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

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement and prospective authorization and coverage for licensed vocational nurse (LVN) skilled nursing home care services for 56 hours per week from the date of service in question, forward. Findings:  The physician reviewer found that spastic cerebral palsy is the most common form of cerebral palsy, representing at least 70% of diagnoses. Cerebral palsy is a group of disorders primarily affecting muscle coordination, balance and voluntary movement. The neurological condition typically appears in infancy or early childhood, resulting from irregular development or damage to the part of the brain responsible for mobility. Among patients afflicted with the spastic type of cerebral palsy, muscle tightness and poor coordination during deliberate movements are consistent, dominant symptoms. As with other forms of cerebral palsy, patients with the spastic type are susceptible to co-occurring conditions, which can impact vision, hearing, swallowing, as well as bladder and bowel functions and other physical systems. Spastic diplegia is a form of cerebral palsy that affects the lower portion of the body. According to the studies published by the National Center for Biotechnology Information, patients with spastic diplegia may see many of the other developmental conditions as those with quadriplegia, including vision problems. Skilled nursing care consists of those services that must be performed by a registered nurse (RN) or LVN. Skilled home health nursing care is the provision of intermittent skilled services to a patient within the home for the purpose of restoring and maintaining the patients maximal level of function and health. These services are rendered in lieu of hospitalization, confinement in an extended care facility, or going outside of the home for the service. The records provided for review support the medical necessity of the requested LVN skilled nursing home care services for 56 hours per week from the date of service, forward for treatment of this patients medical condition. 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 internal medicine and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

A 51-year-old male enrollee has requested laser treatment for treatment of his toenail fungus. Findings:  The physician reviewer found that review of the submitted documentation and relevant literature fails to demonstrate the medical necessity of the requested services. The documentation submitted for review fails to provide support for onychomycosis. There are no positive fungal cultures, microscopic examinations or pathology examinations of the toenails to confirm the diagnosis of onychomycosis. There is no documentation to support pain secondary to the onychomycosis to support treatment of this condition. Further, there is no documentation to support the patients nails are causing pain with pressure affecting shoe gear and ambulation. In addition, there is a lack of medical literature supporting the efficacy of laser treatment for onychomycosis. According to Bristow, The evidence pertaining to the effectiveness of laser treatment of onychomycosis is limited and of poor methodological quality. Future studies using a randomised controlled trial designs with larger study populations and clear procedures are required to permit a full evaluation of this emerging technology. Based on the documentation submitted for review and the peer-reviewed literature cited above, the requested services are not medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld

A 53-year-old female enrollee has requested for bilateral breast MRI for breast cancer screening. Findings:  The physician reviewer found that there is no evidence the patient has a significantly increased risk of breast cancer; this recommendation is medically appropriate and consistent with current guidelines.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Repatha SureClick. Findings: The physician reviewer found that the patient presents with documented obstructive coronary disease, intolerance to multiple statin medications, and LDL that is significantly above a goal of less than 70 mg/dL while on Zetia medication. Repatha is a proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitor studied in and approved for patients with heterozygous familial hypercholesterolemia or for patients with documented atherosclerotic heart disease who require additional lowering of LDL cholesterol. This patient fits the latter criteria and statin intolerance is well documented. In this clinical setting, the addition of a PCSK9 inhibitor such as Repatha has been shown to be safe and effective at lowering cholesterol and has been associated with improved cardiovascular outcomes. Therefore, Repatha SureClick 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 internal medicine with sub-specialty certification in cardiovascular disease 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

