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

The patient is a 50-year-old male who underwent bilateral mastectomy for gynecomastia including liposuction and removal of a mass in the right upper lateral chest wall. The patient has requested reimbursement for removal of breast tissue. The Health Plan has denied the patients request indicating that the available documentation does not demonstrate that the excess tissue was breast tissue as opposed to adipose.There is no information in the preoperative evaluation and work-up to indicate that gynecomastia was causing functional difficulties for this patient. The surgical procedure itself consisted entirely of suction/power-assisted lipectomy without en-bloc excision of typically hard, fibrous male breast tissue, which is consistent with true gynecomastia. The material removed was fat; no pathological evaluation of the tissue was performed. In the absence of pre-operative medical documentation and work-up of functional difficulties resulting from the stated gynecomastia, the procedure at issue was cosmetic in nature. Therefore, I have determined that the procedure at issue was not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Experimental/Investigational
Decision: Upheld

A 44-year-old female enrollee has requested lumbar epidural neuroplasty and neurolysis as needed for treatment of lumbar neuralgia.  Findings:  Three physician reviewers found that the proposed procedure is experimental without established long-term safety and efficacy. There continues to be conflicting views on the safety and efficacy of neuroplasty and neurolysis and these procedures are not generally accepted or widely employed interventions. Credible evidence showing the clinical value of these modalities for the management of post-polio syndrome or degenerative disc disease is lacking and the treatment is experimental for patients such as this patient.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested advanced lipoprotein for the evaluation of the enrollees risk of heart disease.  Findings: Two physician reviewers found that the patient has a history of gastroesophageal reflux and dyslipidemia. Coronary calcium scoring and revealed coronary calcium score of 38. A clinic note documented no cardiac symptoms during active exercise and a normal cardiovascular physical exam. The provider recommended advanced lipoprotein testing for this patient. The test included lipid subfractionation. The Health Plan denied reimbursement for the advanced lipoprotein testing as investigational and experimental for treatment of this patient. In this circumstance, primary prevention guidelines for the management of cardiac risk and dyslipidemia have been established, are periodically updated by expert committees, and are endorsed by several national organizations. These guidelines currently do not recommend routine performance of specialized tests in the context of assessing coronary risk including lipoprotein-associated phospholipase A2 (Lp-PLA2), sub-classifications of low-density lipoprotein (LDL), high-density lipoprotein (HDL) subclasses, lipoprotein (a), C-reactive protein, insulin, insulin resistance testing, fibrinogen, genetic testing and homocysteine.  Treatment change or addition based on the results of screening with these specialized tests has not been shown to improve cardiac outcome incremental to that achievable by treatment based on standard risk factor profiling and basic lipid analysis.  Although results of some of these specialized tests may be abnormal and considered independent risk markers for coronary disease, there is a lack of controlled trials that demonstrate outcome benefits by treating routinely obtained abnormal results.  All told, advanced lipoprotein testing was not likely to have been superior over other methods of evaluating this patient. Final Result: Two reviewers determined that the service at issue was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: All three physician reviewers are board certified in internal medicine with sub-specialty certification in cardiovascular disease and are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

A 52-year-old male enrollee has requested magnetic resonance imaging (MRI) of the head/brain for evaluation of his medical condition. Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested diagnostic procedure.  The medical records indicate the patient has had high blood pressure, lightheadedness, and headache.  He has reported nonspecific symptoms of vibration.  The duration of these various symptoms is not well defined, and no abnormalities are noted on examination.  Imaging of the brain is appropriate in conditions where there is progressive headache, focal neurologic signs, or events such as seizures.  The current medical evidence does not support the requested MRI in this clinical setting.  All told, the requested MRI of the head/brain is not medically indicated for the evaluation of this patient.
Appeal type: Medical Necessity
Decision: Overturned

