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

The parent of an 18-year-old male enrollee has requested orthognathic surgery and one extra day of hospitalization for the treatment of the enrollees maxillary hypoplasia. Findings:  The physician reviewer found that the patient has mandibular hyperplasia and maxillary hypoplasia. He has significant negative overjet and definite maxillary hypoplasia evident, both clinically (from the provided photographs) and radiographically. Appropriate management of this requires both a maxillary and mandibular procedure. Surgically correcting the mandible alone can lead to an unstable result, with the potential to compromise the posterior airway space. Performing surgery on both the upper and lower jaws will result in a better functional outcome. Given the nature of the surgery, which involves procedures of the upper and lower jaw, a two-day hospitalization is appropriate. It is impossible to predict the patients post-op course.  However, given the type of surgery proposed, a request for a two-day stay is reasonable.  This will ensure that the patient has adequately recovered and can be safely discharged. Thus, the maxillary surgery (LeFort procedure) and additional day of hospitalization are medically necessary for this patient.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the occipital nerve block for treatment of the enrollees migraine. Findings:  2/3 of the physician reviewers found that occipital nerve block is one treatment option for a number of headache disorders. There have been some studies that are small that show benefit, especially for acute migraine treatment, and less data for treating chronic migraine. There is currently a paucity of data supporting occipital nerve blocks for chronic tension type headache. There is also a lack of clinical trials comparing the use of occipital nerve black against other standard therapies such as oral medications or Botox. In this patients case, there is inadequate documentation of the patients headache disorder to determine the type of headache disorder, which previous medications have been attempted, and the patients response to those medications. In addition, the procedure report states that nerve blocks were indicated due to significant pain in palpated muscles. Tenderness to palpation is seen in nearly all headache disorders, and is not an indication for any specific treatment. Further, the records do not document that the patient has previously used other preventive therapies such as tricyclic antidepressants, beta blockers, or Botox. Thus, the occipital nerve block was not 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 service at issue was not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: Physician reviewer number one is board certified in neurology with a 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.Physician reviewer number two 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.Physician reviewer number three 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: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for magnetic resonance imaging (MRI) of both knees for evaluation of the enrollees bilateral knee pain. Findings:  The physician reviewer found that submitted documentation does not support the medical necessity of the requested diagnostic procedure for evaluation of this patients knee pain. The medical literature supports MRI examination if the patient has not responded to a trial of conservative treatment for approximately three to six weeks. The records indicate that this patient has had symptoms for many years, has not sustained any recent trauma, and there is no indication that he has an infection or other condition that might demand immediate attention. Patients with persistent or recurrent unexplained pain after three to six weeks of conservative treatment may require MRI. The studies have shown that MRI has little to offer patients who have been diagnosed with non-traumatic knee pain, or those who have no mechanical symptoms and no findings of degenerative arthritis on plain films. Accordingly, MRI of both knees is not supported as medically necessary for the evaluation of this patients bilateral knee pain. Final Result: The reviewer determined that the requested diagnostic procedure is not medically necessary for evaluation of the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is board certified in diagnostic radiology  and is actively practicing. The reviewer is an expert in the evaluation 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 50-year-old male enrollee has requested  for sinus endoscopy with balloon for treatment of ber chronic sinusitis.  Findings:  Two physician reviewers found that there is documentation that he has failed maximal medical therapy.  He is an appropriate candidate for the requested services.  Balloon sinuplasty is the standard of care for this type of problem.  The current scientific literature supports the requested services in this patients case (Vaughan and Levine, et al.).  All told, the requested sinus endoscopy with balloon is likely to be of greater benefit than other treatment alternatives in this clinical setting.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for a Monovisc injection (HCPCS J7327) in the right knee. Per the medical literature, although viscosupplementation may relieve knee pain in some individuals with osteoarthritis, it is not known as to which individuals will benefit. 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 tried and failed other conservative treatments, with the alternative being a total knee arthroplasty. Given the patients limited options and based on the current medical literature, the requested services are medically indicated. Therefore, a Monovisc injection (HCPCS J7327) in the right knee is medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested service is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in orthopedic surgery and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld

