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

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Nerve repair with nerve allograft, each nerve, first strand (cable) (CPT 64912); with approved breast reconstruction (reconstruction breast with free flap (CPT 19364), biopsy or excision of lymph node(s), open, internal mammary node (CPT 38530), intravenous injection of agent to test vascular flow in flap or graft (CPT 15860), open periprosthetic capsulotomy, breast (CPT 19370), and removal of tissue expander(s) without insertion of prosthesis (CPT 11971). Studies reported on a series of 48 innervated DIEP flaps in 36 patients and 61 non-innervated DIEP flaps in 45 patients. The authors concluded that, nerve coaption in DIEP flap breast reconstruction resulted in a significantly better sensory recovery in all areas of the reconstructed breast compared with noninnervated flaps. Researchers reported that, this article shows that it is technically possible to routinely carry out innervated DIEP breast reconstructions and that this may improve sensory recovery of slowly adapting nerve fibers of the reconstructed breast. However, the authors concluded that, there remains insufficient evidence to show that this is of clinically relevant benefit. In response, Studies discussed the recent peer-reviewed contributions and reported that, the results and clinical relevance should be confirmed in a double-blind, randomized, controlled trial that includes patient-reported outcome measures and quantitative sensory testing. In addition, the study did not report on the return of sensation following cadaveric nerve grafting. The medical information received for review demonstrates that the patient has been approved to undergo breast reconstruction. Overall, there are limited peer-reviewed medical literature supporting the safety and efficacy of nerve repair with allograft. For these reasons, the requested nerve repair with nerve allograft, each nerve, first strand (cable) (CPT 64912); with approved breast reconstruction (reconstruction breast with free flap (CPT 19364), biopsy or excision of lymph node(s), open, internal mammary node (CPT 38530), intravenous injection of agent to test vascular flow in flap or graft (CPT 15860), open periprosthetic capsulotomy, breast (CPT 19370), and removal of tissue expander(s) without insertion of prosthesis (CPT 11971) is not medically necessary for treatment of this patient. Final Result: The reviewer determined that the requested services are not medically necessary and not reconstructive in nature for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in plastic surgery and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for bilateral brachioplasty revision surgery. According to the American Society of Plastic Surgeons (ASPS), buttock, thigh or arm lifts can be appropriate to treat functional abnormalities. Most often, these procedures are performed to improve appearance and are therefore cosmetic in nature. This patient reports no functional issues regarding her upper arms.Excess upper arm tissue is not a result of a congenital defect, a developmental abnormality, trauma, infection, tumors or disease. It is not an abnormal structure of the body. It is a normal structural change that is an accommodative response to gain or loss of body mass. The appearance of the patient is normal and consistent with the gain and loss of weight. The ASPS states that cosmetic plastic surgery includes surgical and nonsurgical procedures that reshape normal structures of the body in order to improve appearance and self-esteem. Reconstructive surgery is performed on abnormal structures of the body caused by congenital defects, developmental abnormalities, trauma, infection, tumors or disease. It is generally performed to improve functions but may also be done to approximate a normal appearance. Excess upper arm skin is not an abnormal structure of the body. Rather, it is a normal structural change that is an accommodative response to gain or loss of body mass. The patients excess arm skin is not a result of a congenital defect, a developmental abnormality, trauma, infection, tumors or disease. Moreover, the requested procedure would not improve function or provide a more than minimal improvement in the patients appearance. All told, the requested bilateral brachioplasty revision surgery is not reconstructive in nature for treatment of this patient. Final Result: The reviewer determined that the requested surgery is not medically necessary and not reconstructive in nature for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in plastic surgery and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

The patient is a 21-year-old female who underwent arthroscopic knee surgery in August 2005. Postoperatively she utilized an electronic controlled thermal therapy unit as prescribed by her orthopedic surgeon. The patient is now requesting reimbursement for the cost of the device. The Health Plan denied her request based upon their determination that the thermal therapy unit was not medically necessary following the patients surgery. A thermal (cold) therapy unit is commonly prescribed by surgeons for postoperative rehabilitation following reconstructive surgery. This device is extremely helpful in relieving postoperative pain and swelling. The pad and unit are easy to use, can be applied for long periods of time and give a more uniform application of the cold to the affected area. Therefore, I have determined the device at issue was medically necessary for treatment of the patients medical condition. The Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Overturned

The patient is a 58-year-old man with chronic back pain with a significant radicular component and neuropathic pain elements. He is on chronic narcotics and has undergone several epidural blocks. He has tried and failed amitriptyline and nortriptyline, and finds Neurontin helpful for sleep but not pain control. He also does Pilates and tai chi for pain control. He was started on Lyrica in January 2006 when he had a significant increase in pain, and has been maintained on Lyrica 125mg/day for six months. The submitted records indicate the patient has had sustained improvement and improved quality of life on Lyrica with reduction in other medications.At issue is whether Lyrica is medically necessary for treatment of the patients medical condition.Lyrica has been used successfully by this patient to control his neuropathic and radicular pain. He has been tried on multiple chronic pain medications, undergone a variety of invasive procedures, and participated in a number of non-pharmacologic therapies to control his pain with only modest success. While the Lyrica indication is for neuropathic pain due to postherpetic neuralgia and diabetic neuropathy, the drug is being used successfully by neurologists, pain specialists, and other practitioners to treat a variety of neuropathic pain conditions. Thus, the use of Lyrica by this patient is medically appropriate and is likely to result in continued benefit. As such, I have determined the requested medication is medically necessary for treatment of the patients medical condition. The Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Upheld

