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

Summary Reviewer  
The patient is a 52-year-old female. The patient has requested reimbursement for anesthesia 
provided on 8/30/21. The physician reviewer found that according to the American Society of 
Anesthesiologists guideline for anesthesia care during endoscopic procedures, monitored 
anesthesia care is warranted in prolonged or painful procedures such as complex polyp 
resections, endoscopic retrograde cholangiopancreatography or other biliary procedures, 
endoscopic dilation, or endoscopic resection. Additionally, the guidelines state that monitored 
anesthesia care is more likely necessary in patients with a failed history of moderate sedation 
for the procedure or psychological impediments to cooperation. The provided records do not 
support any of these criteria, or other criteria in the literature, such as difficult intubation, 
airway obstruction, allergies to sedation medications, chronic alcohol or illicit drug use resulting 
in increased tolerance to sedation medications, age greater than 70, pregnancy, increased 
aspiration risk, ASA class III or higher, or morbid obesity. According to the most recent 
guidelines from the American Society for Gastrointestinal Endoscopy, during endoscopic 
procedures (unlike surgery) consciousness during the procedure is acceptable and is the goal 
during most procedures (which are performed with moderate sedation), and monitored 
anesthesia care is recommended for prolonged procedures requiring deep sedation, previously 
anticipated intolerance to standard sedatives, ASA class IV or V, or risk for airway obstruction 
due to anatomic variant. For these reasons, the provided patient records do not support the 
medical necessity of monitored anesthesia care over conscious sedation in this case. Therefore, 
anesthesia provided on 8/30/21 was not medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld

Summary Reviewer  
 
The  patient  is  a  47-year-old  male  with  a  history  of  chronic  low  back  pain  with  lumbar 
radiculopathy, lumbar disc herniation with radiculopathy, and lumbar spondylosis. The provider 
has recommended treatment with lumbar spine surgery, open SI joint fusion, and one associated 
inpatient bed day. The Health Insurer has denied the requested services as not medically 
necessary for treatment of the patients medical condition. The physician reviewer found that 
there are limited large-scale, long-term references showing the safety and efficacy of the 
requested lumbar spine surgery and open SI joint fusion in this clinical setting. This patient is 
being treated for chronic low back pain with lumbar radiculopathy, lumbar disc herniation with 
radiculopathy, and lumbar spondylosis. The provider reported that the patient experiences 
minimal pain with lumbar forward flexion, with apprehension. The patients flexion motion is 
essentially full, but his extension is limited and causes lower back pain. However, dynamic flexion-
extension films are not documented in order to assess the amount of movement or instability at 
the requested surgical level. There is also a lack of documentation regarding potential temporary 
intraoperative instability. According to Resnick and colleagues, As a result of the decompression, 
the inherent instability associated with the spondylolisthesis may progress and lead to further 
misalignment that results in pain or recurrence of neurological complaints. In another study, 
Eismont and colleagues reported that, Although much has been published in the past two 
decades on the surgical management of degenerative spondylolisthesis, the optimal method 
remains controversial. Interbody fusion may improve arthrodesis rates and can be performed via 
numerous  surgical  approaches.  Minimally  invasive  techniques  continue  to  be  developed. 
Furthermore,  there  is  a  lack  of  imaging  or  radiographic  evidence  supporting  a  sacroiliitis 
pathology for this patient. Criteria supporting a sacroiliitis pathology include significant SI joint 
pain and a lack of alternative diagnoses that could be responsible for the patients pain (Lorio 
and Rashbaum). In this case, the records indicated SI joint testing showed minimal pain, and 
multiple other plausible pain generators including at the lumbosacral spine are evident. Finally, 
medical literature does support the use of open SI joint fusion as safe and effective for patients 
with degenerative sacroiliitis refractory to nonoperative management (Smith, et al.; Ledonio, et 
al.). Overall, there is a lack of diagnostic imaging studies corroborating degenerative sacroiliitis 
for this patient. For these reasons, the requested lumbar spine surgery, open SI joint fusion, and 
one associated inpatient bed day are not medically necessary for treatment of this patient.
Appeal type: Experimental
Decision: Overturned

Summary Reviewer 2


A 53-year-old female enrollee has requested reimbursement for the bilateral three dimensional digital breast tomosynthesis provided on 10/16/15. The Health Insurer has denied this request indicating that the services at issue are considered investigational for evaluation of the enrollees risk for breast cancer.  The physician reviewer found that 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, by separating the various layers of breast tissue, one can better detect abnormalities. This patients breasts were described as heterogeneously dense. Thus, in this clinical setting, the use of the digital breast tomosynthesis performed on 10/16/15 was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Based upon the information set forth above, the services at issue were likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The Health Insurers denial should be overturned.
Appeal type: Experimental
Decision: Overturned

