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

A 33-year-old female enrollee has requested  a panniculectomy for treatment of her excess skin. Findings:  The physician reviewer found that reconstructive surgery is defined as a procedure performed to correct or repair abnormal structures due to congenital defects, developmental anomalies, trauma, infection, tumors or disease in order to improve function and/or create a more normal appearance. The surgery must also result in more than minimal improvement in appearance to be considered reconstructive. In the case of this patient, the submitted documentation does not demonstrate the presence of an abnormal structure of the body caused by congenital defects, developmental anomalies, trauma, infection, tumors or disease. While this patient has documented skin laxity, the amount of excess skin is not so great as to be considered an abnormal structure. Nor is there photographic evidence that the patients excess skin is visibly affected by disease or infection. As such, the submitted evidence does not demonstrate the patients condition meets the criterion of an abnormal structure as required by Californias reconstructive surgery statute. Thus, the proposed procedure is not reconstructive in nature. With regard to the medical necessity of the proposed procedure, panniculectomy involves removal of the lower abdominal skin without the muscle tightening or the supraumbilical skin tightening via periumbilical and lower abdominal incisions that comprise an abdominoplasty. Panniculectomy is medically indicated if the removed skin has a history of recurrent infections or is necrotic. With regard to the effects of the pannus on the lower back, the submitted evidence does not demonstrate the size of this patients pannus would likely result in lower back pain. In the absence of objective documentation of hampered range of motion, office visits for skin infections and response to such treatment for skin infection, or photographs that clearly show skin breakdown or rashes, the medical necessity of the proposed panniculectomy is not established.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for digital breast tomosynthesis for the evaluation of the enrollee, who was asymptomatic with respect to her breastsFindings:  Three physician reviewers found that the patient was asymptomatic with respect to her breasts.  On 8/2/16, she underwent a routine screening mammogram consisting of a three dimensional tomosynthesis study with synthetically reconstructed two dimensional views.   The current images were compared to prior mammograms dated and no interval changes were noted.  There were no masses, areas of suspicious calcifications, or areas of architectural distortion.  Her breast parenchyma was described as being dense. The Health Plan has denied reimbursement for digital breast tomosynthesis performed on 8/2/16. Per the Health Plan, the service at issue was investigational for the evaluation of this patient. .Breast tomosynthesis is a technique that was developed several years ago as a problem solving adjunct to routine mammography.  Applying the same basic concept as computed tomography scanning, the logic is that by separating the various layers of breast tissue, one can better detect abnormalities. This has been shown to be most useful in the evaluation of dense breasts. In this particular patient, she has breasts that have been described as being dense. While one could make the argument that her mammogram has not changed since the last study, it is specifically those patients who have dense breasts that can benefit most from tomosynthesis. The ability to separate out the overlapping structures enables the possibility of demonstrating an otherwise occult tumor.  Final Result: All three reviewers determined that  the service 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 diagnostic radiology 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 authorization and coverage for Regenexx spine platelet-rich plasma treatment. Findings:  Three physician reviewers found that per clinical practice guidelines for the management of chronic musculoskeletal low back pain, the focus of treatment should be patient education, self-care, common analgesics, independent exercise and remaining active. In the present case, the patient does not have documented impairments that would preclude him from performing an appropriate exercise program, including stretching and strengthening, as well as independent soft-tissue and palliative interventions, such as self-massage using foam rollers or massage balls, and topical treatments, such as ice or heat. Autologous platelet-rich plasma therapy has not been proven to be an effective treatment for spinal musculoskeletal conditions. Its mechanism of action in this clinical setting remains unclear. Platelet-rich plasma treatment protocols have yet to be standardized. The preponderance of published clinical data to date is anecdotal. One study performed a small clinical trial and reported modest symptomatic improvements with intradiscal platelet-rich plasma versus control in some parameters over a short follow-up period. This trial was small and low quality, and was properly reported to be a preliminary study by its authors. This trial supports the need for higher quality research. Therefore, Regenexx spine platelet-rich plasma treatment is not likely to be more effective than other available treatment options. Final Result: The reviewers determined that the requested services are not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: Physician reviewers 1, 2 and 3 are board certified in physical medicine and rehabilitation 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 reimbursement and prospective authorization and coverage for Botox treatment for treatment of the enrollees chronic migraine headaches. Findings: Two of the three physician reviewers found that there is sufficient