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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for an Orthovisc injection series of the right knee. Findings:  The physician reviewer found that Viscosupplementation or injection of exogenous hyaluronic acid into the knee joint has been studied and found to have limited short-term efficacy in the treatment of osteoarthritic knee pain. There is no scientific evidence indicating hyaluronic acid injection is effective in the treatment of chronic posttraumatic knee pain or improves outcomes following the treatment of multi ligamentous knee injury. As a consequence, no evidence based treatment algorithms recommend hyaluronic acid injection in the clinical scenario of a young patient who has sustained a multi ligamentous knee injury for which surgical ligament reconstruction was performed. In this case, the patient has chronic knee pain following posterior cruciate ligament and posterolateral corner allograft reconstruction. Current medical literature does not support that hyaluronic acid injection would be more effective than standard treatment under these circumstances. Accordingly, the requested Orthovisc injection series of the right knee is not likely to be more beneficial than any other available standard treatments for the patients medical condition.Final Result: The reviewers determined that the requested services are not likely to be more beneficial than any other available standard treatments for the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: Physician reviewers 1, 2 and 3 are board certified in orthopedic surgery and are actively practicing. All three reviewers are experts in the treatment of the enrollees medical condition and are 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

An 81-year-old female enrollee has requested an MRI of the breast for an evaluation of her breast pain. Findings:  The physician reviewer found that there are several indications for an MRI of the breast which include evaluation of pre-operative extent of cancer, post-operative residual cancer, extent of lobular cancer, identification of an occult primary cancer with positive axillary lymph nodes, screening of high-risk patients, and problem solving. An indication for non-malignant disease is evaluation of breast implants. The high-risk patients are those with a personal or family history of breast cancer or a genetic predisposition for breast cancer such as a BRCA 1 or 2 gene. High-risk patients also include those with biopsy proven atypia, lobular carcinoma in situ, radial scar and prior mantle radiation. The symptom of soreness/pain is not an indication for an MRI of the breast. Furthermore, the patients history of breast cancer is quite remote (31 years ago). The patient can be appropriately evaluated with a mammogram, if one has not been performed recently, ultrasound of the breast and correlation with any physical findings. MRI of her left breast is not medically necessary based upon the evidence provided.
Appeal type: Medical Necessity
Decision: Upheld

A 54-year-old female enrollee requested replacement custom foot orthotics for medical treatment of the enrollees plantar fasciitis.  Findings:  The physician reviewer found that after careful review of the enclosed information and the pertinent guidelines, the request for the new pair of orthotics is not medically necessary to treat this patients painful plantar fasciitis. The patient received new custom orthotics and they have been altered. However, the patient states that the current orthotics do not help her pain. There is a lack of specificity as to how the providers new recommended orthotics will differ than the current orthotics. All told, the requested pair of custom orthotics is not supported as medically necessary for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld

A male enrollee requested hyperbaric oxygen therapy for medical treatment of his post-concussive syndrome.  Findings:  Findings:  The physician reviewer found that the literature shows no particular benefit for treatment of post-concussive headache or dizziness with hyperbaric oxygen.  The current medical evidence does not support the requested services in this clinical setting.  All told, the requested hyperbaric oxygen therapy is not medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for durable medical equipment (DME) custom oral device (CPT E0486). Findings:  The physician reviewer found that records provided for review document that this patient failed treatment with continuous positive airway pressure (CPAP) as first-line of treatment due to intolerance. The patient is symptomatic, and her provider has recommended treatment with a custom oral device. Oral mandibular advancement devices are U.S. Food and Drug Administration (FDA) approved for the treatment of patients with mild to moderate OSA. Per the American Academy of Sleep Medicine (AASM) and American Academy of Dental Sleep Medicine (AADSM), treatment with oral appliance therapy is supported for the treatment of patients with moderate OSA (Ramar, et al.) Given the moderate severity of this patients OSA with an apnea/hypopnea index (AHI) of 22.3 events per hour, treatment with a custom oral device is consistent with the recommendations in the medical literature and current guidelines. Therefore, the requested DME custom oral device (CPT E0486) is medically necessary for treatment of this patient. Final Result: The reviewer determined that the requested device 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 subspecialty certification in sleep 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 a positron emission tomography (PET) scan for evaluation of his medical condition.  Findings:  Two physician reviewers found that a PET scan is not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. For pancreatic carcinoma, the standard radiographic work-up is generally ultrasound and then CT scanning.  Once metastases are discovered, the surveillance of the tumor is often sequential with CT scans to monitor the response to therapy. As in all tumors, PET scanning has become increasingly more popular. With regards to pancreatic tumors, a researcher states, The role of PET in the evaluation of possible sites of recurrence has yet to be determined. A small study of 20 patients including patients who had undergone the Whipple procedure, suggested that PET may be useful in clarifying equivocal CT examinations for recurrent disease. This is the critical issue in this patient, as there are no equivocal findings in this patients case.  There are clearly defined metastases which can be accurately measured. Finally, as stated by the National Comprehensive Cancer Network (NCCN) guidelines, PET/CT scan may be considered after formal CT pancreatic protocol in high-risk patients to detect extra pancreatic metastases.  It is not a substitute for high-quality, contrast-enhanced CT. For the reasons provided above, the requested services are not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Final Result: Two reviewers determined that the requested services are 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 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