Summary Reviewer 3

A 41-year-old male enrollee has requested authorization and coverage for sacroiliac joint fusion. The Health Insurer has denied this request and reported that the requested services are investigational for the treatment of the enrollees medical condition. The physician reviewer found that Sacroiliac joint degeneration is a common cause of chronic low back pain which is underdiagnosed. Minimally invasive fusion procedures have demonstrated successful pain relief for these individuals. Recent medical literature has documented two-year follow-up of these procedures demonstrating meaningful clinical improvement and maintained pain relief as well as evidence of a solid fusion on imaging studies. The article by Duhon and colleagues discussed long-term results from a prospective multicenter clinical trial. The authors noted minimally invasive sacroiliac joint fusion using triangular titanium implants showed marked improvements in pain, disability and quality of life at two years. Imaging showed that bone apposition to implants was common, but radiographic evidence of intra-articular fusion within the joint may take more than one year in many patients.  This case illustrates the difficulty encountered in making an accurate diagnosis of chronic low back pain that does not respond to the usual conservative measures. In the absence of evidence of neural compression on the magnetic resonance imaging scan and in the presence of clinical findings of sacroiliac pain which is relieved by injecting the sacroiliac joint, the requested procedure of sacroiliac fusion using the minimally invasive technique is likely to be beneficial for this patient. Thus, the requested sacroiliac joint fusion is likely to be more effective than other treatment options.
Appeal type: Medical Necessity
Decision: Upheld

Summary Reviewer  
 
The patient is an 18-year-old male with a longstanding history of abdominal pain and diarrhea 
with night waking and slow weight gain. The patients parent has requested authorization and 
coverage for treatment with Sucraid 8500 mL solution. The Health Insurer has denied the 
requested medication as not medically necessary since the patients records do not support a 
diagnosis of sucrase isomaltase deficiency. The physician reviewer found that the U.S. Food and 
Drug Administration (FDA) has approved Sucraid for the treatment of patients with congenital 
sucrase-isomaltase deficiency (CSID). Although dietary management of CSID is possible, it is 
highly restrictive and would not be recommended for this adolescent patient with a history of 
poor weight gain. However, this patients records do not support a diagnosis of CSID to support 
an indication for treatment with Sucraid. The patients symptoms may also be consistent with IBS 
(Shah and Pimentel). The patient reportedly underwent C13 breath testing, which reflected low 
sucrase-isomaltase activity. This coupled with the providers report of the patients symptomatic 
improvement with use of Sucraid is suggestive of CSID but is insufficient to support this diagnosis 
without genetic testing. C13 breath testing is unable to distinguish between low sucrase activity 
due to primary enzyme deficiency versus low activity due to mucosal damage. The European 
Society for Pediatric Gastroenterology, Hepatology, and Nutrition recommends using genetic 
testing for to confirm a diagnosis of CSID (Broekaert, et al.). In the absence of testing reporting a 
diagnosis of CSID, this patient does not meet the requirements for treatment with Sucraid. 
Therefore, the requested Sucraid 8500 mL solution is not medically necessary for treatment of 
this patient.
Appeal type: Experimental
Decision: Overturned

Summary Reviewer 2

A 68-year-old female enrollee has requested authorization and coverage for iStent placement (times two).  The Health Insurer has denied this request indicating that the requested services are considered investigational for treatment of the enrollees medical condition. The physician reviewer found the submitted records support the superior efficacy of the services at issue.  This patient has glaucoma in conjunction with cataract, which is the approved indication for the iStent.   The patient is on maximal medical therapy for her glaucoma, and has shown advanced optic nerve cupping and visual field loss in both eyes.  The use of the iStent for patients in this clinical setting has become the standard of care.  Alternative treatment options, such as trabeculectomy or implantation of a tube shunt, are highly invasive and include the risk of serious vision-threatening complications.  The data show that insertion of two stents provides better intraocular pressure control than one stent.  Therefore, the iStent placement (times two) is likely to be of greater benefit than other treatment options.  Based upon the information set forth above, the requested services are likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Insurers denial should be overturned.
Appeal type: Medical Necessity
Decision: Upheld

