Persius/imr-appeals huggingface dataset:
Appeal type: Experimental/Investigational
Decision: Upheld

A 50-year-old female enrollee has requested authorization and coverage for percutaneous tibial nerve stimulation (PTNS) for treatment of the enrollees urinary frequency and urgency with incontinence.  Findings:  Three physician reviewers found that the patient has a history of urinary frequency and urgency with a history of incontinence. The patient was treated with Toviaz and Gelnique. The patient was reported to have significant improvement with Gelnique. The patient was subsequently treated with percutaneous tibial nerve stimulation (PTNS) and was concurrently taking the Gelnique. The Gelnique was eventually discontinued with positive results of the PTNS. The patient has requested authorization and coverage for future treatment with PTNS however the Health Plan has denied this request as investigational. Percutaneous tibial nerve stimulation (PTNS) has been reviewed in several published studies with varying results (Finazzi-Agro, et al; Peters, et al). However, reliable data on the long-term safety and effectiveness of the therapy is still uncertain (Civic and Black). The available studies have not demonstrated PTNS to be more beneficial then other available therapies in the management of symptoms related to overactive bladder. Thus, although this patient reports that she responded well to PTNS, the records also indicate that she experienced a decrease in symptoms with medical therapy (Gelnique). As medical therapy is considered a standard and proven therapy, the requested PTNS is not indicated or likely to be more beneficial than conventional modalities.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Synvisc One injections for both knees. The submitted documentation supports the medical necessity of the requested services. Campbell and colleagues performed a systematic review of overlapping meta-analyses comparing viscosupplementation with other nonoperative treatment modalities for knee osteoarthritis. Per the authors, the current highest level of evidence suggests that intra-articular hyaluronic acid is a viable option for knee osteoarthritis. Its use results in improvements in knee pain and function. The authors noted that viscosupplementation has a good safety profile. The medical evidence supports the requested services in this clinical setting. Therefore, Synvisc One injections for 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: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary:   An enrollee has requested breast tomosynthesis for treatment of her medical condition.   Findings:  Three physician reviewers found that the American College of Radiology (ACR) recommended that breast tomosynthesis be removed from the investigational category due to the advantages this tomographic method brings to radiologists interpreting mammograms. This procedure often allows the reader to separate dense glandular elements from underlying architectural distortion/mass resulting in a decrease in callbacks and increase in detection of small cancers. For these reasons, the addition of tomosynthesis to the usual two dimensional (2D) imaging mammographic protocol was likely of greater benefit to this patient than if the exam had been performed using the two dimensional technique alone. 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.  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: Overturned

The patient is a 37-year-old female with a body mass index (BMI) of 44.9. She has obesity-related comorbidities including urinary stress incontinence and gastroesophageal reflux disease. She wishes to undergo gastric bypass. It does not appear that she has undergone a psychological evaluation to assist in determining whether she is an appropriate candidate for weight loss surgery. The Health Plan has denied authorization for gastric bypass surgery on the basis that it is not medically necessary.With a BMI of 44.9 and comorbid conditions the patient meets nationally accepted medical necessity criteria for consideration of weight loss surgery. Weight loss surgery is medically indicated and necessary for treatment of this patients morbid obesity. Furthermore, scientific evidence demonstrates that once a morbidly obese patient has been identified as an appropriate candidate for weight loss surgery, further conservative attempts at weight loss are not necessary. The study referenced above demonstrates that surgery has the best long-term outcome for the morbidly obese. However, although medically the patient meets criteria for consideration of weight loss surgery, the patient has not undergone a formal psychological evaluation to determine if she is an appropriate candidate for weight loss surgery. Such evaluations are considered standard of care prior to authorization of weight loss surgery. Therefore, I have determined the requested procedure is medically necessary for treatment of the patients medical condition depending upon the results of a psychological evaluation. If the evaluation indicates the patient is an appropriate candidate for weight loss surgery, the requested surgery should be authorized. If the evaluation indicates the patient is not a candidate for weight loss surgery, the requested surgery should not be authorized.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested Anser IFX testing for evaluation of her medical condition.  