A 55-year-old female enrollee has requested for Humatrope growth hormone therapy for treatment of her isolated growth hormone deficiency. Findings:  The physician reviewer found that The patient did not have history of childhood Growth Hormone Deficiency. The patient does has a very low IGF-1 level, but this does not make a definitive diagnosis of AGHD. The definitive diagnosis of AGHD will require the stimulation testing. The current gold-standard recommended test is insulin-induced hypoglycemia. An inadequate response of growth hormone to insulin-induced hypoglycemia is diagnostic of AGHD. Alternatively, testing with the combined administration of GHRH (growth hormone releasing hormone) plus arginine can achieve comparable separation between normal and hypopituitary subjects. The current patients report did not provide any results of stimulation testing and therefore a definitive diagnosis of Adult Growth Hormone Deficiency has not been established.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested proton beam therapy (CPT code 77523) 45 visits for treatment of his gastric cancer. Findings:  Three physician reviewers found that there is scant data on proton therapy for treatment of gastric cancer and limited data supporting the use of proton therapy for esophageal cancer. While proton therapy has a role in the treatment of some cancer patients, this option is not clinically beneficial for treatment of all patients. Moreover, the most recent National Comprehensive Cancer Network (NCCN) guidelines do not address proton therapy for gastric or esophageal cancer. For gastric cancer, treated with palliative intent, proton therapy has no clear clinical benefit. There is a paucity of data to support its use, and while there are some dosimetric advantages, there are other dosimetric disadvantages.  For this patient, any potential dosimetric advantage clinically may not be meaningful. Given that IMRT or conventional 3-dimensional radiation could be used for treatment in this patient, proton beam therapy is not likely to be beneficial. Final Result: The reviewers determined that the services at issue 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: Reviewer 1, 2, and 3 are board certified in radiation oncology and is 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

A 60-year-old male enrollee has requested for endovenous laser treatment for treatment of his venous reflux disease.   Findings:  Two physician reviewers found that Endovenous laser ablation of the great saphenous vein has been studied in two large scale series and numerous smaller studies. Technical success rates, symptomatic improvement, durability and complication rates were found to be similar to the gold standard, which is radiofrequency ablation. Endovenous laser ablation (EVLT) for refluxing tributaries and branch vessels has been considered and is documented in one small case series published by Bush and Hammond, and a case report by Theivacumar and colleagues. In this specific case, EVLT was successful in closing the great saphenous vein but a symptomatic tributary branch remains problematic. Based on the limited data currently available, EVLT for tributary branch vessels is considered investigational. This procedure does not appear to be superior to standard therapy. The gold standard for treatment of these tributary vessels is well documented by Meissner and colleagues and includes microstab phlebectomies and sclerotherapy.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary:  The parent of an enrollee has requested authorization and coverage for Tobii Dynavox SC Tablet (Speech Generating Device, E2510).At issue in this case is whether Tobii Dynavox SC Tablet (Speech Generating Device, E2510) is medically necessary to treat the patients medical condition as defined in Health and Safety code section 1374(a)(3)(A) set forth below. Medically necessary treatment of a mental health or substance use disorder means a service or product addressing the specific needs of that patient, for the purpose of preventing, diagnosing, or treating an illness, injury, condition, or its symptoms, including minimizing the progression of that illness, injury, condition, or its symptoms, in a manner that is all of the following: (i) In accordance with the generally accepted standards of mental health and substance use disorder care. (ii) Clinically appropriate in terms of type, frequency, extent, site, and duration. (iii) Not primarily for the economic benefit of the health care service plan and subscribers or for the convenience of the patient, treating physician, or other health care provider.The American Speech-Language-Hearing Association (ASHA) states, Eligibility policies and practices often preclude children and adults with severe disabilities from accessing needed communication services and supports. The authors also state, It is the position of the National Joint Committee for the Communication Needs of Persons With Severe Disabilities that eligibility for communication services and supports should be based on individual communication needs. Communication services and supports should be evaluated, planned, and provided by an interdisciplinary team with expertise in communication and language form, content, and function, as well as in augmentative and alternative communication (AAC). Morin and colleagues indicate, Using high-tech AAC to teach social-communication skills to individuals with autism spectrum disorder or intellectual disabilities and complex communication needs can be considered an evidence-based practice. Ganz states, Augmentative and alternative communication (AAC) provides a means of effective communication to individuals with autism spectrum disorder (ASD), many of whom are unable to use conventional speech effectively. Ganz concludes, People with ASD stand to greatly benefit from AAC, particularly with current AAC technologies.In this patients case, Tobii Dynavox SC Tablet (Speech Generating Device, E2510) is in accordance with the generally accepted standards of mental health and substance use disorder care. Additionally, the requested device is clinically appropriate in terms of type, frequency, extent, site, and duration. Moreover, the requested device is not primarily for the economic benefit of the health care service plan and subscribers or for the convenience of the patient, treating physician, or other health care provider. Therefore, Tobii Dynavox SC Tablet (Speech Generating Device, E2510) is medically necessary for treatment of the patients medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary:  An enrollee has requested Foundation One gene testing for the evaluation of his medical condition.   Findings:  Two physician reviewers found that there is sufficient support for the services at issue in this clinical setting.  Despite advances in the treatment of non-small cell lung cancer, the prognosis remains poor, especially with advanced disease.  As this patient lacks a driver mutation, such as KRAS, EGFR, or ALK, newer agents are not available to him.  Molecular profiling, such as Foundation One, identifies novel molecular markers to help guide enrollment in clinical trials, many of which require this prior to enrollment.  All told, the Foundation One gene test was likely to have been superior over other methods of evaluating this patient.  Final Result: Two 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 internal medicine with sub-specialty certification in medical oncology 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