A 67-year-old male enrollee has requested full-body PET/CT for an evaluation of his metastatic myxoid liposarcoma. Findings:  Two physician reviewers found that available research does not include large patient series or trials for this uncommon neoplasm. The patients previous metastatic lesions were evident on MR imaging, and his radiation therapy was carried out using the MRI findings. It is not clear why PET/CT imaging has been selected to evaluate the patients current metastatic status. His previous metastatic lesions were evident on MRI imaging, and it would seem reasonable to do MRI imaging at this point in time. If the findings are inconclusive or there are any other unanswered clinical issues, PET/CT should be reconsidered.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for factor V Leiden and prothrombin gene testing services. Researchers note that venous thromboembolism (VTE) is a significant clinical event. Generally, patients with VTE with at least one first degree relative with documented VTE before age 45 have the highest risk of having an inheritable thrombophilia disorder and should be tested for the presence of all five inherited thrombophilia, of which factor V Leiden and prothrombin gene mutation are the most common. In this case, the patient reported that his mother had a history of massive blood clots. In this clinical setting, identification of an inheritable disorder would influence testing needs for other family members and affect future decision making for this patients course, given his higher risks for travel or surgery. Therefore, factor V Leiden and prothrombin gene testing services are likely to be more beneficial for evaluation of the patients condition than any available standard therapy.Findings:  Two of the three physician reviewers found the requested factor V Leiden and prothrombin gene testing services is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the requested services are likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: Physician reviewers 1 and 2 are board certified in internal medicine with sub-specialty certifications in medical oncology and hematology and are actively practicing. Physician Reviewer 3 is board certified in internal medicine with sub-specialty certification in hematology and is 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: An enrollee has requested authorization and coverage for Epclusa-sofosbuvir-velpatasvir tablet 400/100 mg for 12 weeks. Findings:  The physician reviewer found that according to joint guidelines issued by the American Association for the Study of Liver Diseases (AASLD) and the Infectious Diseases Society of America (IDSA), all patients with chronic hepatitis C should be treated except those with life expectancy less than 12 months due to non-liver-related conditions. This applies to all patients, regardless of fibrosis stage. Per the guidelines, Epclusa for 12 weeks is recommended as first-line therapy for treatment naive, genotype 3 patients. This is based on the ASTRAL-3 trial for Epclusa, which showed a high cure rate (98%) with this regimen . AASLD/IDSA guidelines cite data showing reduced survival with delayed treatment . For these reasons, Epclusa-sofosbuvir-velpatasvir tablets 400/100 mg for 12 weeks for the treatment of this patients hepatitis C infection is medically necessary. Final Result: The reviewer determined that the requested medication regimen is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in internal medicine with sub-specialty certification 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: Medical Necessity
Decision: Upheld

The enrollee is requesting reimbursement for inpatient hospital level of care. The enrollee had a total thyroidectomy for thyroid cancer. She had metastases to her lymph nodes and was admitted to out-of-the-country hospital for surgery. During the procedure, a vocal cord polyp was removed and a drain was placed. The drain was removed on the fourth day and the enrollee was discharged. The enrollee reports thyroid cancer removal requires full anesthesia and therefore requires pre-surgical testing and full hospitalization. The enrollees physician reports the decision to fully admit the enrollee to the hospital was to further monitor her pain following surgery. The literature shows this enrollees procedure had can be done in a short hospital stay. The services provided on the first day of stay were not medically necessary on an inpatient basis, as routine pre-operative evaluations, including a cardiology consultation and anesthesia consultation, could have been done as an outpatient. As for the last day of stay, the surgery was performed the day before. There are no medical records provided beyond a post-hoc letter indicating the need for pain control on the last day.  Thus, there is no support for inpatient status on the last day.Final Result: The reviewer determined that the requested services were not medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The physician reviewer is board certified in general 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 similar medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The parent of the enrollee has requested authorization and coverage for occupational therapy sensory integration services. With its focus on developing motor planning skills and problem solving skills, teaching self-help skills, and developing spatial awareness, occupational therapy is well suited to affect positive change in this patient. Combining sensory integration techniques with other occupational therapy approaches is also appropriate. According to the most recent recommendations from the American Academy of Pediatrics (AAP), sensory-based therapies are increasingly used by occupational therapists and sometimes by other types of therapists in treatment of children with developmental and behavioral disorders  occupational therapy with the use of sensory-based therapies may be acceptable as one of the components of a comprehensive treatment plan. For these reasons, the requested occupational therapy sensory integration services are likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.One reviewer found that the requested occupational therapy sensory integration services are not 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 pediatrics with sub-specialty certification in pediatric critical care and is actively practicing. One Reviewer is board certified in pediatrics with sub-specialty certification in neurodevelopmental behavioral pediatrics and is actively practicing.  One Reviewer is board certified in pediatrics with expertise in neurodevelopmental behavioral pediatrics 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.
Appeal type: Experimental/Investigational
Decision: Upheld