Findings: Two physician reviewers found that the testing at issue was not likely to be more effective for this patient than other available options. Prometheus Anser IFX Test is a quantitative measurement of serum infliximab and anti-IFX antibodies. Some evidence exists that low serum levels of infliximab and/or the presence of antibodies to infliximab (ATI) may play a role in primary or secondary response failures. However, there is a lack of well controlled clinical trials to confirm that use of the Anser IFX test leads to improved patient outcomes or quality of life as opposed to the standard method of treatment. Moreover, it has not yet been established whether the use of threshold levels aid in the discrimination of treatment response, nor has the optimal timing of when to measure antibody levels been established. Final Result: Two reviewers determined that the testing at issue was 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 internal medicine with sub-specialty certification in gastroenterology 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: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for advanced lipoprotein testing.Findings:  Three physician reviewers found that this patient has several risk factors for cardiovascular disease. Per the American College of Cardiology/American Heart Association (ACC/AHA) guidelines, statin therapy is indicated in this clinical setting. Per the records, this patient was already on low dose statin therapy. Based on current ACC/AHA guidelines, aggressive lifestyle modification and medium to high dose statin therapy were indicated to achieve a low-density lipoprotein (LDL) level of 70 or lower. Additional risk stratification with advanced lipid profile testing, such as apolipoprotein B, may be appropriate when there is a question about the need for aggressive pharmacologic lipid lowering therapy. In this case, the patient already had a guideline-directed indication for therapy based on her risk factors and standard lipid testing. Therefore, advanced lipoprotein testing was not likely to have been superior over other methods of evaluating this patient. Final Result: The reviewers determined that the services at issue were not likely to have been more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: Physician reviewers 1, 2 and 3 are board certified in internal medicine with sub-specialty certification in cardiovascular disease 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: The patient has a medical history significant for cervical radiculopathy. The patient reported neck pain. The provider reported an abnormal electromyography (EMG) consistent with radiculopathy on the right C4-6. A magnetic resonance imaging (MRI) study revealed cervical foraminal narrowing at C3-4 and C4-5. The patient has been treated with non-steroidal anti-inflammatory drugs (NSAIDs) and muscle relaxants and states that she has failed medications and physical therapy. The provider reported there was decreased range of motion in the neck on physical examination. The provider reported the patient has radicular signs in the lumbar spine due to cervical degenerative disc disease. The patient complained of 7/10 pain with decreased right upper arm strength noted to be 4/5. The provider recommended an epidural steroid injection and to continue with her home exercise program. At issue in this case is whether the requested cervical interlaminar epidural injection is medically necessary for treatment of the patients medical condition. Patients with radiculopathy typically present with neck pain, arm pain or both. Treatment options for radiculopathy include conservative management and non-operative modalities such as physical therapy and steroid injections as well as operative interventions. In this case, two providers report the patient participated in physical therapy and she is currently doing a home exercise program. The patient has also failed oral medications. Literature supports that a home exercise program after physical therapy independent of an epidural can give a patient lasting results. However, this patient has recent physical examination findings and imaging supporting a diagnosis of cervical radiculopathy, for which an epidural steroid injection is indicated. Moreover, the patients condition has not substantially improved with physical therapy and a home exercise program. Therefore, the requested cervical interlaminar epidural injection is medically necessary for treatment of this 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 anesthesiology with sub-specialties in pain medicine and hospice and palliative 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 65-year-old male enrollee has requested a Pillar Palatal Restoration (Pillar) procedure for the treatment of his snoring. Findings:  The physician reviewer found that snoring is not considered to be a medical problem. Although snoring is a social nuisance and can be disruptive, there is no literature to support that it results in adverse health effects. Furthermore, although some outcome results have been published for this procedure, there are no long-term results based on studies performed in the United States. The Pillar procedure when used either in treatment of snoring or for treatment of mild obstructive sleep apnea remains of unproven efficacy.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary:  An enrollee has requested monitored anesthesia care for treatment of her medical condition.  Findings: The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the services at issue.  The patient did not present with a significant history that would require monitored anesthesia care.  The standard of care for monitored anesthesia care for a minimally invasive procedure is airway difficulty, large fluid shifts and comorbid conditions that would put the patient at risk during the procedure.  In this case, there is no documentation of comorbid conditions that would place the patient at risk for complications requiring the need for monitored anesthesia care.  All told, monitored anesthesia care was not medically indicated for the treatment of this patient.  Final Result: The reviewer determined that the services at issue were 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 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 49-year-old female enrollee has requested for low back spinal fusion for treatment of her back pain. Findings:  The physician reviewer found that the role of spine fusion in the treatment of degenerative disorders of the lumbar spine has been the subject of much debate. Arthrodesis may be indicated as an adjunct to decompression of spinal stenosis, in the treatment of degenerative scoliosis or in the presence of iatrogenic instability, but has a poor success rate when used to treat back pain associated with disc degeneration seen on MRI. Lumbar fusion is rarely indicated for routine discectomy, abnormal radiographic results without appropriate clinical findings, or spinal stenosis. The ability to separate spinal from non-spinal sources on discography has not been clearly established, and the response of concordant pain may be less meaningful than assumed. Also, it is unclear to what extent positive pain reproduction corresponds with successful outcomes. All told, the clinical evidence does not demonstrate the patient meets indications for lumbar spine fusion
