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

The patient is a 10-month-old male whose parents wished him to be circumcised in the neonatal period. However, he had medical problems including aspiration pneumonia and gastroesophageal reflux requiring hospitalization for medical treatment in the neonatal intensive care unit. He could not have a circumcision then and for some time afterwards due to his medical condition. He has by now recovered from those medical problems well enough to undergo circumcision, and the parents wish to have it performed. The patients primary care physician referred the patient to an urologist and the patients parents have consulted with the urologist for the purpose of having their child circumcised. However, the Health Plan, which would have covered as a medical routine circumcision in the neonatal period, has denied authorization.The American Academy of Pediatrics 1999 Task Force on Circumcision concluded that parents should determine what is in the best interest of the child after being counseled regarding the potential benefits and risks of this elective procedure. That is the current situation in this case - the parents wish to have their child circumcised. The Health Plan would have authorized the procedure as a covered benefit in the neonatal period, but as much as the parents wanted it performed then, the patient was not in medical condition to have it performed. The patient is currently in the appropriate condition to have the circumcision performed. The circumcision, which was delayed during the neonatal period due to medical reasons, should be authorized and performed. Therefore, I have determined that the requested procedure is necessary for treatment of the enrollees medical condition. The Health Plan denial should be overturned.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a 23-month-old male enrollee has requested for speech therapy for treatment of the enrollees language delay. Findings:  The physician reviewer found that according to Law and colleagues, approximately 6% of children have speech and language difficulties.  The authors noted that children whose difficulties persist into primary school may have long-term problems concerning literacy, socialization, behavior, and school attainment.  These reviewers concluded that there is a positive effect of speech and language therapy interventions for children with expressive phonological and expressive vocabulary difficulties.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Mobi-C two-level artificial cervical disc replacement (codes 22856 and 22858) for treatment of the enrollees left upper extremity radiculopathy and weakness.  Findings:  The physician reviewers found that cervical disc replacement is U.S. Food and Drug Administration (FDA) approved at one or two levels with Mobi-C. The peer-reviewed literature supports one- or two-level cervical disc replacement for specific indications of cervical disc degeneration and myeloradiculoapthy. There is evidence supporting net health outcomes in the presence of well-designed and executed randomized controlled trials with adequate follow-up on two-level cervical disc arthroplasty. In this case, the patient has significant stenosis at C5-7 with correlating clinical signs and symptoms of symptomatic cervical radiculopathy and is an appropriate candidate for a two-level cervical disc replacement. Based on the support in the peer-reviewed literature, two-level artificial cervical disc replacement is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Final Result: Two of three reviewers determined that the requested procedure is 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 number one, two, and three are board certified in orthopedic surgery and 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 forty-two year-old female with chronic back pain and who is status post two back surgeries is requesting reimbursement for her prior use of as well as prospective authorization for Actiq.Reviewers Findings:The reviewing physician found that Actiq has not been approved for the management of failed back surgery pain.  The physician concluded that the Health Plan denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Botox injection to the pelvic muscles (CPT code 20553  trigger point injection(s) x 1 and HCPCS code J0585  injection, onabotulinumtoxinA 1 unit x 200). A review conducted by Karp and colleagues evaluated the effectiveness of Botox for chronic pelvic pain in the current medical literature. The authors found data supporting that Botox can be safely and tolerably injected into pelvic floor muscles in women as an outpatient procedure. Gari and colleagues noted that there is promising evidence to support the use of Botox in cases of refractory pelvic floor muscle dysfunction. The authors concluded that, Further randomized controlled trials are warranted to standardize the use of Botox as a treatment option for these cases. This patients records document chronic pelvic pain refractory to medication management, physical therapy, and interventional nerve blocks including ganglion impar and pudendal blocks. Moreover, the records document that previous treatment with Botox injections did not provide substantial relief of her pain. Given these findings, the requested Botox injection to the pelvic muscles (CPT code 20553  trigger point injection(s) x 1 and HCPCS code J0585  injection, onabotulinumtoxinA 1 unit x 200) are not medically necessary for 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 anesthesiology with subspecialty 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: Experimental/Investigational
Decision: Overturned

A 58-year-old female enrollee has requested for BRCA 1 and 2 testing for evaluation of her medical condition.   Findings:  Two physician reviewers found that National guidelines for genetic testing presume the availability of family history. In the case of an adoption, such as in this patients case, family history may not available. This can include details regarding hereditary origins, including whether the patient is of Ashkenazi Jewish descent (high-risk group) or not. This patient has a history of triple negative breast cancer which is known to be more common in women with BRCA 1 gene mutations.  As this patients family history was unavailable, the probability of a mutation based upon the known variables must be estimated.
Appeal type: Medical Necessity
Decision: Upheld