A 34-year-old female enrollee has requested gastrointestinal (GI) tract capsule endoscopy for evaluation of her Crohns disease. Findings:  Two physician reviewers found that given this patients known mid-small bowel stricture, use of serial capsule endoscopy is not recommended. On one occasion, the capsule was retained, and on another passed the stricture with difficulty. There is a paucity of literature to support use of serial capsule endoscopy in this patients scenario, particularly without preliminary use of a patency capsule to minimize the risk of capsule endoscopy impaction in her stricture. Rather, double balloon enteroscopy appears to be a useful method in determining the need for dilation by assessing for active ulceration (Gill and Kaffes). All told, the GI capsule endoscopy provided was not likely to have been more beneficial for evaluation of the patients medical condition than any available standard alternatives.
Appeal type: Medical Necessity
Decision: Upheld

A female enrollee requested residential treatment for medical treatment of her behavioral health conditions.  Findings:  The physician reviewer found that the patient was responding to treatment and improving in terms of her eating disorder behaviors, which were decreasing and she was learning to reach out to others for help. Although she continued to report the desire to restrict fluids, this did not require 24-hour monitoring. Further, there was no objective evidence to suggest that a lower level of care would have resulted in exacerbation that would necessitate continued residential treatment, given that the patient was cooperative and improving. Thus, residential treatment was not and is not medically necessary for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Findings:  The physician reviewer found that The patient has requested authorization and coverage for Orthovisc injection series (three injections to each knee) given every six months for one year (two series total). An exhaustive review of the current medical literature pertaining to viscosupplementation reveals mixed results. Evidence from eight systematic reviews and six randomized controlled trials indicates that although viscosupplementation may relieve knee pain in some individuals with osteoarthritis, it is not known as to which individuals will benefit. Different studies have tried mixing hyaluronic acid with corticosteroids, platelet-rich plasma, and other agents to make it more effective. Guidelines from organizations such as the American Academy of Orthopedic Surgeons indicate that the evidence is not conclusive. In light of the foregoing, viscosupplementation can only be recommended in individuals with a history of lasting benefit from prior injections and in carefully selected cases where everything else has been tried and the options are limited. In this case, there is a long history of viscosupplementation of both knees with beneficial, lasting results making a tremendous improvement in the quality of life. The submitted documentation noted nine knee surgical procedures and chronic knee pain. Based on the records, this patient will benefit from additional viscosupplementation. Therefore, the requested bilateral Orthovisc injection series (three injections to each knee) is medically necessary to treat the patients medical condition. Additionally, the requested bilateral Orthovisc injection series (three injections to each knee) given every six months for one year (two series total) 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.
Appeal type: Medical Necessity
Decision: Overturned

A 49-year-old male enrollee has requested Flomax for the treatment of his prostatic enlargement. Findings:  The physician reviewer found that this patient has taken the generic drug as requested in the formulary, and it was not effective. The patient reports that Flomax has been effective. Flomax is a selective alpha-1 blocker, and Cardura is a non-selective alpha-1 blocker. Both drugs work, but some patients do not tolerate the non-selective blockers and do respond to the selective alpha-1 blockers.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested abdominoplasty and panniculectomy for treatment of her medical condition. Findings: The physician reviewer found that based on the medical documentation provided for this review, the requested abdominoplasty and panniculectomy should be considered cosmetic interventions for treatment of this patients excess skin. The patient is noted to have a panniculectomy with panniculitis on examination. However, the degree of severity is not detailed and conservative management has not been documented. The patient does have evidence of abdominal pain, but this does not appear to be directly related to the pannus, but more likely associated with the umbilical hernia or other non-specified condition. The photographs provided do not confer a significant condition of the upper abdomen. From the definition of reconstructive surgery from the American Society of Plastic Surgeons (ASPS), reconstructive surgery can be indicated to obtain a more normal appearance. However, in this case the degree of severity is not well-defined, thus the requested surgical intervention is not medically necessary to approximate a more normal appearance. Reconstructive surgery is performed on abnormal structures of the body, caused by congenital defects, developmental abnormalities, trauma, infection, tumors, or disease. It is generally performed to improve function, but may also be done to approximate a normal appearance. Without greater detail from the medical documentation, in regards to the severity of the appearance, the requested surgery is not requested to approximate a more normal appearance. The photographs do not support that the patient has a significantly abnormal appearance. There has not been adequate documentation to support that this is a reconstructive procedure. Moreover, there is insufficient evidence that a functional deficit is present that has failed reasonable conservative management. As the degree of severity has not been adequately documented and that the photographs do not show evidence of clear severity, the requested abdominoplasty and panniculectomy are not reconstructive in nature and not medically necessary.  Final Result: The reviewer determined that the requested surgery is not reconstructive in nature and 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 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.