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

An enrollee has requested reimbursement for lower left extremity sclerotherapy and right lower extremity sclerotherapy.The submitted documentation does not support that the services at issue were medically necessary. Lower extremity sclerotherapy is medically necessary for patients with documented lifestyle limiting pain or discomfort due to enlarged veins of the lower extremity. Typically, veins would be 3 or 4 mm in diameter, or greater. In addition, there should be documentation that truncal vein reflux (such as in the greater saphenous vein) was either successfully treated, treated at the same time, or non-present. There should be documentation of an absence of deep venous obstruction and documentation of satisfactory arterial perfusion. Documentation of failed concerted efforts of a conservative, non-interventional approach would also support medical necessity. In this case, office visit notes indicate that the patient presented with bilateral varicose veins that were asymptomatic. The patient denied significant swelling, night cramping, a history of dermatitis, a history of stasis ulcer, and episodes of superficial thrombophlebitis. Records indicate that the patient had cosmetic varicose veins for which cosmetic sclerotherapy was planned. The services at issue were not performed to treat pain or dysfunction. Under these circumstances, lower left extremity sclerotherapy and right lower extremity sclerotherapy were not medically necessary to treat the patients medical condition.Final Result: The reviewer determined that the services at issue were not medically necessary to treat the patients medical condition. The reviewer also determined that the patients varicose veins did not constitute an abnormal structure of the body and that the services at issue were thus not reconstructive in nature. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is board certified in general surgery and 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: Medical Necessity
Decision: Upheld

A 45-year-old male enrollee has requested a Dynasplint for the treatment of his knee condition. Findings:  The physician reviewer found that at this late date (10 months post-op) one would not expect any form of Dynasplint to make a difference. It must be realized that these are normally used within the first 1 to 3 months postoperatively.  Furthermore, it appears that the patient had achieved within 2 degrees of terminal extension as a result of physical therapy. Further improvement would not be expected with the use of a dynamic splint.
Appeal type: Medical Necessity
Decision: Upheld

A 51-year-old female enrollee requested magnetic resonance imaging (MRI) of the neck spine and chest spine and physical therapy for medical evaluation and medical treatment of her medical condition.  Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested services in this patients case.  There are no documented red flags on history or examination that necessitate advanced imaging modalities.  There are no documented differential diagnoses or issues in the clinical management plan which would require the requested MRIs.  There are no indications that conservative care could not continue without the requested imaging.    There are no documented impairments or functional deficits that would be amenable to therapy, and there are no documented goals of therapy.  All told, the requested MRI of the neck spine and chest spine and physical therapy are not medically necessary for the evaluation and treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary:   An enrollee has requested inpatient hospitalization for treatment of his behavioral health condition.   Findings: The physician reviewer found that although inpatient care was initially indicated, the medical record does not support the medical necessity of subsequent inpatient hospitalization. The patient had a positive marital session; he was neither suicidal nor homicidal. The patient was tolerating his medications, one of which was reduced. The patient remained free of suicidal ideation and continued to improve. His affect was bright. His family was actively involved in his treatment. The patient was receptive to continuing his treatment in a less restrictive setting. In sum, the patient remained symptomatic and in need of ongoing specialty care. However, the record indicates that the acute psychiatric syndrome which prompted admission initially had resolved at this point and the services at issue were not medically necessary for treatment of the patients behavioral health condition. Final Result: The reviewer determined that the services at issue were 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 and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

The patient is a 42-year-old female status post gastric bypass surgery and weight loss of over 100 pounds. She underwent an abdominoplasty and hernia repair in January 2004. The patient has requested approval for a bilateral thigh lift and a lipectomy. At issue is whether the requested procedures are medically necessary for treatment of the patients medical condition.The submitted photographs document a well-healed abdominoplasty scar and saddlebag deformity of regional lipodystrophy. The submitted medical records document no evidence of intertrigo, rashes or ulcer in the thigh area. Thus, there is no evidence of any functional impairment. Based upon the clinical information provided, bilateral thigh lift and lipectomy are cosmetic in nature. Therefore, I have determined that the requested procedures are not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld

The parent of a 10-year-old male enrollee has requested Increlex for the treatment of the enrollees idiopathic short stature. Findings:  The physician reviewer found that while the patient presents as a case of delayed puberty, the adult height prediction given by the endocrinologist falls well below the cut-off limit set by the FDA to justify GH therapy for idiopathic short stature. However, the FDA has not made any guidance about the use of Increlex for idiopathic short stature. The endocrinologists diagnosis of IGF-1 deficiency is presumed to imply a GH insensitivity state, inferred from the patients lack of positive response. If so, it would appear unlikely that he has the Laron phenotype, but rather would have a partial GH insensitivity state. If so, I could only find reference to a peak GH level of 5.1 after L-dopa in the materials provided, a level which is barely in the normal range and certainly not elevated as would be expected in GH insensitivity. Further, the initial IGF-1 was not deficient. The medical literature indicates that the definition of partial GH insensitivity remains to be established, and thus, IGF-1 therapy in this instance remains of unproven efficacy until appropriate studies have been completed. In the absence of evidence demonstrating the basis for the patients adult height prediction of less than 62 and documented evidence that the patients height continues to remain well below 64, the medical necessity of Increlex is not established.
Appeal type: Experimental/Investigational
Decision: Upheld