Summary Reviewer 

The patient is a 51-year-old female who developed neck and left shoulder pain after spending more time using a computer for work. The patient has requested reimbursement for physical therapy services provided from 2/15/21 through 5/05/21. The Health Insurer has denied this request and reported that the services at issue were not medically necessary for the treatment of this patient. This denial is the subject of this appeal and determination. The physician reviewer found that this patient had been undergoing physical therapy for a long time, without documented significant functional benefit. Despite the therapy, she continued to have symptoms. The patient could have been transitioned to independent exercises or modalities that would have been expected to be no less effective for her condition than the ongoing physical therapy under review. There is no proven benefit of prolonged formal exercises or manual therapy for her conditions. The treatment of calcific tendinopathy revolves around analgesics such as nonsteroidal anti-inflammatory drugs (NSAIDs) and steroid injections in the painful acute phase and exercises to avoid stiffness of the shoulder. The treatment of frozen or stiff shoulder consists of addressing etiological factors, addressing pain to allow for range of motion, initiation of a gentle range of motion program, and progression of the program over time. Progression of the program does not require formal therapy. The current medical evidence does not support the services at issue in this clinical setting. Therefore, physical therapy services provided from 2/15/21 through 5/05/21 were not medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Overturned

Summary Reviewer 


A 38-year-old male enrollee has requested authorization and coverage for suction assisted protein lipectomy. The Health Insurer has denied this request and reported that the requested services are not medically necessary for treatment of the enrollees lymphedema. The physician reviewer found the patient as longstanding lymphedema of the right lower extremity that has caused significant functional impairment as his condition has progressed. He complains of pain and difficulty with normal activity, including ambulation. He has undergone extensive conservative management of his condition, including complex congestive therapy with compression, bandaging and manual lymphatic drainage. He has also undergone medical management of his pain, chiropractic treatment, acupuncture and physical therapy.  This has failed to treat his condition. The photographs are supportive of his documented enlarged right lower extremity. Liposuction is a well-known therapy for lipodystrophy and has been shown to provide possible functional improvement in lymphedema. This patient has failed nonoperative current standard of care management. Lymphedema liposuction is a procedure that can likely improve his current condition. Thus, the requested suction assisted protein lipectomy is medically necessary for the treatment of this patient. Therefore, the requested services are medically necessary for treatment of the patients medical condition. The Health Insurers denial should be overturned.
Appeal type: Experimental
Decision: Upheld

Summary Reviewer 2

A 61-year-old female enrollee has requested reimbursement for Botox injections provided on 12/13/17. The Health Insurer has denied this request indicating that the services at issue were considered investigational for treatment of the enrollees low back pain and spasms. The physician reviewer found that there is currently insufficient scientific evidence demonstrating the effectiveness of botulinum toxin in the treatment of back pain. There is a lack of high-quality studies evaluating botulinum neurotoxin injections for patients with low back pain. Among the studies that exist, there is significant heterogeneity in trial design and outcome parameters. The current body of evidence does not support the use of Botox injections to improve pain or function in patients with low back pain. There is only low-quality evidence that Botox injections are more effective than saline or corticosteroid injections or acupuncture for reducing low back pain. The present literature has yet to address the long-term benefits of Botox injections in this setting. In sum, Botox injections provided on 12/13/17 was not likely to have been of greater benefit than other treatment options. Based upon the information set forth above, the services at issue were not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Insurers denial should be upheld.
Appeal type: Experimental
Decision: Overturned

Summary Reviewer 3

A 39-year-old male enrollee has requested authorization and coverage for hypoglossal nerve stimulation or Inspire Upper Airway Stimulation System. The Health Insurer has denied this request indicating that the requested services are considered investigational for treatment of the enrollees obstructive sleep apnea. The physician reviewer found that there is sufficient support for the requested services in this clinical setting. This patient has undergone surgical intervention but still has documented intolerance of CPAP therapy. Based on the records, he does meet criteria for consideration of hypoglossal nerve stimulation. Hypoglossal nerve stimulation therapy has been proven to be an effective modality for the treatment of obstructive sleep apnea in patients with tongue-based obstruction. Thus, hypoglossal nerve stimulation or Inspire Upper Airway Stimulation System is likely to be more effective than other treatment options. Based upon the information set forth above, the requested services are likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Insurers denial should be overturned.
Appeal type: Medical Necessity
Decision: Overturned

