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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for transoral incisionless fundoplication (TIF). The efficacy of TIF has been studied in randomized controlled trials. However, the conclusions are inconsistent. In addition, the American College of Gastroenterology guidelines for treatment of gastroesophageal reflux disease (GERD) report that the usage of current endoscopic therapy or TIF cannot be recommended as an alternative to medical or traditional surgical therapy. In 2013, the Society of American Gastrointestinal and Endoscopic Surgeons reported that numerous published series have reported significant adverse events and that there is a lack of sham-controlled trials comparing TIF with anti-reflux surgery. Furthermore, there is a lack of data supporting the long-term safety and efficacy of endoscopic procedures for GERD in patients with complicated GERD, which is defined to include patients with Barretts esophagus. This patient is noted to have Barretts esophagus, which has not been shown to benefit with the TIF procedure over standard therapies. All told, the requested TIF procedure utilizing the EsophyX device (CPT code 43210) 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 TIF procedure utilizing the EsophyX device (CPT code 43210) is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. For these reasons, the Health Plans denial should be upheld. Final Result: The reviewers determined that the requested TIF procedure utilizing the EsophyX device (CPT code 43210) is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Credentials/Qualifications: Physician reviewers 1, 2 and 3 are board certified in gastroenterology 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 OxyContin 20 mg tablets, quantity of 120 tablets per month for treatment of the enrollees systemic lupus erythematosus. Findings:  The physician reviewer found that the requested OxyContin 20 mg tablets, quantity of 120 tablets per month is not medically necessary for treatment of this patients medical condition. The current standard of care for chronic pain associated with disc herniation is treatment in a multidisciplinary practice to include physical therapy, massage therapy, behavioral therapy, and injections to help reduce pain. There are a variety of anti-convulsants and anti-depressants considered adjunctive to this therapy. Long-term opioids are associated with a high risk of dependence and tolerance. Therefore, long-term administration is not recommended. Researchers reported that high dose and short acting opiates might contribute to pain sensitization via opioid-induced hyperalgesia, decreasing patient pain threshold and potentially masking resolution of a preexisting pain condition. In this retrospective study, the majority of patients undergoing detoxification of high dose opiates for chronic pain reported a significant decrease in pain at the end of the study, further supporting the theory of opioid-induced hyperalgesia.  Final Result: The reviewer determined that the requested medication quantity 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 anesthesiology with sub-specialty certification in pain 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: Overturned

Nature of Statutory Criteria/Case Summary:The patient has requested authorization and coverage for acupuncture. In investigating the efficacy of acupuncture for acute migraine attacks, the researchers found the results suggested acupuncture was effective in relieving pain and reducing the usage of acute medication. Researcher noted, Acupuncture seems to be at least as effective as conventional drug preventative therapy for migraine and is safe, long lasting, and cost-effective. It is a complex intervention that may prompt lifestyle changes that could be valuable in patients recovery. In this case, the patient continues to be symptomatic, with migraines episodes on a weekly basis, and is non-responsive to medication. Given that current medical literature suggests acupuncture is safe and effective for migraine prevention and for pain management, the requested services are medically indicated for this patient. Therefore, acupuncture is medically necessary for the 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.Credentials/Qualifications: The reviewer is board certified in oriental 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

A 53-year-old female enrollee has requested a brow lift for treatment of her brow ptosis. Findings:  The physician reviewer found that no fully automated peripheral field studies (with eyelids taped and with eyelids untaped) have been provided for review. Given the lack of testing performed to determine whether the patients issue is eyelid ptosis, brow ptosis or another condition, her diagnosis is unclear. The Health Plan states the patients excess skin laterally is outside the eyelid boundary and would not cause visual encroachment. Visual field studies could determine whether or not this is the case. Lacking these diagnostic studies, a brow lift is not medically necessary. Additionally, based on the photographic evidence provided, the patients condition appears to be consistent with the natural aging process and does not constitute an abnormal structure of the body.
Appeal type: Medical Necessity
Decision: Upheld

