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

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for epidural injections (CPT codes 64483 and 64484). Lumbar spinal stenosis is associated with neuroforaminal and central stenosis commonly related to degeneration of the spine with aging. Lumbar epidural steroid injections under fluoroscopic guidance are safe and effective for the treatment of low back and lower extremity radicular pain, as well as neurogenic claudication caused by spinal stenosis. Rivera reported that data shows that these procedures are relatively safe and effective, especially for the short-term treatment of radicular pain. In this case, the patient has symptoms and findings consistent with spinal stenosis associated with radiculopathy and corroborated by the imaging studies. Given the support in the medical literature, the requested epidural injections (CPT codes 64483 and 64484) are medically necessary for 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: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient is a 14-year-old male who has been diagnosed with short stature. On 7/14/17, his height was 136.4 cm, which was -1.7 cm standard deviations below the mean, as extrapolated by the expert reviewer using standard pediatric growth charts, placing him in the fourth percentile. On 11/20/17, the patients height was noted to be in the third percentile. A growth chart was not provided with the heights of the patient prior to initiation of growth hormone (GH). Treatment with somatropin was initiated sometime between July 2017 and November 2017. On 9/12/18, the patients height had increased from the third percentile to the tenth percentile, with a height of 149 cm. On 3/15/19, the patients height was 153.9 cm. His bone age was reported to be 13 years and six months at the chronological age of 13 years and seven months. The patients parent has requested authorization and coverage for somatropin (Saizen-Saizenprep). The Health Plan denied the request and reported the requested medication is not medically necessary for the treatment of this patient. At issue in this case is whether somatropin (Saizen-Saizenprep) is medically necessary for the treatment of the patients medical condition. A study found that GH therapy is appropriate for children diagnosed with idiopathic short stature (ISS) with a current height below -2.25 standard deviations of the mean, in whom the epiphyses are not closed, and whose expected adult height based on bone age is below the normal range. This corresponds to an adult height less than 63 inches for males. Growth hormone therapy was not recommended unless there is compelling evidence supporting the concerns of current or future adverse psychosocial consequences related to short stature. In this case, the patients pre-treatment height was at -1.7 standard deviations below the mean, as extrapolated by the expert reviewer using standard pediatric growth charts, which is normal. There was no evidence showing decreased growth velocity for the patients Tanner stage during the year prior to initiation of GH. The medical evidence does not support the requested medication in this clinical setting. Therefore, somatropin (Saizen-Saizenprep) is not medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested medication is 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-subspecialty certification in pediatric endocrinology 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

A 30-year-old female enrollee has requested for a wearable cardioverter-defibrillator for treatment of her wide complex tachycardia.   Findings:  Two physician reviewers found that without electrophysiology guidance, it would be impossible to definitively assess a medication that would be able to suppress this symptomatic arrhythmia, and repeat cardioversion may be necessary. Therefore, a reasonably clinically acceptable alternative would in fact be a Life Vest for detection and electrical treatment of a recurrent dysrhythmia. A Life Vest for this patient was medically indicated and continues to be appropriate for the time it takes to complete a cardiac MRI and electrophysiology study to determine the etiology of her tachycardia.
Appeal type: Medical Necessity
Decision: Overturned

