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

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the Afirma gene test. Findings:  Three physician reviewers found that the Afirma gene expression classifier test conducted was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The cytopathology of the thyroid nodule was consistent with AUS which carries a risk of malignancy of 5-15%. The American Thyroid Associations (ATA) guidelines state that for nodules with AUS/follicular lesion of undetermined significance (FLUS) cytology, after consideration of worrisome clinical and sonographic features, investigations such as repeat FNA or molecular testing may be used to supplement malignancy risk assessment in lieu of proceeding directly with a strategy of either surveillance or diagnostic surgery. The ATA guidelines also recommends taking the patients history, ultrasound appearance and other clinical factors in consideration. In this case, the nodule was worrisome, given the size of the nodule and the fact that it was cold in scan. If the genetic test is suspicious, the risk of malignancy increases to 40%. However, the risk of malignancy decreases to less than 6% with benign findings by genetic testing. Final Result: Three reviewers determined that the testing at issue was 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: All three physician reviewers are board certified in internal medicine with sub-specialty certification in endocrinology, diabetes and metabolism 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 reimbursement for spinal fusion surgery. In the medical literature, Resnick and colleagues recommend surgery for spinal stenosis for patients who do not improve with conservative treatment. Numerous studies have demonstrated the role of surgical decompression in this patient population. However, few studies have investigated the utility of fusion in patients without underlying instability. The inclusion of fusion is recommended for patients with demonstrated spinal instability or the likelihood of iatrogenic instability. In addition, Weinstein and colleagues reported on a clinical trial comparing the effectiveness of surgery for spinal stenosis to non-surgical treatment. The authors concluded that patients who underwent surgery showed significantly greater improvement in all primary outcomes than patients who were treated non-surgically. Similarly, Kovacs and colleagues concluded that decompressive surgery, with or without fusion, was more effective for patients with symptomatic lumbar spinal stenosis than continued conservative treatment following failure of three to six months of conservative treatment. This patient had a history of chronic low back radicular pain. She had failed extensive non-operative treatment including epidural, sacroiliac, and facet joint injections, as well as medications. Further care has included activity modification, physical therapy, and a home exercise program. She presented to the emergency department after sustaining a fall at home due to severe low back pain and lower extremity weakness. Clinical examination findings documented motor and sensory deficits consistent with reported imaging evidence of L4-5 herniated nucleus pulposus, lateral recess stenosis, and facet joint hypertrophy. There was reported radiographic evidence of spondylolisthesis at the L4-5 level with 5 mm of spinal segmental instability on flexion and extension x-rays. Given the severity of the patients pain and worsening lower extremity neurologic signs, surgical intervention consisting of L4-5 decompression and fusion with instrumentation was indicated. Based on review of the medical records and consistent with evidence-based medical criteria, the L4-5 decompression and fusion was medically necessary for treatment of this patients medical condition. Final Result: The reviewer determined that the service at issue was 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: Overturned

The patient has requested authorization and coverage for facial feminization surgeries (CPT codes: 21138, 21139, 67900, 20680, 21121, 15828, 15839, and 21209). Facial feminization surgery is medically necessary for many transgender women to help alleviate the psychological distress they experience related to gender dysphoria. Moreover, the World Professional Association for Transgender Health (WPATH) supports facial feminization surgery in well-selected patients. WPATH noted that non-genital surgical procedures are oftentimes of greater practical significance in the patients daily life than reconstruction of the genitals. The guidelines further report that, these reconstructive procedures are not optional in any meaningful sense, but are understood to be medically necessary for the treatment of the diagnosed condition. The physician reviewer found that this patient meets the WPATH criteria for gender dysphoria and indication for facial feminization surgery based upon clinical documentation of persistent gender dysphoria related to the presence of masculine facial features. The providers noted that the patients distress related to her masculine features is likely to be alleviated with the requested facial feminization surgeries. She has already undergone vaginoplasty and feminizing mammoplasty. All told, the requested facial feminization surgeries (CPT codes: 21138, 21139, 67900, 20680, 21121, 15828, 15839, and 21209) are medically necessary for 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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for speech therapy services.According to the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), autism spectrum disorder (ASD) is characterized by deficits in social communication, social interaction, and restricted and repetitive patterns of behavior or interests. Depending upon the severity level, individuals with ASD may have deficits in verbal and nonverbal communication. According to the American Speech-Language-Hearing Association (ASHA), it is important to accurately diagnose and address co-morbid speech sound disorders, in addition to addressing the language and communication difficulties associated with ASD. The ASHA state that in the case of ASD, social communication impairment is a core feature and that a diagnosis of ASD therefore indicates the inclusion of communication services. The ASHA notes that individuals with ASD can continue to develop communication abilities across their lifespan. They also note that when determining