support in the medical literature for the medication at issue. Botox is U.S. Food and Drug Administration approved for the treatment of migraine headaches. Migraine headaches are more complicated and more difficult to manage than episodic migraine. Migraine headaches have larger disease burden and comorbidities. Other, treatments require daily medication, often with limiting side effects. This patient has reportedly tried and failed multiple oral preventives before trying Botox therapy. In this patients case, the records indicate three to five headache days per week at baseline, or up to 20 headache days per month. When she received Botox injections, she is noted to have dropped the number of headache days, between five to ten days, a reduction of 50 to 75%. The patient also reported that the remainder of her migraines was easier to manage with Botox. This degree of benefit in this patient is consistent with what is documented in the clinical literature and medical evidence. This patient is documented to be a good responder to the Botox therapy. Final Result: The reviewer determined that the medication at issue was and 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: Reviewers 1, 2, and 3 are board certified in neurology 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 any or all of the lipedema surgeries (stage 1: bilateral lower extremity posterior, CPT code 15879 modifiers --22, --50 RT/LT, lipedema reduction surgery trunk CPT code 15877-22; stage 2: bilateral lower extremity anterior, CPT code 15879 modifiers --22, --50 RT/LT; stage 3: bilateral upper arms, CPT code 15878-22-50 RT/LT and/or stage 4: excision excessive skin/subcutaneous tissue CPT code 15832-22-50 RT/LT). Buso and colleagues note that weight loss measures exhibit minimal effect on the abnormal fat distribution that characterizes lipedema. For the treatment of lipedema, Dadras and colleagues note that liposuction is an effective surgical option. Wollina and Heining note that micro-cannular liposuction in tumescent anesthesia is an effective treatment for painful lipedema and that the procedure should be performed in specialized centers. Schmeller and colleagues report that tumescent liposuction is a highly effective treatment for lipedema with good morphological and functional long-term results. Baumgartner and colleagues found in a single-center study of 85 patients with lipedema that beneficial results from liposuction surgery persisted eight years after treatment. In this case, the patient has lost over 200 pounds with diet and exercise. The remaining adipose/weight in her thighs and buttocks is consistent with a diagnosis of lipedema. She has tried and failed conservative measures such as diet, exercise, compression garments, manual lymphatic drainage, pneumatic compression pump, and multiple medications including Cymbalta. Photographs of the patient suggest type II lipedema, showing disproportionate adipose distribution in the bilateral hips, buttocks, and thighs with relative sparing of the arms, lower legs, and feet. In this clinical setting, lipedema reduction surgery to treat the patients trunk and lower extremities, excluding the arms, is medically indicated. Therefore, lipedema surgeries (stage 1: bilateral lower extremity posterior, CPT code 15879 modifiers --22, --50 RT/LT, lipedema reduction surgery trunk CPT code 15877-22; stage 2: bilateral lower extremity anterior, CPT code 15879 modifiers --22, --50 RT/LT; and stage 4: excision excessive skin/subcutaneous tissue CPT code 15832-22-50 RT/LT) are medically necessary for the treatment of this patient.Final Result: The reviewer determined that a portion of the requested services are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be partially overturned.Credentials/Qualifications: The reviewer is board certified in vascular surgery and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/ Case Summary:The parent of an enrollee has requested authorization and coverage for the RT300 Functional Electrical Stimulator (FES) cycle therapy system for treatment of the enrollees cerebral palsy. Findings:  Two physician reviewers found that according to one study Although the evidence is limited we conclude that neuromuscular electrical stimulation in patients with central nervous system lesions can be an effective modality to improve function, and that combination with other treatments has an additive therapeutic effect. In addition, another study states that Functional electrical stimulation assisted cycling was tolerated well and resulted in increased cadence, power output, and heart rates and decreased variability in cycling performance. Such improvements in cycling ability with the application of FES assistance may make cycling for fitness attainable for individuals with CP with impaired cycling ability. In this case, the patient has a diagnosis of CP and has increased tone in the left side of his body. The patient has experienced muscular wasting/disuse atrophy, intensifying muscle spasticity and severe spasticity. The patient has the ability to utilize the cycle independently, once electrodes are placed. The peer-reviewed literature indicates that FES assisted cycle can be an affective modality to improve function and that neuromuscular electrical stimulation therapy along with conventional physiotherapy more efficiently improves walking ability and functional outcomes as compared to conventional physiotherapy alone in children with spastic cerebral palsy. Final Result: Two reviewers determined that the requested equipment is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Credentials/Qualifications: One reviewer is board certified in pediatrics and is actively practicing. One reviewer  is board certified in pediatric rehabilitation and is actively practicing. One reviewer is board certified in neurology 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: Experimental/Investigational
Decision: Upheld