A 58-year-old female enrollee has requested transcranial magnetic stimulation (TMS) treatments for her depression.  Findings:  The physician reviewer found that transcranial magnetic stimulation (TMS) is supported by an increasing body of evidence in the peer-reviewed medical literature. Ueyama and colleagues identified a possible mechanism for the antidepressant effect of TMS. It is a well-tolerated procedure that helps reduce the possible need for treatment in a more restrictive setting, such as acute hospitalization. Most compelling in support of its application, TMS is cleared by the Food and Drug Administration and endorsed by the American Psychiatric Association (APA) in its current clinical practice guideline for the treatment of individuals with depression. In this particular case, the patient was experiencing an acute major depressive episode that was causing significant functional impairment. She had been treated with standard therapies without substantial improvement. The patient had not exhausted available therapies. However, considering the medical records, the endorsement from the American Psychiatric Association (APA), and the expanding peer-reviewed literature base, TMS was appropriate to treat this patients depressive symptoms. Consistent with these findings, the TMS therapy provided from the date indicated and forward were medically necessary for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a 13-year-old female has requested coverage for 12 hours per day of in-home skilled nursing services for treatment of her functional quadriplegia.  Findings:  The physician reviewer found that according to the American Academy of Pediatrics Guidelines for Home Care of Infants, Children, and Adolescents with Chronic Disease, the goal of a home health care program for adolescents with chronic conditions is the provision of comprehensive health care within a nurturing home environment that maximizes the capabilities of the individual and minimizes the effects of the disabilities. In the case of this patient, she is a medically fragile adolescent with complex medical problems including uncontrolled seizures that place her at great risk for morbidity and even mortality. She feeds orally, but is considered by staff to be at high risk for aspiration, including pneumonia, particularly should she have a seizure while eating. Further, her musculoskeletal deformities place her at risk for skin breakdown and decubitus ulcer formation. Moreover, she has central sleep apnea and apnea with seizures, jeopardizing her respiratory status. In light of these medical issues, the level of care that the patient requires necessitates experience and attention to detail, with ability to rapidly intervene should difficulties arise. Her care is not custodial in nature. The patient requires 12 hours per day of in-home skilled nursing services to prevent complications and morbidity as a result of her complex medical problems.
Appeal type: Medical Necessity
Decision: Overturned

The patient has requested reimbursement for an oral appliance. The patient was diagnosed with obstructive sleep apnea (OSA). Researchers reported that oral appliances (OA) have emerged as an alternative to continuous positive airway pressure (CPAP) for obstructive sleep apnea (OSA) treatment. Researchers also noted that the mandibular advancement appliance (MAA) is the most common type of a dental device in use today. The device makes the mandible protrude forward, preventing or minimizing the upper airway collapse during sleep. A significant variability in the patients response to treatment has been observed, which can be explained by the severity of sleep apnea at baseline and duration of treatment. In some trials, patients with mild OSA show a similar treatment effect after the use of CPAP or MAA. It is worthwhile to give it a try with an oral appliance of MAA type in snoring, mild-to-moderate sleep apnea, and in individuals who are intolerant to CPAP treatment. In this case, the patient has been diagnosed with OSA and was intolerant to CPAP. The medical evidence supports the device at issue in this clinical setting. Therefore, an oral appliance was medically necessary for the treatment of this patient.Final Result: The reviewer determined that the device at issue was 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 oral facial and maxillary 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: Urgent Care
Decision: Upheld

