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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for radiofrequency ablation of the lower extremities. This patients documentation does not support the medical necessity of radiofrequency ablation. The areas of reflux do not match the providers assessment based on the patients symptoms. It is noted the patient is not having symptoms in the area of his varicose veins. Additionally, the assessment of arterial perfusion is insufficient to rule out the presence of significant peripheral artery disease in the presence of the patients medical condition. All told, the requested radiofrequency ablation of the lower extremities is not supported as medically necessary for treatment of this patients medical condition. Final Result: The reviewer determined that the requested services are not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in vascular surgery and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary:  An enrollee has requested reimbursement for intravascular ultrasound (IVUS) imaging (CPT 92978). Findings:  The physician reviewer found that (ACCF/AHA/SCAI) guidelines, Intravascular ultrasound (IVUS) provides a unique coronary artery assessment of lesion characteristics, minimal and maximal lumen diameters, cross-sectional area, and plaque area. Diagnostic uses for IVUS include the assessment of angiographic indeterminant coronary artery stenoses, determination of the mechanism of stent restenosis or thrombosis, and postcardiac transplantation surveillance of coronary artery disease (CAD). The authors conclude, IVUS is superior to angiography in the early detection of the diffuse, immune-mediated, cardiac allograft vasculopathy. Additionally, the authors also state, IVUS is reasonable for the assessment of angiographically indeterminant left main CAD.In this case, the IVUS was used to image the left circumflex. IVUS is an appropriate method to define the nature of this indeterminate coronary lesion, severity of stenosis and guide the percutaneous coronary intervention (PCI) procedure. IVUS is accepted and within current ACCF/AHA/SCAI guidelines. Therefore, intravascular ultrasound imaging (CPT 92978) provided on was likely to have been more beneficial for evaluation of the patients medical condition than any available standard therapy.Findings: Three out of three physician reviewers found that IVUS imaging (CPT 92978) was likely to have been more beneficial for you than any available standard therapy.Final Result: The reviewers determined that the service at issue were likely to have been more beneficial than any available standard treatment for the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer 1, reviewer 2, and reviewer 3 are board certified in internal medicine with sub-specialty certification in cardiovascular disease. All reviewers are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

A 37-year-old female enrollee has requested mental health outpatient therapy sessions with a psychiatrist three times per week for treatment of her behavioral health issues.  Findings:  The physician reviewer found that the psychiatric progress notes suggest that the patient had initially made some improvements in therapy. However, the most recent progress note indicates that she had worsened symptoms in a majority of the measurable domains that are documented in the progress notes; these include worsening of: depression, anxiety, sleep; panic; and hopelessness. Overall, it appears that the patient has experienced deterioration in her condition with her current therapy. While it is often the case that a patient's symptoms can worsen during the initial phases of therapy, after nine months of intensive therapy, some improvement should be evident. According to the relevant literature, a patient is likely to have improvement or remission within six months of therapy for PTSD using EMDR - `At 6-month follow-up, 75% of the adult-onset (compared with 33% of the childhood-onset) patients receiving EMDR achieved remission as compared to none of the patients receiving fluoxetine.` (van der Kolk and colleagues). All told, it does not appear that the patient is showing improvement with her current therapy regimen of three visits per week. Given the lack of improvement in the patients condition, the medical necessity of the requested frequency of service is not supported.
Appeal type: Medical Necessity
Decision: Upheld

The patient is a 49-year-old woman with a body mass index (BMI) of 47.8. She has undergone the necessary presurgical evaluations in preparation for weight loss surgery. The patient has requested authorization for the duodenal switch procedure. The Health Plan has denied the patients request indicating that the duodenal switch procedure is not medically necessary for treatment of the patients medical condition.Duodenal switch has gained increasing acceptance as several large studies have been published in the last few years. In 2003, Anthone, et al. demonstrated acceptable perioperative morbidity and mortality with duodenal switch. However, at this time there are no randomized, prospective trials establishing the superiority of duodenal switch vs. Roux-en-Y gastric bypass in patients such as this patient with moderate morbid obesity. The more malabsorptive procedures such as duodenal switch can be appropriate in the super morbidly obese where body habitus or massive hepatomegaly makes conventional Roux-en-Y untenable. This patient can be appropriately and effectively treated with Roux-en-Y gastric bypass. The information submitted provides no compelling reason why duodenal switch would be more advantageous for this patient than Roux-en-Y gastric bypass. Therefore, 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: Experimental/Investigational
Decision: Upheld