An 18-year-old female enrollee has requested breast augmentation with implants for treatment of her hypomastia. Findings:  The physician reviewer found that the submitted evidence does not establish that the patients breast condition is related to a chromosome 14 anomaly. Nor is there significant scientific literature supporting this contention. Based on the documentation provided, the patients breasts are normal and very small given the visible breast buds, normal nipple areola complexes and presence of pectoralis major muscles. There is no evidence of Polands syndrome, which would be classified as abnormal if present. The report from a genetics evaluation found that the patients lack of breast development represented a birth defect, yet the geneticist did not examine the patients breasts. Further, although the geneticist found a chromosomal abnormality with respect to the long arm of chromosome 14, he stated that the significance of this is totally unclear at this point. While the patients mother is concerned that complete lack of anatomical maturity of the breasts will alter the ability of the breasts to function as a sensual organ and will interfere with breastfeeding, these issues will not be corrected with the insertion of breast implants. All told, the documentation does not support the presence of an abnormal structure of the body in the patient caused by congenital defect, developmental abnormality, infection, trauma, tumor or disease. There is insufficient evidence that the patients condition is related to a congenital or developmental abnormality. Further, the tissue deficit is not so great so as to be considered abnormal. Thus, the patient does not meet the criteria of the reconstructive surgery statute. Moreover, there is no evidence that the patients condition results in a functional impairment for which breast augmentation would be considered medically necessary.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested authorization and coverage for Norditropin FlexPro. The records provided for review document that this patient has been receiving growth hormone (GH) therapy for diagnosed GH deficiency. The patients epiphyses remain open. In addition, the patients growth velocity is greater than two cm per year. Further, the patient has not yet reached their mid-parental target height. Thus, it is medically necessary to continue GH therapy at pediatric doses for treatment of GH deficiency.  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 pediatrics with sub-specialty 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: Medical Necessity
Decision: Overturned

The enrollee is requesting authorization and coverage for medication Emtricitabine-Tenofovir Alafenamide (Descovy). The enrollee has a medical history of diabetes mellitus and high cholesterol. The enrollee indicates he would like to take advantage of an alternative from his current medication with a better safety profile, especially in maintaining healthier kidney functions. A governmental body approved Descovy for use as a pre-exposure prophylactic medication for the prevention of human immunodeficiency virus infection. A study showed both agents were effective in reducing the likelihood of human immunodeficiency virus infection. Final Result: The reviewer determined that the requested service is medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The physician reviewer is board certified in internal 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 similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

A 50-year-old female enrollee has requested percutaneous skeletal fixation of tarsometatarsal joint dislocation for treatment of her plantar calcaneal spur. Findings:  The physician reviewer found that review of the submitted documentation and relevant literature fails to demonstrate the medical necessity of the requested services. The medical records show that the radiology report does not confirm the diagnosis of fracture, subluxation or dislocation. Skeletal fixation is indicated for fracture and manipulation is indicated for a displaced fracture or subluxation of the joint, which there are no radiographic findings for. Based on the documentation submitted for review and the peer-reviewed literature cited above, the requested services are not medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld

A forty-one year old female who has had difficulties with her right leg is requesting authorization and coverage for surgical intervention.Reviewers Findings:  The reviewing physician found that there are no clinical indications for surgical intervention.  The reviewing physician found that the Health Plan denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for anesthesia services provided during a colonoscopy for treatment of the enrollee, who underwent a screening evaluation of the colon. Findings:  The physician reviewer found that the submitted documentation supports the medical necessity of the services at issue.  The Health Plan noted that MAC was not medically necessary because the provider performing the endoscopy could have injected a short acting pain medicine and short acting sedative.  Propofol is a short acting sedative anesthetic. The onset of action is dose dependent and on average is 30 seconds. The duration of action lasts 3 to 10 minutes depending on the dose. The administration of propofol necessitates a practitioner qualified to rescue the patient should they enter a state of general anesthesia. The determination of medical necessity of MAC should take into consideration many aspects of care including, but not limited to, the patients ASA classification. The selection and appropriate amount of sedation and/or anesthesia required for colonoscopy is not one size fits all. There is sufficient support for MAC in this clinical setting.  All told, anesthesia services provided during a colonoscopy were medically necessary for the 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 anesthesiology 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 a 53-year-old female with recurrent diverticulitis. She is currently a candidate for sigmoid colectomy due to her recurring symptoms. The patients provider has recommended a laparoscopic sigmoid colectomy rather than an open colectomy. The Health Plan indicates a laparoscopic sigmoid colectomy is not medically necessary for treatment of the patients medical condition.Analysis and Findings:Current literature documents the safety and efficacy of laparoscopic surgery for a variety of colorectal disorders. The laparoscopic approach is the standard of care for patients such as this patient. There is substantial data showing laparoscopic colectomy results in shorter hospital stays and decreased complications. Thus, a laparoscopic colectomy is an acceptable and preferred alternative to a standard open colectomy. Therefore, I have determined that the requested procedure is medically necessary for the 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: The parent of an enrollee has requested Genotropin for treatment of the enrollees medical condition. Findings: The physician reviewer found that this patient's growth factors are normal for early puberty, and his provocative growth hormone testing revealed a normal peak growth hormone response.  Thus, he does not have classic growth hormone deficiency.  In the setting of his underweight status and chronic cardiac disease, the patient cannot be classified as having idiopathic short stature.  Longitudinal growth data prior to the age of 14 are not provided.  Thus, it is difficult to determine to what extent that the patients underlying cardiac disease and treatment affected his growth velocity.  The safety and efficacy of growth hormone therapy in a patient with dilated cardiomyopathy and arrhythmia requiring a pacemaker has not been studied in children.  All told, the requested Genotropin is not medically indicated 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-specialty 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 33-year-old female enrollee has requested Botox injections and prospective future Botox injections for treatment of her chronic migraines.  Findings:  Two physician reviewers found that in the past, the patients headaches have been quite disruptive to her life.  She has tried Advil, Vicodin, Elavil and Imitrex for her headaches, with minimal relief.  More recently, she has tried a course of Botox with documented substantial improvement in the number of her headaches.  Her headache specialist has recommended the continued use of this therapy. Although Botox is not a first-line therapy for chronic headache disorders, there is adequate literature supporting the use of Botox for refractory headaches. In this particular case, the patient has failed several first-line therapies for headaches.  In addition, she had a documented response to a prior trial of Botox.  In this clinical scenario, Botox injections were and are likely to be the most beneficial treatment option.
Appeal type: Medical Necessity
Decision: Upheld