A 19-year-old male enrollee has requested burr hole surgery and deep brain stimulation (DBS) electrode implant for treatment of his Tourettes syndrome. Findings:  Two physician reviewers found that there is insufficient medical literature supporting the use of burr hole surgery and deep brain stimulation (DBS) electrode implant in this setting. A recent comprehensive review by Muller-Vahl of the surgical treatment of Tourettes syndrome (TS), identified 34 studies which included 90 patients. The author noted that while DBS is a promising treatment, randomized controlled studies including a large number of patients are still lacking. The authors concluded that no definite conclusion as to the efficacy of this treatment can be drawn at this time. Moreover, in a similar review by Viswanathan and colleagues, they describe the surgical techniques, stimulation parameters, outcomes of deep brain stimulation (DBS) in TS, and critically review target choices. The authors concluded that Determination of the optimal surgical target will require a multicenter, randomized trial, and an expanded understanding of the neurobiology of TS. For the reasons provided above, burr hole surgery and deep brain stimulation (DBS) electrode implant for the treatment of TS is not likely to be more beneficial for treatment of the patients medical condition than other available modalities.
Appeal type: Medical Necessity
Decision: Upheld

The patient is a 55-year-old female status post gastric bypass in November 2004 for morbid obesity. Her weight decreased from 306 pounds to 177 pounds. She has numerous complaints referencing problems of skin irritation, rashes, yeast or bacterial infections, hygiene, back pain, neck pain, shoulder pain, lifting over ten pounds, and standing for prolonged periods. The skin issues are reportedly caused by trapped moisture in the patients skin folds present from the massive weight loss she accomplished following her gastric bypass surgery. The patients request for authorization of abdominoplasty was denied by the Health Plan based upon a determination that the procedure is not medically necessary.A letter from one of the patients providers dated January 2006 notes chafing and discomfort in the abdominal area and recommends reconstructive surgery for the abdomen and legs. There are no corresponding clinical notes from any of her providers that fully document this condition. Chafing, irritation and discomfort are not indications for panniculectomy or abdominoplasty without further notes and documentation of the severity of symptoms, chronicity of treatment, and attempts and failures of treatment. There is insufficient medical information documenting the patients complaints to support the need for an abdominoplasty in this case. Based upon the information set forth above, I have determined the requested procedure 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: The parent of a patient has requested authorization and coverage for growth hormone, Nutropin. The Health Plan has denied this request indicating that the requested medication is not medically necessary for treatment of the patients short stature. The submitted documentation does not support the medical necessity of the requested medication. This patient experienced a drop in weight prior to a fall-off in height. This is a pattern that is not consistent with growth hormone deficiency and is more likely to be related to decreased caloric intake, constitutional delay, and/or malabsorption. The patients height is not more than two standard deviations below the mean for the patients age and gender, and there is no information provided regarding bone age or pubertal status. The results of other tests ruling out additional causes of growth fall-off are not provided. Low growth hormone levels in response to stimulation testing cannot be taken as sole evidence of growth hormone deficiency. Therefore, Nutropin is not medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested medication is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in pediatrics with sub-specialty certification in pediatric endocrinology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld

A 36-year-old female enrollee has requested Avastin for the treatment of her breast cancer. Findings:  Three physician reviewers found that the scientific data reveals that the single-agent activity of Avastin is very poor. Other more standard agents like Navelbine and Gemcitabine have not been tried. They do not have proven superior activity in combination with Avastin. Thus, the use of Avastin alone or in combination with standard agents is not likely to be more efficacious for this patient than available standard agents in this setting.
Appeal type: Medical Necessity
Decision: Upheld