A 61-year-old female enrollee has requested an MRI of the breast for evaluation of her inverted breast nipple. Findings:  Two physician reviewers found that the patient did not meet appropriateness criteria for a breast MRI.  This patient does not have known BRCA1 or BRCA2 mutation. She has no known first-degree relatives with these mutations. She does not have a history of receiving radiation therapy to the chest between 10 and 30 years of age. Moreover, the patient has no personal history of breast cancer. All told, the use of breast MRI in this clinical situation is not supported by the literature and was not likely to yield clinically significant information that was unavailable through conventional testing.
Appeal type: Medical Necessity
Decision: Upheld

A 32-year-old female enrollee has requested spinal cord surgery to de-tether the spinal cord for the treatment of her tethered spinal cord syndrome. Findings:  The physician reviewer found that this patient has a severe spinal cord surgery who presents less than one year post-surgery. As expected, a block was seen at the injury site by myelography. The submitted treatment notes document that the patient noted improvement in her condition. No deterioration or worsening of neurologic condition is noted and no new symptoms are documented in the records provided. With no progression, no worsening and no new symptoms, surgery is not indicated for this patient. She does not have a progressive myelopathy.
Appeal type: Medical Necessity
Decision: Upheld

This patient is a 48-year-old male with chronic viral liver disease and cirrhosis. He has been twice treated with PEG interferon and ribavirin without success. The patient is requesting a third trial of therapy with Infergen and ribavirin.There are few data indicating substantive success with re-treatment with Infergen and ribavirin after failing what is generally considered the current gold standard therapy, PEG interferon plus ribavirin, in the setting of two previous treatment courses. There are also little high quality data suggesting that Infergen and ribavirin in this clinical setting (or as maintenance for those failing viral clearance), retards progression or increases time to transplant. Until supporting data become available, treatment with Infergen and ribavirin cannot be supported outside of clinical research trials. Therefore, I have determined that the requested therapy is not medically necessary for the treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld

A sixty-two year-old female who has recurrent substernal chest pain is requesting reimbursement for Enhanced External Counterpulsation (EECP) therapy.  Reviewers Findings:  The reviewing physician found that in this particular case, there does not appear to have been a concerted attempt at medical management.  The reviewing physician found that the Health Plan denial should be upheld.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for bronchial thermoplasty for treatment of the enrollees asthma.  Findings:  2/3 of the physician reviewers found that although, bronchial thermoplasty has been U.S. Food and Drug Administration (FDA) approved for the treatment of severe persistent asthma, based on the review of current peer-reviewed literature, the quality of literature available is poor in regards to objective evidence of therapeutic benefits, as well as long-term safety and efficacy.  The majority of literature available shows only modest improvement in quality of life and lower rates of asthma exacerbation. The literature fails to show evidence that bronchial thermoplasty provides significant benefits in asthma control scores. The majority of literature also supports that additional research is needed to provide a better understanding with regards to its long-term safety and benefits as compared to other treatment options, as well as to clarify the role that bronchial thermoplasty plays in the management of severe asthma.  In sum, the requested bronchial thermoplasty is not likely to be superior over other treatment alternatives in this patients case.  Final Result: 2/3 of the reviewers determined that the requested services are 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 internal medicine with sub-specialty certification in pulmonary disease 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 internal medicine with sub-specialty certification in pulmonary disease 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 internal medicine with sub-specialty certification in pulmonary disease 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 38-year-old female enrollee has requested radiofrequency lesioning of the sacroiliac joint nerves treatment of her chronic back pain.  Findings:  Two physician reviewers found that this patients records demonstrate clear SI mediated pain isolated to the left posterior SI joint and capsule. In the medical literature, Dreyfuss and colleagues concluded that L5 dorsal ramus block and S1-3 lateral branch blocks were successful at demonstrating diagnostically mediated pain of the SI complex. There is emerging literature that would support the safety and efficacy of RF ablation of the L5 primary dorsal ramus and S1-3 lateral branches as medically appropriate in this case (Cohen, et al. and Kapura, et al.). All of this patients objective findings on exam and interventional diagnostics indicate the SI joint is her pain generator. She has failed all standard therapies including PT, a home exercise program (HEP), medications, and cortisone injections. Given the length of pain duration and the patients level of disability due to the pain, the best option for long-term control of the pain is the requested RF ablation. Based upon the foregoing, I have concluded that the requested therapy is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.
Appeal type: Medical Necessity
Decision: Upheld

