomosynthesis for the enrollees breast cancer screening. Findings:  The physician reviewers found that breast tomosynthesis is a technique that was developed several years ago as a problem solving adjunct to routine mammography.  Applying the same basic concept as computed tomography scanning, the logic is that by separating the various layers of breast tissue, one can better detect abnormalities. This has been shown to be most useful in the evaluation of dense breasts.  In this particular patient, the patients breast tissue was described as being heterogeneously dense. While her mammogram has not changed since the last study, it is specifically those patients who have dense breasts that can benefit most from digital breast tomosynthesis. The ability to separate out the overlapping structures enables the possibility of demonstrating an otherwise occult tumor. Therefore, digital breast tomosynthesis was likely to have been of greater benefit than other methods of evaluating this patient. Final Result: All three reviewers determined that the service at issue was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications:  Physician reviewers number one, two, and three are board certified in diagnostic radiology and actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for digital breast tomosynthesis. Findings:  Three physician reviewers found that the patient has a history of having had bilateral breast cancer.  The malignancies were in 1996 on the right, and 2002 on the left. The submitted records noted that the malignancies were treated with lumpectomies, radiation therapy, and chemotherapy. In addition, the patient reported that her mother and sister were also diagnosed with breast cancer.  The patient underwent a routine screening mammogram with breast tomosynthesis. The current images were compared to prior mammograms and no interval changes were noted. There were no masses or areas of new suspicious calcifications.  In the upper outer quadrant of her right breast, an area of scarring and dystrophic calcifications was seen. Applying the same basic concept as computed tomography (CT) scanning, the logic is that by separating the various layers of breast tissue, one can better detect abnormalities.  This has been shown to be most useful in the evaluation of dense breasts. In this particular patient, on the basis of breast density, one could not justify the superior effectiveness of tomosynthesis. But in terms of surveillance in a patient who has had breast cancer, studies have demonstrated that specificity increased from 20.7% to 74% when digital breast tomosynthesis (DBT) was applied in a study. Operative bed recurrence could be more confidently excluded from scarring, which reduced the number of indeterminate findings by proving either a definite benign or malignant diagnosis. DBT allowed unnecessary biopsy to be avoided in 37.3% of patients. Final Result: Three reviewers have determined that the service at issue was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: 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: Experimental/Investigational
Decision: Overturned

A 61-year-old male enrollee has requested enhanced external counterpulsation (EECP) for the treatment of his angina. Findings:  Two physician reviewers found that the use of EECP in the treatment of chronic angina refractory to medications in patients who cannot be safely revascularized is a generally accepted treatment modality. The current recommendations for treatment of angina remain anti-anginal therapy or revascularization as first-line therapy, with EECP reserved for those symptomatic patients who fail a reasonable trial of medications and cannot be revascularized.  Currently, to meet criteria for EECP, patients have disabling angina and must be refractory to maximum medical therapy and not readily amenable to revascularization.  In this particular case, the patient was on multiple anti-anginal agents, including carvedilol, amlodipine and isosorbide. This is considered maximal medical therapy. Partial revascularization was performed, and the documentation notes continued disabling angina. As the patient has continued class 3 angina despite maximal medical therapy and the partial revascularization of the patient was unsuccessful, EECP is the medically appropriate next step for this patient.