A 43-year-old female enrollee has requested an abdominal panniculectomy for the treatment of her excess skin status-post gastric bypass. Findings:  The physician reviewer found that the submitted clinical evidence does not establish that the proposed procedure is reconstructive in nature. Although the submitted photographs demonstrate that the patient has excess hanging abdominal skin, it is not severe and does not hang over the undergarment. As such, the patients excess skin condition does not constitute an abnormal structure caused by congenital defect, developmental abnormality, trauma, infection, tumor or disease. The patients condition is normal in that the excess skin is not visibly affected by disease or infection. Nor is the amount of excess skin so great as to be considered abnormal. Thus, the proposed procedure does not meet the definition of reconstructive surgery as defined by California Health and Safety Code Section 1367.63. Furthermore, with regard to general concepts of medical necessity, there is no documented objective evidence of a functional impairment. Office visit notes describe no rashes. There is no description of office visits or physician treatment for skin rashes due to sagging skin. There are no rashes or areas of skin breakdown visible in the submitted photographs. Therefore, the medical necessity of the proposed panniculectomy has not been established.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for the RT300 Functional Electrical Stimulation (FES) therapy system. There is a lack of evidence in current medical literature demonstrating that exposure to passive exercise, such as would be provided by the requested device, improves function or health outcomes in a clinically significant manner for neurological conditions, including complete traumatic paraplegia. Researchers report that while treatment options using neurostimulation to enable or enhance intense training appear promising, regaining lost motor function remains challenging, and characterizing long-term benefits and side-effects in clinical trials also remains crucial. Medical literature noted that in a study of 14 patients with recent spinal cord injury, there were no clear effects of FES cycling on increasing urine output, decreasing lower limb swelling and spasticity. Researchers note that more rigorous research involving a greater number of participants is needed before determining the efficacy of FES cycling as an intervention for youth with spinal cord injury. Researchers note that patients with traumatic spinal cord injury benefit from active exercise using volitionally intact muscles, and the general encouragement of active participation in educational, social, recreational, avocational and vocational activities. Given that current medical literature does reflect that the use of the requested device would improve cardiovascular health, pulmonary health or other health parameters in any clinically significant manner, the requested device is not medically indicated. Therefore, the RT300 FES therapy system is not medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested device 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: Medical Necessity
Decision: Overturned

A 65-year-old female enrollee has requested Botox injection (OnabotulinumtoxinA injection  HCPCS code J0585 and chemodenervation of muscle; innervated by facial nerve, unilateral  CPT code 64612) for medical treatment of the enrollees hemifacial spasm. Findings:  The physician reviewer found that currently, Botox is considered the standard therapy for treatment of hemifacial spasm and has been proven to be more effective than any other treatment.  Botox weakens or paralyses the muscle it is injected into if the dose is adequate and the placement is correct. The standard of care in the treatment of blepharospasm and hemifacial spasm is to continue treatment approximately every three months and vary the paradigm depending on the last treatment response. All told, the requested Botox injection (onabotulinumtoxinA injection  HCPCS code J0585 and chemodenervation of muscle; innervated by facial nerve, unilateral  CPT code 64612) is medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned

The patient is a 58-year-old male who was diagnosed with moderate sleep apnea in January 2005 and more recently diagnosed with mitral valve prolapse and regurgitation. A follow-up sleep study completed in May 2005 showed his arousal index decreased from 22.5 to 17.9 and his respiratory disturbance index (RDI) decreased from 18.4 to 3.6 with nasal CPAP at pressures of six to eight cm/H2O. His physician has recommended continued CPAP use. The Health Plan had denied the patients request for the CPAP device on the basis it is not medically necessary.The patient has documented obstructive sleep apnea (OSA), moderately-scored. The patients provider recommended a trial of CPAP therapy. The patient utilized a CPAP device with good results as supported by a second sleep study. As such, CPAP therapy is the treatment of choice for this patient. Therefore, I have determined the requested device is medically necessary for treatment of the patients medical condition. The Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Upheld

The parents of a four-year-old female enrollee have requested a consultation and treatment with a pediatrician specializing in integrative medicine for treatment of possible autism/developmental delay.  Findings:  The physician reviewer found that the benefit of consultation and treatment with an integrative medicine physician is not clear from the documents provided for review. The physician identified by the family does not list credentials that would qualify him to treat a child with a developmental disability or a child with an autistic spectrum disorder. There are two other reports from qualified professionals that indicate an intent follow the patient and to make the needed treatment recommendations. The record also indicates there is a pediatrician currently involved in the patients care.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Trulance. Findings: The U.S. Food and Drug Administration (FDA) has approved the use of Trulance, a guanylate cyclase-C agonist, for chronic idiopathic constipation (CIC). A study noted that plecanatide significantly improved constipation and its related symptoms with a low rate of adverse events, and may be a useful treatment option in the management of CIC. The most recent guidelines for the treatment of constipation recommend the use of osmotic and then stimulant laxatives before advanced agents such as Trulance and note, A newer agent should be considered when symptoms do not respond to laxatives.  In this case, while the patient has chronic constipation, the documentation does not show a failure of laxative alternatives prior to treatment with an agent such as Trulance. Therefore, Trulance is not medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested medication is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is board certified in internal medicine with sub-specialty 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: Medical Necessity
Decision: Overturned