A 23-year-old female enrollee has requested emergency services for treatment of her condition. Findings:  The physician reviewer found that at issue in this case is whether a prudent layperson in the patients circumstances would believe she was experiencing an emergency medical condition. Also at issue is whether the dermatology clinic providers additional treatment of a non-healing sore on the enrollees right 4th finger would be considered urgent services necessary to prevent serious deterioration of the enrollees health, resulting from an unforeseen illness, injury, or complication of an existing condition for which treatment could not be delayed until the enrollee returned to the Plan service area.A prudent layperson with an average knowledge of health and medicine would not believe she was experiencing acute symptoms of sufficient severity such that the absence of immediate medical attention could reasonably be expected to result in serious harm. The patient had three erythematous raised rashes in a circular pattern, with central sparing on lower extremities. Her condition was undiagnosed by the ED physician who directed the patient to obtain close follow-up with a dermatology clinic for possible insect bites. The records indicate the patients symptoms had improved and she had not filled the prescription that she was given at the time of discharge from the ED. Although the patient had been directed by the ED physician to seek follow-up care with the dermatologist, her symptoms had improved such that she did not need to fill the prescription she received. All told, the submitted evidence does not demonstrate that the patient was continuing to experience acute symptoms such that a prudent layperson would reasonably believe that failure to seek follow-up care with a dermatologist would result in serious harm.With regard to the additional services provided by the dermatology clinic provider, the evidence does not demonstrate that these services were necessary to prevent serious deterioration of health, resulting from an unforeseen illness, injury or complication of an existing condition, for which treatment could not be delayed until the patient returned to the Health Plans service area. The patients condition was described as a non-healing sore on her right ring finger that she had for several years. This condition had been present for years and thus did not result from an unforeseen illness, injury or complication of an existing condition. There is no evidence that the patient experienced a sudden change in the finger lesion since leaving her service area such that treatment could not be delayed until the patient returned to her service area.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for suction assisted lipectomy. The submitted documentation supports the medical necessity of the requested services. The records document evidence of lipedema of the lower extremities complicated by secondary lymphedema. She is well-documented to have undergone extensive conservative management. Her lipedema has been noted to have adversely affected her function, with chronic pain. Photographs support the abnormal lower extremity enlargement consistent with her diagnosis. Liposuction is a well-known therapy for lipodystrophy and has been shown to provide functional improvement in lipedema. The medical evidence supports the requested services in this clinical setting. Therefore, suction assisted lipectomy is medically necessary for the treatment of this patient. Additionally, the patients condition constitutes an abnormal structure of the body. Lipedema is an abnormal distribution of fat and is a well-recognized disorder. Lipedema is classified as a disease. The requested services are likely to both improve function and create a normal appearance to the extent possible. The requested suction assisted lipectomy is likely to result in more than a minimal improvement in the appearance of the patient. Thus, the requested suction assisted lipectomy is reconstructive in nature. Final Result: The reviewer determined that the requested services are medically necessary for treatment of the patients medical condition and are reconstructive in nature. Therefore, the Health Plans denial should be overturned.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. Findings:  The physician reviewer found that
Appeal type: Medical Necessity
Decision: Overturned