Physician 1: The patient is a 36-year-old male who has a long history of degenerative disc disease with chronic low back pain. The patient states he has tried epidural injections, massage, chiropractic care, VAX-D treatments, and anti-inflammatories without long-term relief. His physician has recommended artificial disc replacement surgery using the Charite artificial disc. The Health Plan has denied this request indicating the requested procedure is investigational and therefore, not a covered procedure. The patient is a male with L5-S1 degenerative disc disease with chronic low back pain. He has not had improvement with conservative measures and is a candidate for surgery. Unfortunately, artificial disc replacement is of unproven efficacy for the treatment of chronic low back pain. The long-term results of this procedure are not yet known. Further studies are needed to determine outcomes beyond two years. Therefore, I have determined that the requested procedure is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Plans denial should be upheld. Physician 2: This patient is a 36-year-old man with a diagnosis of degenerative disc disease. He has requested coverage for artificial disc replacement surgery. The Health Plan has denied coverage for the requested procedure on the basis it is considered investigational. There is little data supporting the long-term efficacy of artificial disc replacement. There is presently at least a 35% failure rate associated with this procedure. Additionally, revision remains a potentially life threatening proposition. At present, the efficacy of disc replacement remains unproven. Therefore, I have determined that the requested procedure is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Plans denial should be upheld. Physician 3: The patient is a 36-year-old male who has a long history of back pain caused by degenerative disc disease. He has undergone several conservative management therapies, which have not produced relief for his pain. The patient has requested authorization and coverage for artificial disc replacement surgery. The Health Plan indicates the efficacy of artificial disc replacement has not been established. Artificial disc replacement has only recently been FDA approved. The procedure is of unproven efficacy. Long-term results are unknown and the procedures risks, long-term viability, and complications are unclear. Though a small study has been completed and short-term results are favorable, further studies and results are needed. As such, the procedure cannot be recommended at this time. Therefore, I have determined the requested procedure is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Plans denial should be upheld.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for collagen meniscus implant surgery.  Findings:  Three physician reviewers found that there is a lack of scientific evidence to suggest the collagen meniscal cartilage implant and/or bone marrow aspirate are likely to be more beneficial than standard non-surgical treatment or partial meniscectomy. High quality scientific evidence from prospective randomized sham controlled surgical trials have not demonstrated superiority of surgery over non-surgical treatment. There is a lack of high quality comparison trials evaluating standard non-surgical treatment or meniscectomy with collagen meniscal implant and bone marrow aspirate. There is limited short-term evidence of efficacy in patients with persistent pain following partial meniscectomy and there is a paucity of evidence of improved outcomes in this setting of initial surgery for degenerative meniscal tearing. In this patients case, there is no documentation of any non-surgical treatment. All told, the collagen meniscus implant surgery was 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 service at issue was 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: All three physician reviewers are board certified in orthopedic surgery 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

The patient has requested reimbursement and prospective authorization and coverage for residential treatment center (RTC) services. Per the American Society of Addiction Medicine (ASAM) criteria, this patient meets Level 3.5 criteria for Clinically Managed High-Intensity Residential Services. For dimension 1, the patients CIWA score supports mild to moderate withdrawal symptoms. For dimension 2, the presence of tremor and chronic fatigue syndrome may interfere with the patients ability to perform self-care. The patient meets the criterion for dimension 3 given the coexisting PTSD, MDD and GAD, which have been associated with worsening substance use disorders. For dimension 4, the patient has blamed others for his use behaviors and has demonstrated low accountability. This suggests that the patient is not ready for change. With regard to dimension 5, the provider noted that the patient is prone to immediate gratification and impulsivity, which supports that the patient is at high risk for relapse. For dimension 6, the patient has roommates who are heavy users and the patient lacks a strong support system. The patient requires a safe and stable living environment in order to develop his recovery skills. Thus, the patient qualifies for ASAM Level III treatment, similar to the services provided at the current RTC. Given these findings, the RTC services provided were and are medically necessary for treatment of this patient. Final Result: The reviewer determined that the services at issue were and 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 psychiatry with expertise in addiction 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.