The patient is a 46-year-old male who was diagnosed with HIV in 1995. The patient has been taking antiretroviral medications since he was diagnosed. As a result the patient has developed lipodystrophy of the face, chest, neck, and back. The patient underwent liposuction of the chest, back, and neck areas in January 2004. A second procedure was performed in April 2004. The patient has requested authorization and coverage for a revisional procedure of the axillary and chest areas. The Health Plan has denied the patients request indicating that the requested procedure is cosmetic in nature and therefore, is not medically necessary.Lipodystrophy is well-known sequelae of antiretroviral therapy. The patient has undergone two suction-assisted liposuction procedures to address extensive fat accumulation in the neck, shoulder, back, and axilla. At the present time there are no functional deficits. Suction-assisted lipectomy of the body is a sculpting procedure with the stated goal of improving ones appearance. Irregularities may, and often do, result and are more common in conditions with extensive underlying pathologic change. In the case of this patient, he is disturbed by the results of the procedure in the axillary region. This represents a cosmetic deficit with no functional component. A functional result has been achieved. The previous procedures have resulted in a normal appearance to the extent possible. Further surgery would offer only limited improvement in the patients appearance.Cosmetically acceptable results cannot be guaranteed following reconstructive or cosmetic procedures. There will always be a less than perfect result following any surgical procedure. Scarring, unnatural feeling, and irregularities following liposuction are all examples of the downside of surgical intervention. Furthermore, the more pathologic the preexisting condition, the less likely a complete resolution will be achieved. In the present case, liposuction of significant fat accumulation resulted in residual fullness and skin excess following two procedures. Further surgery would only offer limited improvement and would require the excision of skin, which will result in axillary and thoracic scars. Based upon the information set forth above, I have determined that the requested procedure is not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the gene mutation test prothrombin G20210A (Factor II). Findings:  Three physician reviewers found that this testing is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. DVT and pulmonary embolism may be caused by hereditary thrombophilias. The increased risk is worth knowing, especially in situations of estrogen therapy, prolonged immobility such as surgery, long car trips, or long airplane flights. These complications may be prevented by appropriate interventions. There are also known interactions between drugs and other variables and gene mutations in Factor V or II. For example, there is a known interaction between estrogens and the Factor V mutation. There is extensive literature supporting the testing that was done in this case. The Factor V mutation, also known as Factor V Leiden, definitely has the potential to induce hypercoagulopathy if the right environment were provided, such as a long airplane flight or automobile trip as in this specific case. Colleagues have found that the Prothrombin G20210A mutation adds to this risk, such that compound heterozygous patients can have up to 20-fold increased odds of developing DVT. The prothrombin G20210A (Factor II) gene mutation test was medically appropriate and necessary, and would directly alter treatment or prevention recommendations. Therefore, the services in issue were likely to have been more beneficial than any available standard treatment for the patients medical condition.Final Result: The reviewers determined that the services in issue were 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, 2 and 3 are board certified in internal medicine, with subspecialty certification in hematology, and are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage of Epclusa tablet 400/100 mg at a quantity of one tablet daily for twelve weeks or treatment of the enrollees hepatitis C virus. 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 in all cases, regardless of fibrosis stage. In this patients case, there is imaging evidence of cirrhosis. Per the guidelines, Epclusa for 12 weeks is recommended as a first-line regimen for treatment naive genotype 3 patients. This is based on the ASTRAL-3 trial for Epclusa, which showed a high cure rate of 98%. AASLD/IDSA guidelines cite data showing reduced survival with delayed treatment. For these reasons, treatment is needed at this time, and the requested treatment with Epclusa tablet 400/100 mg at a quantity of one tablet for twelve weeks is supported as medically necessary for the treatment of this patients hepatitis C infection. 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: Overturned

Nature of Statutory Criteria/Case Summary: The patient has experienced weight regain after a Roux-en-Y gastric bypass. She has been in a supervised diet and weight loss program for one year.  The upper gastrointestinal series revealed significant findings. The patient has multiple obesity-related comorbidities, including hypertension, diabetes mellitus type 2, which is complicated by retinopathy, acid reflux, and obstructive sleep apnea. The patient has requested authorization and coverage for gastric bypass revision surgery.  The Health Plan has denied the request as not medically necessary for the treatment of the patients weight regain.In this case, the patient has a sufficient BMI to support a bariatric surgery such as Roux-en-Y gastric bypass, based on guidelines from the American Heart Association (AHA), American College of Cardiology (ACC), the Obesity Society and from the National Institutes of Health (Jensen, et al).  Additionally, this patient has anatomic defects confirmed with imaging, a dilated gastrojejunostomy and pouch, which can result in loss of restriction followed by weight regain.  A systematic review reports that indications for corrective procedures after gastric bypass include inadequate weight loss, weight regain, or recurrence of weight-related co-morbid conditions.This patient meets these criteria. The patient has a BMI over 40 kg/m2, for which primary surgery would be indicated to prevent obesity-related complications. She also has a recurrence of weight-related comorbidities and is at risk for multiple additional complications of weight regain in the future if weight regain is not reversed. Diet and lifestyle modifications have been attempted but has not resulted in sufficient weight loss to prevent obesity-related complications.  For these reasons, the request for revision of gastric bypass is supported as medically necessary for the treatment of this patients medical condition.Final Result: The reviewer determined that the requested surgery 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 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.