A 51-year-old male enrollee has requested knee brace (CPT code L1845) and knee brace add-ons (CPT codes L2810, L2820, L2830, and L2850) for the treatment of his right knee, status post anterior cruciate ligament (ACL) reconstruction surgery. Findings:  The physician reviewer found that the use of a medial unloader brace was medically necessary for this patients specific clinical situation. Although the medical records do not include a description of the patients knee in reference to genu vera or genu valga, the medical records do document chondroplasty of the medial femoral condyle. This patient, at age 51, is an outlier as far as anterior cruciate repair in patients. The duration of the instability in the knee is important to the development of degenerative osteoarthritis within the joint. This is because cartilage surfacing of the knee joint is strong in compression, but weak in shear. The fact that a chondroplasty was performed on this patient, combined with his age, and further combined with an episode of knee effusion (occurring seven months after his surgery), all suggest not only pathology of an ACL insufficient knee, but of early development of medial compartment degenerative osteoarthritis. The medical literature supports the efficacy of orthotics as a conservative measure in the long-term conservative management of medial compartment degenerative osteoarthritis. The study by Ramsey and colleagues demonstrated that patients utilizing a medial unloader brace (such as was used by this patient) showed an associated reduction in pain. Thus, the knee brace at issue (CPT code L1845) and associated add-ons (CPT codes L2810, L2820, L2830, and L2850) were medically appropriate and necessary for this particular patient.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested authorization and coverage for the medication Vyvanse. The Health Plan has denied this request indicating that the requested medication is not medically necessary for treatment of the enrollees autism and Attention Deficit Hyperactivity Disorder (ADHD). At issue in this case is whether the requested medication Vyvanse is medically necessary for treatment of the enrollees medical condition. Treatment guidelines and literature on ADHD for preschool age children indicate that: When the clinician and parents agree that medication is warranted for a preschool child, we suggest methylphenidate rather than amphetamines or nonstimulant medication. Overall there is minimal literature and studies on the use of stimulants in preschool age children and Controlled studies comparing methylphenidate with other medications for preschool children are lacking. The majority of literature and practice guidelines for children of the patients age recommend trials of methylphenidate as a first-line treatment. Methylphenidate comes in chewable, patch and liquid formulations. The requested medication Vyvanse is not approved for the patients age group and the records and do not indicate that the patient has tried or failed any methylphenidate formulations. Therefore, the requested medication, Vyvanse, is not medically necessary.Final Result: The reviewer determined that the requested medication is 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 subspecialty certification in child and adolescent 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: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for ovarian artery embolization for treatment of the enrollees pelvic pain and menorrhagia. Findings:  The physician reviewer found that this patient underwent UAE for fibroids, pressure symptoms, and menorrhagia. She did have on submucosal fibroid when she had the first imaging, but this resolved after the UAE, when only a small posterior myoma remained. As noted in the medical literature, predictors of a greater improvement in symptom score following the procedure include a presenting symptom of heavy menstrual bleeding rather than other symptoms, smaller leiomyoma size, and submucosal location. This patient no longer has a submucosal myoma, so it is unlikely that the residual small fibroid is causing her ongoing symptoms, or that ablating the fibroid would improve her clinical situation. She does have a bulky uterus, which is probably residual from the ablated fibroids but could also represent another condition, such as adenomyosis, which could be causing her ongoing symptoms and will not respond to a repeat ablation procedure. Overall, there is sparse literature available on ovarian artery embolization for treatment of fibroids. Embolizing the ovarian vessels can also impact the ovaries and cause premature menopause, which could create new issues for the patient. Final Result: The reviewer determined that the requested service is 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 obstetrics and gynecology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: A 32-year-old female enrollee has requested authorization and coverage for S-Boulardii, Lifeway Kefir (lactose free), pyrroloquinoline quinone 20 mg, L-Arginine low dosage, D-Ribose pure powder 500 mg, and Natural Calm plus calcium supplements for treatment of the enrollees medical condition.   Findings:  The physician reviewer found that The request for Saccharomyces boulardii (S-boulardii) is supported as medically necessary for treatment of this patients medical condition. This probiotic has demonstrated efficacy for the treatment of irritable bowel syndrome, which this patient has (Kelesidis and Pothoulakis,). However, the remaining requested items are not supported as medically necessary. Data to support the use of L-arginine supplementation for medical diseases is sparse, and possible benefits published in current medical literature may include hypertension and reduction hospital-acquired infection, although the data are limited; these are not the requested indications in this case (McRae). Overall, there is a lack of peer-reviewed published medical literature citing clinical trial data to support the use of Lifeway Kefir (lactose free), pyrroloquinoline quinone 20 mg, D-Ribose pure powder 500 mg, and Natural Calm for any medical indication. The American College of Gastroenterology (ACG) guidelines for the management of IBS do not support these therapies for treatment of patients with IBS (Ford, et al). For these reasons, the request for S-boulardii is supported as medically necessary in this case, but the Lifeway Kefir (lactose free), pyrroloquinoline quinone 20 mg, L-Arginine low dosage, D-Ribose pure powder 500 mg, and Natural Calm plus calcium supplements are not supported as medically necessary. Final Result: The reviewer determined that a portion of the requested products are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be partially 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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage Otrexup 20 mg/0.4 mL auto injector. Findings:  The physician reviewer found that the submitted documentation and relevant literature fails to demonstrate the medical necessity for the requested medication. Per the peer reviewed evidenced based guidelines, Otrexup is indicated for the treatment of severe, active rheumatoid arthritis or patients who have had an insufficient therapeutic response to or are intolerant of an adequate trial of first line therapy. The available medical records indicate that this patient does not have a diagnosis of rheumatoid arthritis, but does have a diagnosis of psoriatic arthritis. Furthermore, the patient has not previously had an adequate response to oral or injectable methotrexate. Based on the peer reviewed guidelines and available medical documentation, the request for Otrexup 20 mg/0.4 mL auto injector is not medically necessary for treatment of this patients medical condition. Final Result: The reviewer determined that the requested medication is 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 internal medicine with sub-specialty certification in rheumatology 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 male enrollee requested magnetic resonance (proton) imaging, brain (including brain stem) without contrast for medical evaluation of his migraine headaches.  Findings:  The physician reviewer found that according to the documentation submitted for review, the patients more severe headaches, as characterized by the treating provider and the patient are diagnostic of migraine, but there appears to be other more mild headaches that are not well characterized. In general, patients with migraine and a normal neurologic examination do not need an imaging study. However, in this case, the patients diagnosis has not been established. In order to be certain this patient does not have a secondary headache, an imaging study is appropriate. All told, the requested magnetic resonance (proton) imaging, brain (including brain stem) without contrast is supported as medically necessary.
Appeal type: Medical Necessity
Decision: Upheld