An enrollee has requested authorization and coverage for five dental implants. The patient has a history of myofascial pain and headaches. The records document missing premolar teeth. The submitted records do not demonstrate a causal relationship between the missing teeth and the pain described, as the literature describes multiple factors which may lead to temporomandibular joint pain and myofascial pain. Although the patients provider recommended dental implants to stabilize the patients occlusion, the orthodontic treatment the patient previously received would have been reasonably expected to stabilize the occlusion and did not result in relief of the symptoms. As stabilizing the patients occlusion orthodontically has failed to correct the reported myofascial pain, there is a lack of evidence that dental implants would more effectively address the chief complaint of myofascial pain. There is a lack of support for the requested services in this clinical setting. Therefore, the requested five dental implants are not medically necessary for the treatment of this patient. 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 dentistry 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 requested authorization and coverage for donut lift of left breast and reduction and full lift of the right breast, and placement of breast implants four to six months after the first surgery. Ellart and colleagues report that tuberous breast deformity is a breast anomaly with different clinical signs. The most consistent sign is the constricting ring at the base of the breast with frequently associated breast asymmetry. There is also deficiency in the horizontal and/or vertical dimensions of the breast and often herniation of breast parenchyma toward the nipple-areola complex with areola enlargement. This patient presents with marked breast asymmetry with bilateral tuberous breast deformity. No functional problems are documented as marked breast asymmetry with bilateral tuberous breast deformity is without functional significance. Given the lack of functional problems related to the patients breast asymmetry, the requested donut lift of the left breast and reduction and full lift of the right breast, and placement of breast implants four to six months after the first surgery are not supported as medically necessary. The California reconstructive surgery statute requires health insurers to cover reconstructive surgeries, defined as surgery performed to correct or repair abnormal structures of the body caused by congenital defects, developmental abnormalities, trauma, infection, tumors, or disease to do either of the following: (1) to improve function; or (2) to create a normal appearance, to the extent possible. This patients marked breast asymmetry with bilateral tuberous breast deformity is an abnormal structure of the body caused by a developmental abnormality. The requested surgical procedures to correct the patients breast asymmetry is for the purpose of creating a normal appearance, to the extent possible. The requested surgery would provide more than a minimal improvement in the appearance of the patient. The proposed donut lift of the left breast and reduction and full lift of the right breast are reconstructive in nature per the California reconstructive surgery statute and are thus medically necessary. Per the California reconstructive surgery statute, the patients marked breast size asymmetry is an abnormal structure of the body caused by a developmental abnormality. A surgical procedure to correct the issue by placement of breast implants four to six months after the first surgery is for the purpose of creating a normal appearance, to the extent possible. The surgery would provide more than a minimal improvement in the appearance of the patient. The proposed placement of breast implants four to six months after the first procedure is reconstructive in nature per the California reconstructive surgery statute and is thus medically necessary.