A 32-year-old female enrollee requested a positron emission tomography/computed tomography (CT) scan (CPT code 71270 for medical evaluation of her right eye tumor and possible malignancy. Findings:  The physician reviewer found that in the medical literature, metastatic tumors of the retina are rare, and that the diagnosis is often delayed. Muzaffar and colleagues reviewed a total of 8,430 PET/CT reports from August 2006 to June 2011. The authors noted that whether the findings are apparent or very subtle, as in the case of abnormalities within the orbit, they can have a profound impact on patient management and appropriate follow-up. Given this patients differential diagnosis and concern, PET/CT can provide meaningful information toward the further evaluation of this patients retinal lesion. For these reasons, the requested PET/CT scan is medically necessary.
Appeal type: Medical Necessity
Decision: Overturned

A 58-year-old female has requested past and future coverage for portable (home) sleep studies for evaluation of her sleep apnea.  Findings:  The physician reviewer found that home sleep monitoring is now considered an accepted alternative to laboratory testing in selected patients. Specifically, it is recommended by the American Academy of Sleep Medicine and is approved by Medicare. In this case, a follow-up after surgery was indicated to determine if the patients sleep apnea was controlled. Control of sleep apnea was one of the goals of the surgical procedure. A home sleep test is a clinically reasonable method for determining whether the surgical treatment for sleep apnea was effective. The Stardust II recorder was used during the test, which fully satisfies the American Academy of Sleep Medicine Level III device criteria for home sleep monitoring. With regard to future portable (home) sleep studies, there may be an indication for this, should the patient experience significant weight loss, which can lead to resolution or decrease in the severity of sleep apnea. However, use of the home sleep studies are not considered medically necessary to repeat if the patient has gained weight or if there are no changes in her condition. Moreover, they are not indicated for CPAP evaluation. For these reasons, the requested future use of portable sleep studies is not supported as medically necessary at this time.
Appeal type: Medical Necessity
Decision: Upheld

The spouse of an 87-year-old female has requested skilled nursing facility services for the treatment of the enrollees cellulitis at gastrostomy tube site and urinary tract infection. Findings:  The physician reviewer found that the patient had been in an acute hospital prior to her skilled nursing facility admission. The medical records note that she was medically stable. The physician orders included an order for vital signs to be checked two times per day. Intravenous treatment every 12 hours can be administered at a lower level of care than skilled nursing care. The patients vital signs and examination were stable and did not suggest that the patient required skilled nursing facility care. This patient could have safely been treated at a lower level of care.
Appeal type: Medical Necessity
Decision: Upheld

The patient is a 41-year-old female with an apparent past history of Graves disease. The submitted notes state the patient has moderate skin excess and mild second-degree ptosis. The patient reports her lashes point downward obstructing her vision. The patients provider has recommended a bilateral upper blepharoplasty. The Health Plan has denied coverage for the requested procedure on the basis that it is not medically necessary.In general Graves disease (if it is in fact present here) causes problems with exposure. The need in such cases is not to open the eyes more but to be able to close them to protect the cornea and avoid the problems of keratitis and possible corneal ulcers, etc. The submitted photographs show the patients pupils are not covered and her eyelids do not obscure her vision. As such, there is no medical indication for the requested procedure. Therefore, I have determined the requested procedure is not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.