A female enrollee requested chiropractic services for medical treatment of her sprain/strain of neck, nonallopathic lesion of ribcage, sprain and strain of ribs, spasm of muscle, and lumbar sprain and strain. Findings:  The physician reviewer found that the patients diagnoses are not clearly supported by the patients complaints or examination history. In addition, the x-ray report does not correlate with the patients symptoms. Further, the providers notes lack a thorough initial examination, consultation, formulation of a diagnosis and treatment plan with specific goals. Therefore, the chiropractic treatment visits at issue were not medically necessary for treatment of the patients medical conditions.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for breast magnetic resonance imaging (MRI) for evaluation of the enrollees medical condition.  Findings:  The physician reviewers found that screening with both MRI and mammography might rule out cancerous lesions better than mammography alone in women who are known or likely to have an inherited predisposition to breast cancer.  The data support an essential role for screening MRI in women with an increased risk for breast cancer.  Final Result: All 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: 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: Medical Necessity
Decision: Overturned

The patient has requested authorization and coverage for weekly biofeedback therapy, weekly eye movement desensitization and reprocessing therapy (EMDR), weekly internal family systems (IFS) for trauma, weekly PTSD acceptance and commitment therapy (ACT), and weekly cognitive hypnosis, somatic experiencing, positive psychology and resilience therapy. The American Association of Community Psychiatrists Level of Care Utilization System (LOCUS) provides a reliable framework for determining the appropriate level of care for adults needing mental health treatment. Using LOCUS, providers score patients on a scale of 1-5 using a six-pronged Dimensional Rating System. The six dimensions include: (1) risk of harm; (2) functional status; (3) medical, addictive and psychiatric comorbidity; (4) recovery environment (a. stressors and b. supports); (5) treatment and recovery history; and (6) engagement. The composite score is then used to determine the level of care needed. Applying the LOCUS framework, this patient meets the criteria for the requested services. This gives the patient a composite score which is consistent with medically monitored community based services. Thus, a lower level of care is indicated to attenuate her risk factors and minimize further compromise of her mental health. 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 psychiatry and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

A 52-year-old male enrollee has requested the prescription medication Solodyn (90 mg) for the treatment of his skin condition. Findings:  The physician reviewer found that minocycline is commonly used in rosacea treatment.  Brand name extended release minocycline (Solodyn) is clinically known to have fewer associated side effects than generic formulations.  For this reason, Solodyn is usually prescribed for patients intolerant of or unresponsive to generic minocycline.  This particular patient presents with both intolerance and unresponsiveness to generic minocycline.  As generic minocycline has been tried and has failed in this case, Solodyn is the next indicated and appropriate clinical treatment for this patient.
Appeal type: Medical Necessity
Decision: Upheld

A 42-year-old female enrollee has requested a reduction mammaplasty for treatment of her neck, shoulder and back pain.  Findings:  The physician reviewer found that breast reduction surgery is effective in relieving the symptoms related to large breasts such as back pain, neck pain, and skin breakdown, if they are present. However, the medical records provided do not document the presence of such symptoms. Nor do the available records document any physician visits or treatments specifically for the patients reported symptoms, other than the referral to a plastic surgeon. There also are no shoulder bra strap grooves in the submitted patient photos. All told, the documentation provided does not establish that a reduction mammaplasty is medically necessary to resolve a functional impairment. With regard to whether the proposed procedure is reconstructive in nature, the submitted photographs do not show a condition that would constitute an abnormal structure of the body. The patient has moderately sized breasts with grade II ptosis and the right breast is slightly larger than the left. Her condition does not meet the criterion of an abnormal structure of the body as required by Californias reconstructive surgery statute. Therefore, the requested procedure is not considered reconstructive in nature but rather is cosmetic.
Appeal type: Medical Necessity
Decision: Upheld

The patient is a 45-year-old woman with a history of morbid obesity, hypertension, back pain, and diabetes. The patient currently utilizes an electric scooter to ambulate within her home and for community mobility. The patient states that she cannot access certain areas of her home while utilizing the electric scooter and therefore, is requesting authorization for an electric wheelchair. The Health Plan has authorized a manual wheelchair.The Health Plans denial should be upheld. The patients records do not demonstrate that the patient cannot operate a manual wheelchair. There is no documentation from the patients physical therapist or the patients physician demonstrating that the patient cannot operate a manual wheelchair. Therefore, an electric wheelchair is not considered medically necessary at this time. Furthermore, given the patients history and current condition, a manual wheelchair appears more clinically appropriate. For these reasons I have determined that the requested equipment is not medically necessary. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld

A 63-year-old female enrollee has requested 14 transcranial magnetic stimulation treatments for treatment of her major depressive disorder.  Findings:  The physician reviewer found that transcranial magnetic stimulation is a non-invasive, neuro-stimulatory intervention endorsed by the American Psychiatric Association for the treatment of acute phase depression in the adult population.  A typical treatment course for transcranial magnetic stimulation is four to six weeks.  The current medical evidence does not support the services at issue in this patients case.  At this time, there is a lack of adequately powered, controlled studies showing the benefit of longer courses of transcranial magnetic stimulation therapy.  It was not reasonably expected that the therapy would improve the patients condition or prevent a more serious episode of illness.  Further, there was no mention of the specifics of the psychotherapy being provided or the extent of specialty care directed towards her co-occurring eating disorder.   The medical evidence does not support a longer duration of transcranial magnetic stimulation therapy in this case while the medical records indicate that standard therapies had not been exhausted.  All told, 14 transcranial magnetic stimulation treatments provided from the time period specified were not medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Overturned

A 64-year-old male enrollee requested transcranial magnetic stimulation (TMS) for medical treatment of the enrollees depression.   Findings:  The physician reviewer found that the records document that treatment with antidepressants and augmentation strategies have not successfully brought on remission in this patients condition. In the medical literature, Schutter and colleagues reported that TMS had a moderate effect on treatment resistant depression. George and colleagues showed that TMS was significantly more likely than sham treatment to produce remission in patients with treatment resistant depression. Avery and colleagues provided evidence that TMS is a safe and effective treatment for major depressive disorder. Moreover, the American Psychiatric Association (APA) guidelines state that the acute phase treatment may include TMS. Thus, although relatively new, TMS is an effective treatment that has been granted a category I CPT code by the American Medical Association (AMA) and is U.S. Food and Drug Administration (FDA) approved for patients with treatment resistant major depressive disorder. All told, TMS is medically necessary for treatment of this patients depression.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a seven-year-old enrollee has requested a crocodile gait trainer for medical treatment of the enrollees hypotonia and myoclonus.  Findings:  The physician reviewer found that as the documentation indicated, the patient would be utilizing this assistive gait trainer to be more independent and participate more effectively in the school environment. Without this device, the patient is confined to a chair or to the floor, limiting their effective interaction with their peers. Further, the patients provider reports the patient has a previously used gait trainer, but it is too heavy to be transferred to and from school, therefore limiting her independence in certain environments. The requested gait trainer would be used for pre-ambulatory training, in an attempt to build lower extremity muscle strength, and eventually walk with less extensive devices. Moreover, the gait trainer is appropriate for use in the home, and is able to be transported to other locations to allow the patient to complete instrumental activities of daily living, which are more complex tasks required for independent living. The expected health benefits from use of this device include increased bilateral lower extremity muscle strength, continued and improved ergonomic use of the upper body, and to prevent muscle atrophy of both the bilateral upper and lower extremities. Therefore, the requested crocodile gait trainer is medically necessary and an acceptable piece of durable medical equipment. As such, the requested device (custom crocodile gait trainer E1399) is medically necessary for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld

The parent of a five-year-old male enrollee has requested  the insulin pump OmniPod System for treatment of the enrollees diabetes.  Findings:  The physician reviewer found that several studies in the peer-reviewed literature have shown that insulin pump therapy is safe and effective in children and adolescents with type 1 diabetes.  Compared to conventional insulin treatment, continuous subcutaneous insulin infusion improves glycemic control, limits excessive weight gain, and reduces the frequency of hypoglycemic events.  However, the submitted documentation fails to establish the medical necessity of the requested equipment in this patients case.  This patient was diagnosed with diabetes on the date in question. A six-month trial of injections is medically appropriate prior to transition to insulin pump therapy.  Information regarding the precise number of daily injections and blood glucose values at least four times per day were not submitted.  The submitted documentation does not demonstrate that the patient and his family have completed a comprehensive pump education class.  All told, the requested insulin pump OmniPod System is not medically necessary for the treatment of this patient at this time.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for epinephrine auto injector. Findings:  The physician reviewer found that candidates for immunotherapy are patients whose symptoms are not controlled adequately by medication and avoidance. The allergy immunotherapy practice parameter recommends that at the onset of immunotherapy, patients should be counseled on the possibility of immediate and delayed systemic reactions. Accordingly, the decision to prescribe epinephrine auto injectors to patients receiving immunotherapy should be at the providers discretion. Patients should remain in the providers medical clinic for at least 30 minutes after receiving an injection, but longer waits are reasonable, as directed by the provider. Some providers might request that patients who are considered at increased risk of a serious systemic reaction outside of the medical clinic carry injectable epinephrine. These patients should be instructed in the use of epinephrine to treat a systemic reaction that occurs after they leave their providers office or other location where the injection was administered. In addition, biphasic anaphylactic reactions are characterized by complete clinical resolution of initial symptoms followed by onset of late phase symptoms, usually within 24 hours. The literature indicates that biphasic anaphylactic reactions are reported to occur 1% to 20% of the time and that biphasic reactions occur in 10% and 23% from immunotherapy reactions. As such, the use of more than one dose of epinephrine auto injector would be crucial. Based on the documentation provided, epinephrine auto injector would be indicated in this patient. Therefore, authorization and coverage for epinephrine auto injector is medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested medication 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 allergy and immunology 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.