the language of treatment for an individual with ASD, speech language pathologists (SLP) should carefully consider the individual's linguistic environments. Treatment is provided either by a bilingual SLP or through the use of trained interpreters, when necessary.In this case, the patient has autism spectrum disorder. Although he was not found to have stuttering or dysfluencies during his speech therapy evaluation, the patient was noted to have speech and language deficits characteristic of autism. According to the AHSA guidelines, it is important to address language and communication difficulties associated with ASD and a diagnosis of ASD indicates the inclusion of communication services. In addition, the patient is not too old to benefit from communication services, as individuals with ASD can develop communications abilities regardless of age. Finally, in accordance with AHSA guidelines regarding cultural and linguistic factors, it is important to address the family's preference in considering the choice of a specialist who is fluent in their language. Accordingly, the requested speech therapy services are medically necessary to treat the patient's medical condition.Final Result: The reviewer determined that the requested services are medically necessary to treat the patient's medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer 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: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for a prenatal test. Findings:  Three physician reviewers found that the submitted documentation supports the superior efficacy of a portion of the services at issue. The screening with NIPT for the aneuploidies trisomy 13, 18 and 21, which are indicated for advanced maternal age, were supported in this clinical setting due to this patients age. However, the screening for the 22Q11.2 microdeletion involves a rare disorder, and unlike the screening for aneuploidies trisomy 13, 18 and 21, there is a lack current guidelines that would support screening for the 22Q11.2 microdeletion with NIPT. Most of the professional societies recommend against offering microdeletion/duplication syndrome testing as part of routine screening. In sum, the NIPT screening for the aneuploidies trisomy 13, 18 and 21 of the prenatal test performed on 9/15/17 was likely to have been superior over other modalities of evaluating this patient. However, the portion of the test with regards to fetal sex and chromosomal microdeletions was not likely to have been superior to the current standard forms of evaluating this patients medical condition. Final Result: 3 of 3 reviewers determined that a portion of the services at issue was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be partially overturned. Credentials/Qualifications: All three physician reviewers are board certified in obstetrics and gynecology 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: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for lipedema liposuction for treatment of the her lipedema. The physician reviewer found that this enrollee has a diagnosis of lipedema, which is an abnormal enlargement of the extremities. This should be considered a developmental abnormality, as this appears to have begun at an early age. However, the requested surgery is not likely to improve function, as this appears to have already failed to provide improvement with her surgery in 2015. Further, the submitted medical documentation and photographs do not clearly document the surgery will create a normal appearance to the extent possible or provide more than a minimal improvement in the patients appearance. Final Result: The reviewer determined that the requested services are not medically necessary for treatment of the patients medical condition and are not reconstructive in nature. 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.
Appeal type: Medical Necessity
Decision: Overturned

The patient is an eight-year-old female who was adopted from Russia. While in Russia, she received speech therapy for a language delay in her primary language. The patient moved to the United States and began learning a new language. She was subsequently diagnosed with a receptive and expressive language delay. She was also noted to be bright, cooperative and interested in learning. The patient began receiving speech therapy services. The Health Plan denied coverage for speech therapy services as of 5/3/04 on the basis the services at issue were not medically necessary for treatment of the patients condition.The patient has a complicated history with language delays in both her primary (Russian) and secondary (English) languages. Services to improve speech were not covered from 5/3/04 through 12/13/04. Multiple evaluations and treatment plans indicate speech therapy was indicated. The patient required the skills of a qualified speech therapist. Furthermore, there was a reasonable expectation of achieving measurable significant functional improvement with continued therapy. Given the patients history and the findings of her therapist, I have determined the therapy at issue was medically necessary for treatment of the patients medical condition. The Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary:  An enrollee has requested a power wheelchair for treatment of her mild degenerative disease in the bilateral hip joints status post bilateral hip arthroplasty, bilateral knee pain, and back pain.  The physician review found that the Centers for Medicare and Medicaid Services (CMS) guidelines for the use of powered mobility devices states that these devices should be reserved for patients that are unable to use a walker or manual wheelchair safely. This patient has normal strength, well situated knee replacements and no spinal instability. In addition, she is capable of using a walker. The current medical literature also describes the benefit of walking and mobility for patients with chronic low back pain. In the absence of any significant physical findings explaining the need for a powered mobility device, exercise and walking are beneficial to chronic pain patients. Consistent with these findings, the requested power wheelchair is not supported as medically necessary for treatment of this patients medical condition. Final Result: The reviewer determined that the requested device 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 physical medicine and rehabilitation 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