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested authorization and coverage for speech therapy for treatment of the enrollees autism spectrum disorder and mild expressive language disorder. Findings:  The physician reviewer found that in this case, the parent reports concerns for the patients speech articulation and clarity. In general, children at the age of three to four may have articulation differences with Y, Sh and other complex sounds. Based on the speech therapy evaluation, the patient is very close to his peers in expressive language and at average level for receptive language skills. In addition, all children with autism spectrum disorder do not require direct one-on-one speech therapy. 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 pediatrics with sub-specialty certification in developmental and behavioral pediatrics 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

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the residential treatment center (RTC) services provided for treatment of the enrollees polysubstance dependence. Findings:  The physician reviewer found that the patient did not show significant post-acute withdrawal symptoms. He was not a danger to self or others. He did not show violent behavior. There were no emotional, behavioral, or cognitive factors that would require ongoing residential treatment. His activities of daily living were intact. He was medically and psychiatrically stable, with conditions that could have been treated in an outpatient setting. He was not agitated, manic, or psychotic. The patient was not reportedly treated for his anxiety. His opiate use disorder could have been addressed in an outpatient setting with medically assisted treatment such as suboxone. He showed good motivation as evidenced by his participation in groups, individual, and 12 step meetings. His mother was supportive and his home environment was safe. No new problems had arisen and there was no reason that returning him to the community would lead to decompensation. He did not require 24-hour monitoring and could have continued relapse prevention planning and coping skills development at an ambulatory level of care, with concomitant community supports in the 12 step groups and counseling. All told, the RTC services provided were not medically necessary for treatment of the patients medical condition. Final Result: The reviewer determined that the services at issue were 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 psychiatry with sub-specialty certification in addiction 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: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested lipoprotein testing for evaluation of his medical condition. Findings: Three physician reviewers found that the submitted documentation fails to demonstrate the superior efficacy of the services at issue.  Primary prevention guidelines for the management of cardiac risk and dyslipidemia that have been established, are periodically updated by expert committees and are endorsed by several national organizations. These guidelines currently do not recommend routine performance of specialized tests in the context of assessing coronary risk including lipoprotein-associated phospholipase A2 (Lp-PLA2), sub-classifications of low-density lipoprotein, high-density lipoprotein subclasses, lipoprotein (a), C-reactive protein, high sensitivity C-reactive protein, insulin, fibrinogen, genetic testing and homocysteine.  Treatment change or addition based on the results of screening with these specialized tests has not been shown to improve cardiac outcome incremental to that achievable by treatment based on standard risk factor profiling and basic lipid analysis.    Although results of some of these specialized tests may be abnormal and considered independent risk markers for coronary disease, there is a lack of controlled trials that demonstrate outcome benefits by treating routinely obtained abnormal results.  In sum, advanced lipoprotein testing was not 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 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 internal medicine with sub-specialty certification in cardiovascular disease 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 breast tomosynthesis for evaluation of her medical condition. Findings:  Three 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 (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 patients case, there were indications for breast tomosynthesis.  The first is the presence of what were apparently felt to be suspicious calcifications. Calcifications can often be better characterized by tomosynthesis.  Second, the overall dense nature of her breasts is a reasonable indication for tomosynthesis.  It is specifically those patients who have dense breasts that can benefit most from breast tomosynthesis. The ability to separate out the overlapping structures enables the possibility of demonstrating an otherwise occult tumor.  Therefore, breast tomosynthesis was likely to have been more effective 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.