A 61-year-old female enrollee has requested Botox injections for the treatment of her hypertonicity of her pelvic floor musculature. Findings:  The physician reviewer found that there are a very small number of peer-reviewed articles reporting the use of botulinum toxin type A for the treatment of chronic pelvic pain. There are some scattered case reports as well as a couple of original research studies. In a 2004 pilot study from Australia of women with chronic pelvic pain and demonstrable spasm in the pelvic floor muscles, a reduction in pressure was found when botulinum toxin type A was injected, and a diminution of pain symptoms were noted. A follow-up study with a small patient number was performed by the same research group in 2006 to evaluate the treatments effect on pelvic floor pressure, pain response, and the impact on quality of life. Women with chronic pelvic pain and pelvic floor muscle spasm were randomized to receive botulinum toxin type A or placebo injections to the pelvic floor muscles. The use of botulinum toxin type A, which blocks cholinergic transmission at the neuromuscular junction, is reported to decrease pain and improve function in cervical dystonia, limb spasticity after a cerebrovascular accident, and headaches. In this double-blind, placebo-controlled study, significant intergroup differences for individual pain scores were not demonstrated. A significant placebo effect was noted. There were significant intragroup differences in pain, but it can be concluded that there is no significant treatment effect when compared to placebo. The use of botulinum toxin may hold future promise for this indication. However, further trials are needed to confirm its effectiveness in the treatment of chronic pelvic pain.
Appeal type: Medical Necessity
Decision: Upheld

The patient is a 47-year-old woman who reports that she has Lyme disease complicated with infections of Mycoplasma and Babesiosis diagnosed in March 2005. There is no stated history of a tick bite or rash.  One of the patients providers noted that she was deteriorating off IV Rocephin.  Another of her providers indicated that her symptoms include fatigue, poor stamina, muscle pain, headache, blurry vision, poor balance, confusion, forgetfulness, poor short term memory, poor attention, problems absorbing new information, disorientation, mood swings and disturbed sleep. Her treatment was documented to include Doxycycline, Biaxin, hydroxychloroquine, Cipro, IV Rocephin and Zithromax.  The records provided include visits to both physicians between August and December 2005. These records detail symptoms and treatment as noted above.The patient is seeking reimbursement for antibiotic therapy beyond September 2005 as well as authorization and coverage for future IV therapy. The Health Plan has denied this request on the basis that the therapy at issue is not medically necessary.The submitted clinical evidence does not include any documentation of physical examination findings suggestive of Lyme disease (e.g., evidence of arthritis or CNS disease). Laboratory test results disclose a positive IgG for Mycoplasma pneumoniae (indicating a past Mycoplasma infection), a Babesia microti IgG of 1:20 (at the lowest level of positivity and not meaningful as a single value), and a Lyme IgG Western Blot with three positive bands (negative by CDC criteria, which requires five positive bands).  Even if there was convincing evidence of Lyme disease, there is no peer-reviewed data supporting more than 30 days of IV antibiotic treatment for Lyme disease in any form.Based upon the information set forth above, I have determined the therapy at issue was/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 57-year-old male enrollee has requested coverage for muscle flap/biological wound product FlexHD.   Findings:  Two physician reviewers found that the patient has a history of an injury to his leg four or five years prior.  He was evaluated for an ulcer on the lateral aspect of his foot.  A bone scan was performed.  This raised the possibility of osteomyelitis, greatest at the plantar lateral aspect of the calcaneus, which is where he had drainage.  The patient was taken to the operating room, and the ulcer was excised.  It was noted that the ulcer did not extend to the periosteum of the calcaneus.  He underwent adjacent tissue transfer to close the defect.  FlexHD was inserted into the wound under the subcutaneous tissue.  Although a preoperative bone scan raised the suspicion of osteomyelitis, there was no evidence of this at the time of the ulcer excision and adjacent tissue transfer.  The medical records noted that FlexHD was placed to add bulk.  There is some evidence supporting the use of FlexHD as an allograft to facilitate breast reconstruction and ventral hernia reconstruction.  However, there is a lack of evidence indicating that FlexHD is beneficial for placement into wounds to add bulk or fill dead space in surgical cavities.  In this clinical situation, if additional bulk were needed, this would have been the role of adjacent tissue transfer to fill the void and add volume to the area excised.  All told, the services at issue were not likely to be more effective than other available treatment options in this patients case.
Appeal type: Medical Necessity
Decision: Upheld