Summary Reviewer 

The patient is a 60-year-old female with osteoporosis. She has had a suboptimal response to Actonel, Forteo and Evista. The physician reviewer found that Osteoporosis is an increasingly widespread condition, and fractures are the most dangerous aspect of osteoporosis. This can lead to acute and chronic pain. A newer medication, denosumab (Prolia) is a fully human monoclonal antibody which has been approved for the treatment of osteoporosis, treatment-induced bone loss, bone metastases, multiple myeloma, and giant cell tumor of bone. Prolia is indicated for the treatment of postmenopausal women with osteoporosis at high risk for fracture or patients who have failed or are intolerant to other available osteoporosis therapy. This patient has failed therapy with multiple other agents in the past. There is sufficient support for the medication at issue in this setting. Therefore, Prolia provided on 3/20/18, 10/15/18, 5/10/19 and 12/16/19 was medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Overturned

Summary Reviewer 

The patient is a 40-year-old female with low back pain and right L5 and S1 radiculopathy. She is status post decompression and fusion at L5-S1 with pedicle screw fixation. The physician reviewer found that the requested laminectomy, facetectomy and foraminotomy are medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld

Summary Reviewer 

The patient is a 20-year-old male without a significant past medical history who presented to the emergency room with complaints of bilateral arm pain after lifting weights.  He presented from an urgent care. At the time of presentation to the emergency department, his vital signs were stable. The physician reviewer found that at the time of admission, the patient was hemodynamically stable and afebrile with normal oxygen saturations on room air. He was diagnosed with rhabdomyolysis without acute kidney injury or any significant electrolyte disturbances. The inpatient admission was not medically necessary for this patient. Inpatient care is necessary when the patientas signs and symptoms and general medical condition can only be managed safely in an acute inpatient setting, when the patient requires diagnostic studies in an inpatient setting, or if it is medically necessary for the patient to remain in the acute inpatient setting. In this case, the patient was admitted in stable condition and could have been treated at a lower level of care. Therefore, inpatient admission provided from 9/23/19 through 9/26/19 was not medically necessary for the treatment of this patient.
Appeal type: Experimental
Decision: Upheld

Summary Reviewer 3


A 44-year-old female enrollee has requested reimbursement for an AmniSure test that was performed on 4/7/14. The Health Insurer has denied this request indicating that the test at issue is considered investigational for evaluation of the rupture of the fetal membrane. The physician reviewer found that at issue in this case is whether the AmniSure test was a better tool to evaluate this patients leakage of fluid than any other standard available test, such as a traditional speculum exam with PH and microscopic evaluation of the fluid. The diagnosis of rupture of membranes (ROM) is made based upon patient history and clinical exam including a speculum evaluation of the vagina and cervix. Typically, the patient history, with a description of leakage of fluid, can help to rule in or rule out the diagnosis. This coupled with a sterile speculum exam to evaluate vaginal/cervical secretions (pooling), to evaluate the PH of any secretions, and to perform a microscopic examination for cervical ferning are used to complete the exam. In this case, there was no documentation of any sterile speculum/pelvic exam. A complete speculum exam would allow for better evaluation of any vaginal fluid to help determine if vaginal pooling occurred or to gather a specimen for evaluation of cervical ferning. For these reasons, the AmniSure test used to evaluate for ROM was not likely to be more beneficial than the standard tests available. Based upon the information set forth above, the test at issue was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The Health Insurers denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned

Summary Reviewer 

A 59-year-old male enrollee has requested reimbursement for magnetic resonance imaging of the knee provided on 12/03/19. The Health Insurer has denied this request and reported that the services at issue were not medically necessary for the evaluation of the enrollees medical condition. The physician reviewer found that total knee replacement is a relatively common successful procedure for pain relief and functional restoration in patients with advanced osteoarthritis. The key to long-term success in both primary and revision total knee arthroplasty is stability, as well as adequate and stable fixation between components and underlying bone. As ligamentous balancing is the key to success, it is necessary to know if a pre-operative trauma has resulted in ligamentous disruption, particularly of the medial or lateral collateral ligament, in order to decide if a posterior stabilized or a more constrained implant will be required. In this case, there was a history of significant trauma to the knee resulting from the large dog running into the knee. This had resulted in pain, swelling, and instability. As such, it was necessary to find out the cause of the reported instability before the surgery. Therefore, the surgeon found it necessary to obtain an MRI scan to evaluate the ligaments prior to the surgical procedure. There is sufficient support for the services at issue in this clinical setting. Therefore, magnetic resonance imaging of the knee performed on 12/03/19 was medically necessary for the evaluation of this patient.