A 48-year-old male has requested coverage for a past stay and a continued stay for post-acute inpatient rehabilitation for treatment of his medical condition.  Findings:  The physician reviewer found that based on review of the available records, the patient sustained a brain injury from brain abscess and surgical treatment, with significant neurologic residuals including mobility, self-care, safety, and judgment. However, the record does not show significant medical instability or behavioral issues that make outpatient rehabilitation unsafe. The standard care for patients with post-traumatic memory, judgment, and cognitive impairments includes multi-disciplinary therapies, including occupational therapy, speech therapy, and physical therapy as appropriate, to facilitate safety and recovery to an optimal level of independence. Appropriate level of care varies per patient, and needs to address safety, level of in-home support, and strategies for community integration. These services can be provided as an outpatient at the day treatment level. Literature shows that with intensive therapies, rate of recovery may be more rapid, but does not show that ultimate degree of recovery is improved. In addition, there is lack of evidence that overall inpatient or outpatient care is preferable in facilitating recovery after brain injury. Thus, with appropriate supervision, and in the absence of significant behavioral or mobility issues that would make outpatient rehabilitation unsafe, the patient should be considered for a day treatment program as an outpatient.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a six-year-old male has requested speech therapy services for the treatment of the enrollees congenital muscular dystrophy, dysarthria and mental delay. Findings:  The physician reviewer found that because the patients oral-motor speech disorder (dysarthria) is due to his congenital disorder, treatment for the speech disorder should be considered medically necessary. It appears that the private speech-language pathology services being provided have different goals than those provided under his school-based Individualized Educational Plan. The private therapy emphasizes oral-motor skills in its goals, and is showing greater results in this domain than school-based therapy, which successfully emphasizes functional augmentative communication strategies. The private therapy is also addressing saliva management, which will have a medical impact (e.g., helping to minimize the risk of aspiration, facial skin irritation, etc.). Thus, these therapies complement each other. The records demonstrate that private speech therapy has been and continues to be a medically necessary intervention based on the patients medical condition. The therapy should be continued at a frequency of two hourly sessions per week. The patient should be re-evaluated in six months to determine if continued therapy is indicated at that time.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary:   The parent of an enrollee has requested an adaptive feeding chair (Rifton activity chair) for treatment of the enrollees medical condition.  The physician reviewer found that the current medical evidence supports the requested equipment in this clinical setting.  This patient requires specialized equipment in order to participate in activities of daily living while minimizing risk of complications.  Since she is unable to sit independently, she must have a seating device that provides necessary trunk, head, and foot support.  The harness must be adequate to prevent injury should she experience a seizure.  The use of a tray allows for hand positioning as well as additional trunk support should she fall forward.  Finally, the support provided by the chair improves her feeding positioning by supporting her head, neck, and torso.  Functional mobility is medically necessary to maximize her developmental potential.  All told, the requested adaptive feeding chair (Rifton activity chair) is medically indicated for the treatment of this patient.   Final Result: The reviewer determined that the requested equipment 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 pediatrics with sub-specialty certification in pediatric critical care 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: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for implantation of the Bioness StimRouter System. Occipital neuralgia is a condition characterized by frequent and severe headaches with paroxysmal stabbing pain in the distribution of the greater or lesser occipital nerves. The pain is located in the occipital area and may spread. The treatment plan for occipital neuralgia depends upon many factors, such as the severity of the dysfunction and pain, the type and location of the pain, as well as ongoing medical conditions and ability to tolerate other medical therapies. Standard treatment may include medications to relieve pain and muscle spasms, localized injections, physical therapy, or massage. Over time, data has accumulated to support use of neuromodulation of the distal branches of C2-3 to treat refractory headache disorders. This is accomplished via implantation of subcutaneous electrodes to stimulate peripheral nerves in the occipital region. Although there is a lack of prospective clinical trials showing the safety and effectiveness, researchers concluded that occipital nerve stimulation is likely to be safe and effcicacious treatment for highly intractable chronic migraine patients even afterfollow-up of a median of over three years. This patient has failed treatment with lidocaine drip, mexiletine, gabapentin, nortriptyline, and lidocaine patches. Furthermore, the provider reports the patient experienced an excellent response to stimulation therapy for left occipital neuralgia. Given this support, the requested implantation of the Bioness StimRouter System is likely to be more beneficial for treatment of this patients occipital neuralgia than standard therapies. One reviewer found that the requested implantation of the Bioness StimRouter System is likely to be more beneficial for treatment of this patients medical condition than standard therapies. 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 neurological surgery and is actively practicing. One Reviewer is board certified in neurological surgery and is actively practicing.  One Reviewer is board certified in neurological surgery 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.