An enrollee has requested reimbursement for sub-acute detoxification Residential Treatment Center (RTC) services for a period of seven (7) days, and for substance abuse rehabilitation Residential Treatment Center (RTC) services for twenty (20) days.The submitted documentation supports that sub-acute detoxification Residential Treatment Center (RTC) services were medically necessary for an initial period of four (4) days. During the first four (4) days of sub-acute detoxification Residential Treatment Center (RTC) services, the patients vital signs, CIWA scores and reported symptoms reflect that she had mild to moderate symptoms of alcohol withdrawal. Under these circumstances involving managed detoxification and symptoms of withdrawal, sub-acute detoxification Residential Treatment Center (RTC) services provided during the initial period of four (4) days were medically necessary to treat the patients medical condition.The submitted documentation does not support that sub-acute detoxification Residential Treatment Center (RTC) services were medically necessary during the final three (3) of seven (7) days these services were received, or that substance abuse rehabilitation Residential Treatment Center (RTC) services were medically necessary for twenty (20) days. Applying the American Society of Addiction Medicine (ASAM) dimension analysis for placement with substance use disorders, the patient did not meet Level 3.5 criteria for Clinically Managed High-Intensity Residential Services. Accordingly, sub-acute detoxification Residential Treatment Center (RTC) services provided during the final three (3) of seven (7) days these services were received were not medically necessary to treat the patients medical condition, and substance abuse rehabilitation Residential Treatment Center (RTC) services provided for twenty (20) days were not medically necessary to treat the patients medical condition.Final Result: The reviewer determined that a portion of the services at issue were 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 psychiatry and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has been diagnosed with atopic dermatitis (AD). Findings:  The physician reviewer found that the patient had tried and failed treatment with clobetasol, triamcinolone, and mupirocin. The patient had also been treated with topical steroids, oral antihistamines, and oral prednisone. The patient has requested authorization and coverage for Dupixent. At issue in this patients case is whether Dupixent is medically necessary for the treatment of the patients medical condition. The Health Plan recommended formulary medications prior to beginning treatment with Dupixent. This patient is of childbearing age and most of the suggested on formulary treatments are contraindicated, as they are teratogenic. Current studies show that Dupixent is considered a first line treatment for severe disease and is safe and effective long-term, with minimal side effects. Dupilumab treatment, as monotherapy or as part of combination therapy, was associated not only with improvements in skin lesions but also with rapid and substantial reductions in pruritus. Patients treated with dupilumab had marked and rapid improvement in all the evaluated measures of atopic dermatitis disease activity. Medical evidence supports the requested medication in this clinical setting. Therefore, Dupixent is medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested medication is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in dermatology 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: An enrollee has requested authorization and coverage for Stelara, 90 mg, every 7 weeks.Current medical literature supports dose escalation of Stelara to 90 mg, every 7 weeks, in this case. The patient has active disease symptoms. Iron deficiency and anemia are signs of active Crohns disease, and recurrent iron deficiency and anemia suggest persistent disease activity. In addition, fatigue can be a sign of active Crohns disease rather than anemia. A large randomized controlled trial has demonstrated safety and efficacy for induction and maintenance of remission in patients with moderate-severe Crohns disease that was resistant to anti-tumor necrosis factor (TNF) therapy, which this patient has failed. Another study showed a 73% response in patients with anti-TNF-resistant Crohns disease, and 80% of responders maintained remission for one year. A significant majority of these patients were able to discontinue steroids. The mechanism of Stelara (ustekinumab) is entirely different than that of anti-TNF medications, which the patient has failed. Another study showed that dosing of Stelara at 90 mg, every 4 weeks, was used frequently to address inadequate disease control, and a large proportion of patients were able to maintain response with dose escalation to 90 mg, every 4 weeks. Multiple studies have shown that a majority of patients in whom Stelara dosing every 8 weeks failed to control symptoms responded to dosing every 4 weeks.In this case, the patient has failed prior therapies, and failed to adequately respond while taking Stelara 90 mg every 8 weeks. Continuation of the current dose of 90 mg, every 8 weeks, is not sufficient and therefore may result in complications such as fistula, stricture, bowel obstruction, flare, hospitalization, need for surgery, or other complications. Accordingly, Stelara 90 mg, every 7 weeks, is medically necessary for the treatment of the patients medical condition.Final Result: The reviewer determined that the requested medication is medically necessary for treatment of the patients medical condition at this time. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in internal medicine, with subspecialty certification in gastroenterology, 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 sixteen year-old male with recurrent Ewings sarcoma is seeking authorization for off-label use of Celebrex. He was treated with combination chemotherapy, followed by a stem cell transplant, followed by local radiation therapy.  This resulted in stabilization of the tumor in his pelvic region. He was then started on vinblastine and celecoxib (Celebrex) to prevent tumor progress by suppressing angiogenesis of tumor vessels.Reviewers Findings:The three reviewing physicians found that this combined therapy has been adopted by the Childrens Oncology Group and is part of their protocol for Ewings sarcoma therapy and there is no alternative therapy to offer this patient at this time.  These reviewers found that the Health Plan denial should be overturned.
Appeal type: Experimental/Investigational
Decision: Upheld

A 30-year-old female enrollee has requested percutaneous tibial nerve stimulation (PTNS) for treatment of her bladder dysfunction. Findings:  Three physician reviewers found that the available medical literature regarding PTNS for the treatment of pelvic pain, urinary symptoms and interstitial cystitis consists of non-randomized and non-controlled studies. The literature relates that the therapeutic benefit seen from PTNS is neither clinically nor statistically significant. At this time, there is a lack of well-designed, large scale, case controlled studies demonstrating that the use of PTNS results in a superior clinical outcome in this patient population as compared to standard therapies. Further studies are needed before the clinical validity of PTNS in this setting can be established.