A 48-year-old female enrollee has requested lumbar spinal fusion at L3-4 and L4-5 for treatment of her back pain.  Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested services.  The current medical evidence does not support the requested lumbar spinal fusion in this clinical setting.  Although the records document that she had pain that had not responded to conservative treatment and a positive lumbar discogram at L3-4 and L4-5, there is lack of evidence of moderate to severe degeneration of the disc with modic changes at the L3-4 level.  Per the submitted documentation, she had some noted discogenic marrow changes on MRI at L4-5.  However, there is lack of evidence that these changes were moderate to severe in intensity.  Moreover, the request is for a two-level lumbar fusion which is not currently supported by the medical literature for discogenic low back pain.  All told, the requested lumbar spinal fusion at L3-4 and L4-5 is not medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld

This patient is 16-year-old female with large pendulous breasts that, according to her chiropractor, are at least partially the cause of her back pain.  Her weight is stated as 180 pounds. The patients mother would like her daughter to undergo a breast reduction for the relief of back, neck, and shoulder pain of unknown duration. The patients primary care provider wrote a letter of support for the procedure, but submitted no additional clinical records. The Health Plan has denied the requested procedure based upon their determination that it is not medically necessary.The submitted clinical records and color photographs of the patient were reviewed. The photographs suggest that the patient may be symptomatic, but at the present time her breasts are compatible in size with her body habitus. If there is a substantial weight loss, the question of breast reduction should be revisited. However, presently there is insufficient evidence the requested procedure is medically warranted. Based upon the information set forth above, I have determined the requested procedure is not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned

The patient has requested reimbursement for residential treatment center (RTC) services. Per the American Society of Addiction Medicine (ASAM) criteria, this patient meets Level 3.5 criteria for clinically managed high-intensity residential services. ASAM criteria focuses on six dimensions to determine the appropriate level of care, which includes: (1) intoxication and withdrawal potential; (2) biomedical conditions; (3) emotional, behavioral and cognitive conditions; (4) readiness to change; (5) relapse, continued use, or continued problem potential; and (6) recovery environment. The patient reported continued use without any period of sobriety longer than one week. The patient placed himself and others at risk due to his driving while intoxicated. The patient has a history of HIV and chronic lumbar back pain with sciatica. The patients emotional conditions include a diagnosis of major depressive disorder. The provider reported that the patient was in the contemplation stage of recovery as evidenced by his ambivalence and discomfort about participating in Alcoholics Anonymous. The patient was at continued risk of relapse, as he reported cravings of 5/10 and he lacked distress tolerance skills, impulse control, and insight. The patients recovery environment did not include a sober support network. The patient required a safe and stable living environment in order to develop his recovery skills. He qualified for ASAM Level III treatment, similar to what patient received at the RTC facility. Given the severity of the patients illness, the RTC services were medically necessary for treatment of this patient.Final Result: The reviewer determined that the services at issue were 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 with expertise 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: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary:  An enrollee has requested nasal surgery (removal of nose polyps, inferior turbinate resection, repair of nasal septum, irrigation of the maxillary sinus, exploration of the sinuses and removal of ethmoid sinus) for treatment of her sinusitis. The physician reviewer found that the submitted documentation fails to establish the medical necessity of the requested surgery. The American Academy of Otolaryngology Head and Neck Surgery define clinical sinus disease with nasal polyps as that of chronic rhinosinusitis and suggests appropriate medical therapy prior to any consideration of surgical intervention. The evidence-based peer-reviewed literature suggests medical therapy be performed prior to consideration of surgical intervention. In this case, there is a lack of documentation demonstrating medical therapy has been attempted or trialed on this patient. The medical records lack documentation of medical therapies utilized to help restore normal sinus activity. A CT scan of the sinuses confirms evidence of inflammatory partially obstructive sinonasal disease with presence of polypoid degeneration. However, the history of the patient's symptoms is not documented in the medical records. Moreover, the submitted documentation does not show evidence of functional nasal airway blockage by any nasal septal deviation. The CT scan report did not state that there was any severe obstructive nasal septum. For this reason, the indications for nasal septal reconstruction are not met. Turbinate reconstruction can be considered in patients with severe hypertrophy or allergic manifestations, but in this case based on the clinical examination there is no evidence of any enlargement of the turbinates or obstructive nature of them. As such, turbinate surgical intervention is not indicated. Based on the medical literature cited above and the documentation submitted for review, the request for nasal surgery (removal of nose polyps, inferior turbinate resection, repair of nasal septum, irrigation of the maxillary sinus, exploration of the sinuses and removal of ethmoid sinus) is not medically necessary for treatment of the patients medical condition.  Final Result: The reviewer determined that the requested surgery is 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 otolaryngology and head and neck 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.