The parent of a 16-year-old male enrollee has requested genetic testing for hereditary hypertrophic cardiomyopathy for evaluation of the enrollees medical condition.  Findings:  Two physician reviewers found that there are 14 known genes that can cause familial hypertrophic cardiomyopathy (FHCM), and testing is available for 12 of them. Two genes, MYH7 and MYBPC3, account for 80% of FHCM, and 2 genes, TNNT2 and TNNI3, account for an additional 10% of cases.  Genetic testing in the setting of FHCM is medically indicated and appropriate in select patients to assist in identifying presymptomatic individuals who can be monitored closely to prevent tragic outcomes, such as sudden death, and to identify unaffected individuals who will not require annual screening to monitor for this condition. However, testing of a patient such as this patient, whose affected status has not been clarified, is not indicated.  A negative result in this situation would not be informative because one would not be able to interpret negative results definitively, as negative testing could result from either true unaffected status, or because the gene in the family cannot be identified by the current testing.  In the latter scenario, negative testing might falsely reassure the patient.  The standard of care in this setting is to perform testing on a clinically affected individual, such as the one living affected individual who has a pacemaker/defibrillator. If the mutation is identified in that individual, then testing for that specific mutation in at-risk family members is appropriate, after the patient has had sufficient counseling to understand the risks and benefits of testing.  Given that a mutation has not been identified in one of the patients family members, the patient is not currently an appropriate candidate for the requested genetic testing.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a four-year-old male enrollee has requested coverage for applied behavioral analysis (ABA) therapy. The Health Plan has denied this request indicating that the requested therapy is not medically necessary for treatment of the enrollees autism.  Findings:  The physician reviewer found that Applied behavioral analysis (ABA) has been shown to be effective in treating behaviors associated with autism spectrum disorder (Rogers and Vismara). Treatments based on operant principles of learning are more effective for reducing maladaptive behaviors than alternative treatments. Warren and colleagues reviewed 34 studies of early intervention in autism. The authors concluded that studies of Lovaas-based approaches and early intensive behavioral intervention variants and the Early Start Denver Model resulted in some improvement in cognitive performance, language skills, and adaptive behavior skills. Additional studies have shown that ABA methods continue to result in positive outcomes in patients with autism and intellectual disability (Granpeesheh, et al). Evidence-based studies also noted improvement of function in older children with autism spectrum disorders using intense ABA interventions (Sallows and Graupner). The goals for older children often are to identify and remediate particular deficits. This patients behaviors include non-compliance, social skills deficits, and tantrums occurring on a daily basis. The review supports the autism spectrum diagnosis. Consistent with these findings, the requested ABA therapy is medically necessary for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned

The patient is a 44-year-old male who underwent ACL reconstruction in December 2004. Following surgery he was prescribed a continuous passive motion (CPM) machine, which he used for nine days. The patient paid out of pocket, and is now requesting reimbursement for the CPM device and related accessories. The Health Plan has denied this request based upon their determination that the equipment at issue was not medically necessary.The use of the CPM device aids in regaining motion following surgery. CPM therapy is beneficial to the healing and rehabilitation processes. Many surgeons prescribe the CPM machine for their patients postoperatively and such prescriptions are consistent with the surgical communitys standard of care. The use of the CPM device was medically appropriate and indicated in this clinical setting. Therefore, I have determined the equipment 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 authorization and coverage for water-assisted liposuction (WAL) surgery. Findings:  The physician reviewer found that the requested WAL surgery is not medically necessary for treatment of the patients medical condition. In general, the diagnosis of lipedema is based on clinical features. Symmetrical edema in the lower limbs with fatty deposits located to the hips and thighs usually appears at puberty. Main disorders considered for differential diagnosis are lymphedema, obesity, lipo-hypertrophy and phlebedema. Treatment protocols comprise of conservative therapy and surgical approaches. Lipedema is a condition in which excessive adipose tissue is deposited in a symmetrical pattern in the legs. It most commonly affects women, and, unlike almost all other causes of lower leg enlargement, lipedema spares the feet. However, there is limited data in the peer-reviewed literature supporting WAL surgery for the treatment of lipedema. In addition, there is concern for risk of venous thromboembolism given the patients history of DVT, BMI and Factor V Leiden. For the reasons provided, the requested surgery 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 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: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for balloon dilation Eustachian tuboplasty. Eustachian tube dysfunction (ETD) is a disorder for which there are limited medical and surgical treatments. Data suggests that Eustachian tube balloon dilation is one potential intervention, which may have a positive effect on objective and subjective indicators for chronic dilatory ETD in adult patients (Satmis and van der Torn). A prospective, multicenter, randomized, controlled study demonstrated superiority of balloon dilation of the Eustachian tube with balloon catheter and medical management compared to medical management alone to treat dilatory ETD in adults. However, there is insufficient evidence in the peer-reviewed literature demonstrating the long-term safety and efficacy of this procedure. Therefore, the requested Eustachian tube dilation is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Findings:  Three physician reviewers found the requested Eustachian tube dilation is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the requested Eustachian tube dilation is 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 reviewers 1, 2 and 3 are board certified in otolaryngology 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: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for advanced lipoprotein testing, procedure codes 81240, 81291, 82172, and 83698. Findings:  Three physician reviewers found that, in this circumstance, guidelines for the management of cardiac risk and dyslipidemia have been established. These guidelines currently do not recommend routine performance of specialized tests in the context of assessing coronary risk including lipoprotein-associated phospholipase A2 (Lp-PLA2), sub-classifications of low density lipoprotein (LDL), high density lipoprotein (HDL) subclasses, lipoprotein (a), insulin, fibrinogen, genetic testing and homocysteine. Treatment change based on the results of screening with these specialized tests has not been shown to improve cardiac outcome incremental to that achievable by treatment based on standard risk factor profiling and basic lipid analysis. Even though results of some of these specialized tests may be abnormal and considered independent risk markers for coronary disease, there is a lack of controlled trials that demonstrate outcome benefits by treating routinely obtained abnormal results. Moreover, the services at issue are not standard for screening for cardiovascular or thromboembolic risk in this clinical situation. Therefore, the advanced lipoprotein testing, procedure codes 81240, 81291, 82172, and 83698 performed was not likely to have been more effective than any other available standard modality for the evaluation of this patients medical condition. Final Result: 3 of 3 reviewers determined that the services at issue were not likely to have been 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 physician reviewers are board certified in internal medicine with sub-specialty certification in cardiovascular disease 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: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested retroactive authorization and coverage for Afirma gene testing for evaluation of the enrollees thyroid nodule. Findings: Three physician reviewers found that while a fine needle aspiration biopsy of a suspicious thyroid nodule is typically an accurate means of assessing whether the nodule is benign or malignant, approximately 15% of fine needle aspiration biopsy results are considered to be indeterminate.  Until recently, the only way to establish whether the nodule was thyroid cancer was via surgical excision, even though the majority of the cases turn out to be benign.  Afirma gene testing utilizes a gene expression classifier in order to help determine the likelihood of malignancy of nodules with indeterminate cytology on fine needle aspiration biopsy, thereby decreasing the need for unnecessary surgeries.  Because it is very sensitive and has a high negative predictive value, a negative Afirma result is rather suggestive of a benign nodule and can therefore preclude such surgical procedures.  All told, Afirma gene testing was likely to have been superior over other methods of evaluating this patient.Final Result: 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: 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: The patient has requested authorization and coverage for Nurtec 75 mg tablet every other day. Calcitonin generelated peptide (CGRP) monoclonal antibodies are biologic agents that have demonstrated efficacy, safety, and tolerability for the preventive treatment of episodic and chronic migraine in phase 2 and phase 3 randomized, placebocontrolled trials. Per the American Headache Society (AHS), this patient meets the criteria for treatment with a CGRP monoclonal antibody medication. In 2020, the U.S. Food and Drug Administration (FDA) approved Nurtec, an orally administered CGRP receptor antagonist, for the acute treatment of migraine with or without aura in adults and preventive treatment of episodic migraine in adults. The FDA approved Nurtec based on results of a randomized, double-blind, placebo-controlled trial published by Croop and colleagues. The authors noted that when taken every other day, Nurtec was effective for the preventive treatment of migraine. In this case, the patient has a history of migraines that have not responded to multiple preventative medications. The patients provider has recommended treatment with Nurtec, which is an alternative treatment approved by the FDA for the prevention of migraines in adults. Given this support, the requested Nurtec 75 mg tablet every other day is medically necessary for 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 neurology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

The patient is a 17-year-old female who, while being investigated for abdominal pain, was discovered to have an incidental hepatic mass. The hepatic mass is not thought to be related to the patients presenting symptoms. Further evaluation of the mass suggests the likely diagnosis is a focal nodular hyperplasia (FNH) tumor. The patients treating providers have suggested that the appropriate management strategy includes re-imaging the tumor in six months and defer a decision on biopsy or surgery until that time. The patient and the patients mother want to proceed with surgery immediately. The appropriate management of suspected FNH such as this tumor is watchful waiting unless there is evidence this patients tumor FNH is related to the patients symptoms. There is no evidence the tumor in this matter is related to the patients symptoms. Therefore, removal of the tumor is not indicated at this time because of the potential that biopsy or surgery would cause the patient more harm than good. Because there is greater risk than benefit to biopsy or surgery at this time, the requested procedure is not medically necessary and is, in fact, contraindicated. The Health Plans recommendation for re-imaging in six months is appropriate and standard of care.Based upon the information set forth above, I have determined the requested procedure is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.