A 28-year-old female enrollee has requested cryosurgical ablation for treatment of her fibroadenoma. Findings:  Two physician reviewers found that standard treatment options for fibroadenomas include close observation or surgical excision. Cryoablation has been proposed as an alternative approach for patients who desire more than watchful waiting yet want to avoid an operation.  While the technique was approved by the FDA as being safe and effective therapy, the scientific literature lacks follow-up beyond four years.  Reports which include larger numbers of patients report satisfaction with short-term results, but advise that longer follow-up is needed to understand the time course for resolution of these lesions both physically and radiographically. There is also the possibility that some patients may still require excision if the lesion does not completely resolve.  Surgical excision remains the standard of care for symptomatic or enlarging fibroadenomas with minimal morbidity. The procedure can also be performed under local anesthesia and provides complete histologic evaluation of the lesion. In this patients case, the requested cryosurgical ablation is not likely to be of greater benefit than other available standard treatments.
Appeal type: Medical Necessity
Decision: Upheld

The patient is a 61-year-old female with a body mass index (BMI) less than 46.1. The patient also has a number of comorbid conditions including irritable bowel syndrome. She has undergone a psychological evaluation and has been found to be an appropriate candidate for weight loss surgery. She believes Lap-band is likely to be the most beneficial procedure for treatment of her condition. The Health Plan has denied authorization and coverage for a Lap-band procedure. Current scientific literature does not demonstrate that Lap-band surgery results in any clear benefit for any specific group of patients. Most of the scientific data available have small numbers, short-term follow-up, and unacceptable success rates. The Lap-band results in the slowest and least amount of weight loss when compared to other procedures. All told, gastric banding is less efficacious than alternative weight loss procedures and is not indicated in this case. Therefore, I have determined that the requested procedure is not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Experimental/Investigational
Decision: Upheld

Findings:  The physician reviewer found that An enrollee has requested reimbursement for DecisionDx-Melanoma genomic testing (CPT 81529).Findings:  Three physician reviewers found that commercially available gene expression profiling (GEP) testing, such as the DecisionDx-Melanoma test, has been marketed as being able to classify cutaneous melanoma into separate categories used on risk of metastasis. However, it remains unclear where these GEP platforms provide clinically actionable prognostic information when used in addition to or in comparison with known clinicopathologic factors or multivariate nomograms that incorporate patient sex, age, tumor location and thickness, ulceration, mitotic rate, lymphovascular invasion, micro satellites, and sentinel lymph node biopsy (SLNB) status. Furthermore, the impact of these tests on treatment outcomes or follow-up schedules has not been established. It remains unclear whether this GEP profile is reliably predictive of outcome across the risk spectrum of melanoma. Prospective validation studies (as have been performed in breast cancer) are required to more accurately define the clinical utility of molecular testing prior to widespread implementation of GEP for prognostication of cutaneous melanoma, and in particular to determine its role in guiding surveillance imaging, SLNB, and adjuvant treatment decisions. Existing and emerging GEP platforms and other prognostic techniques should also be compared with optimized contemporary multivariable phenotypic models (i.e., the AJCC 8th edition melanoma risk calculator/prognostic tool in development). Accordingly, the DecisionDx-Melanoma genomic testing at issue was not likely to have been more beneficial than any other available standard therapy for the patient's condition.Final Result: The reviewers determined that the services at issue were not likely to have been more beneficial than any other available standard therapy for the patients condition. Therefore, the Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary:  An enrollee has requested authorization and coverage for a stairway chairlift. Findings:  The physician reviewer found that according to Siddiqi and Ruberg, the hallmark pathophysiology of cardiac amyloidosis is biventricular thickening and stiffening due to amyloid deposition, resulting in diastolic, then eventually systolic dysfunction. Other pathophysiology includes vessel infiltration, resulting in angina and myocardial infarction, and involvement of the cardiac conduction system, resulting in arrhythmias. Tuzovic and colleagues state that there is a risk of sudden cardiac death, often due to an electromechanical dissociation not amenable to restoration of cardiac function by defibrillation. Typical symptomatic manifestations of cardiac amyloidosis include dyspnea on exertion, orthopnea, paroxysmal nocturnal dyspnea and lower limb edema. Treatment options include diuretics, sodium restriction, specific targeted therapy for different types of amyloidosis, consideration of pacemaker/defibrillator implantation, chemotherapy for specific treatable amyloid subtypes, and supportive/compensatory treatment. Siddiqi and Ruberg also state that standard cardiomyopathy pharmacotherapy such as beta blockers and angiotensin converting enzyme inhibitors are often poorly tolerated and generally avoided due to adverse effects such as hypotension and fatigue.Final Result: The reviewer determined that the durable medical equipment 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: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary:  An enrollee has requested breast tomosynthesis for evaluation of her medical condition.  Findings:  Three physician reviewers found that breast tomosynthesis was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. There is sufficient support for the services at issue in this clinical setting. The study by Skaane and colleagues concluded that The use of mammography plus tomosynthesis in a screening environment resulted in a significantly higher cancer detection rate and enabled the detection of more invasive cancers. In sum, the services at issue are strongly supported by the medical literature cited above. 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 reviewers are board certified in diagnostic radiology and are 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: Experimental/Investigational
Decision: Upheld

A 61-year-old male enrollee has requested radiofrequency ablation (RFA) procedure (endovenous ablation) of the left lower extremity for treatment of his venous insufficiency. Findings:  Two physician reviewers found that this patient has a type 2 reflex (proximal, from the SFJ or saphenopopliteal junction (SPJ) to a tributary or perforating vein above the level of the malleoli). The current data shows the only about one third of patient limbs may require treatment of a refluxing GSV in the thigh. This patient has focal reflux without a perforator. The current data does not support ablation of his vein with his symptoms and in the absence of a large thigh perforator. All told, the peer-reviewed medical literature does not indicate the requested RFA of the left lower extremity is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.