The patient is a 62-year-old woman who has a history of gastroparesis. She has low back pain and diabetes and is on multiple medications. The patient takes naloxone to treat her narcotic induced constipation. She has requested authorization and coverage for continued use of naloxone. The Health Plan has denied her request on the basis that the requested medication is not medically necessary.The Health Plans denial is correct. While naloxone has been effective in reversing the effects of narcotics in cases involving opioid overdose, the use of this medication to treat constipation induced by narcotics is quite unusual. This is neither the standard of care nor the community standard. There are other ways to treat the patients condition that are more clinically appropriate. Therefore, I have determined the requested medication is not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the pelvis magnetic resonance imaging (MRI) performed for evaluation of the enrollees elevated prostate specific antigen (PSA). Findings:  The physician reviewer found that there is limited data regarding the patients prostate examination, and there is no record of a digital rectal examination. In addition, there is no record of ultrasound guided prostate biopsy or imaging prior the MRI performed. No follow-up PSA level was obtained. Given the current guidelines from the National Imaging Associates (NIA), the use of MRI as a screening tool for prostate cancer in this clinical setting was not indicated. Final Result: The reviewer determined that the diagnostic procedure at issue was not medically necessary for evaluation of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in diagnostic radiology 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: The patient has requested authorization and coverage for Supartz injections in both knees. Hyaluronic acids are naturally occurring connective tissues materials that help cushion and lubricate joints. Intra-articular injection of avian-derived or synthetic hyaluronic acid, also called viscosupplementation, can decrease osteoarthritis symptoms in some, but not all patients. The American Academy of Orthopaedic Surgeons (AAOS) guidelines do not recommend hyaluronic acid for patients with symptomatic osteoarthritis, based on strong evidence. In this case, the submitted clinical documentation does not support the use of viscosupplementation injections to treat the patients knee pain. The requested treatment is not endorsed by the AAOS due to lack of evidence supporting its efficacy. Therefore, the requested Supartz injections in both knees are not likely to be more beneficial for treatment of the patient's medical condition than any available standard therapy. Final Result: Two of the three 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:  One reviewer is board certified in orthopedic surgery and is actively practicing. One Reviewer is board certified in orthopedic surgery and is actively practicing.  One Reviewer is board certified in orthopedic 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.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for compounded medication estradiol 20%, estriol 80%, and testosterone 0.1% topical, one gram daily. Custom-compounded hormones are multi-hormone regimens with dose adjustments based upon serial hormone monitoring. The hormones most commonly compounded are estradiol, estrone, estriol, progesterone, testosterone, and DHEA. The North American Menopause Society or American College of Obstetricians and Gynecologists do not support the use of custom-compounded hormones. In addition, there is a lack of evidence to support the safety and efficacy of custom-compounded hormone therapy when compared with standard estrogen and progestin formulations. Moreover, randomized trials have not demonstrated the safety and efficacy of compounded bioidentical hormone therapy for treating menopausal symptoms. Therefore, the requested compounded medication estradiol 20%, estriol 80%, and testosterone 0.1% topical, one gram daily is not medically necessary for 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 obstetrics and gynecology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

A 48-year-old female enrollee has requested an MRI of the lumbar spine for evaluation of her back and leg pain and irregular menstrual bleeding.  Findings:  The physician reviewer found that review of the submitted clinical documentation demonstrates that the patient indeed had low back pain with radicular features, however, there was no proven neurological deficit. While the patient had significant discomfort, there was no documented attempt at traditional physical therapy and the medical records do not document that an appropriate course of anti-inflammatory medication was completed. Moreover, this patient had a prior history of similar findings of back and leg pain on an episodic basis. Finally, there is insufficient evidence regarding concerns for malignancy to support the use of MRI in this setting. In this case, the medical necessity of an MRI of the lumbar spine has not been established, as there was no documented neurological deficit and conservative treatment had not been exhausted.
Appeal type: Medical Necessity
Decision: Upheld

The patient is a 56-year-old male who was seen by a dermatologist in October 2003. Apparently the patient was referred to a dermatologist for treatment of a basal cell carcinoma of his right superior shoulder. The dermatologist then referred the patient to a plastic surgeon. The information submitted does not provide evidence of why the dermatologist referred the patient to a plastic surgeon. On 12/3/03, the plastic surgeon indicated the patient had a history of solar damage. The patients physical exam indicates multiple areas of sun damage with no areas suspicious for malignancy. The plastic surgeon recommended follow-up by the patients dermatologist. The patient has requested laser resurfacing for a spot on the side of his face, which frequently bleeds from shaving.The treatment of a bleeding telangiectasis is medically necessary. However, that treatment involves local destruction of the bleeding spot, not laser. Also, it is essential that the spot be evaluated for possible skin cancer. Neither the dermatologist nor the plastic surgeon describes a bleeding spot. Thus, there is no identifying history or physical exam. Furthermore, no information has been provided demonstrating the location of the bleeding spot. The patient describes that spot as being on the side of the face. This description does not provide enough specific information as to where the patients bleeding spot is located. Regardless, although the patient may require local destruction of the identified bleeding spot, laser resurfacing is not medically necessary or medically indicated for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for a lumbar epidural steroid injection. A peer-reviewed medical literature noted that epidural steroid injection has shown short-term improvement for patients with radicular pain but not for other types of low back pain. The current standard of care supports epidural steroid injection for patients with object examination findings of radiculopathy due to herniated nucleus pulposus, but not spinal stenosis.  In addition, radiculopathy must be corroborated by imaging studies and/or electrodiagnostic testing, and the condition must be initially unresponsive to conservative treatment including exercises, physical methods, non-steroidal anti-inflammatory drugs (NSAIDs) as well as muscle relaxants. This patients medical records do not document physical examination and imaging study findings consistent with radiculopathy to support the request for epidural steroid injection. Given these findings, the requested lumbar epidural steroid injection is not medically necessary. Final Result: The reviewer determined that the requested service is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in 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.