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 brachioplasty, breast lift and excess skin removal surgeries. The American Society of Plastic Surgeons practice parameters on the surgical treatment of skin redundancy for obese and massive weight loss patients notes that when surgery to remove extensive skin redundancy and fat folds is performed solely to enhance a patient's appearance in the absence of any signs or symptoms of functional abnormalities, the procedure should be considered cosmetic in nature. In this case, the documentation show that the patient has some residual fatty tissue fullness in her epigastric region, minimal abdominal skin laxity, and no abdominal pannus. While the patient reports rashes, the documents do not reflect that they are resistant to appropriate medical treatment. There is no functional disability from the patients reduced breast size and moderate breast ptosis. Therefore, brachioplasty, breast lift and excess skin removal surgeries are not medically necessary for the treatment of this patient.The California reconstructive surgery statute requires health insurers to cover reconstructive surgeries, defined as surgery performed to correct or repair abnormal structures of the body caused by congenital defects, developmental abnormalities, trauma, infection, tumors, or disease to do either of the following: (1) to improve function; (2) to create a normal appearance, to the extent possible. In this case, skin laxity after massive weight loss 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 the gain or loss of body mass. The appearance of the patient is normal and consistent with the gain and loss of weight. While the patient reports rashes, the documents do not reflect that the rashes are resistant to appropriate medical treatment. The requested services are not a surgical correction for normal function. For these reasons, brachioplasty, breast lift, breast augmentation, and excess skin removal surgeries are not reconstructive in nature for this patient.Final Result: The reviewer determined that the requested services are not medically necessary for treatment of the patients medical condition and are not reconstructive in nature. 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

A 58-year-old male enrollee requested hip resurfacing arthroplasty for treatment of his right hip osteoarthritis.  Findings:  The physician reviewer found that this patient has developed progressive degenerative joint disease in his right hip. He has had a successful left hip resurfacing and wishes to pursue this for his right hip. He has failed conservative measures. As this patient has already had a resurfacing on his contralateral hip and he is aware of the risks as with any other procedure, this procedure is supported as medically necessary for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for acupuncture services for treatment of the enrollees chronic neck and back pain. Findings:  The physician reviewer found that The physician reviewer found there is sufficient support for the requested services in this clinical setting. Given that the patient continues to be symptomatic with complaints of chronic, severe lower back and neck pain, an acupuncture trial for pain management and improvement in function is medically appropriate. A study concluded that adequate acupuncture treatment may reduce chronic pain in the neck and shoulders and related headache, and the effect lasted for three years. Researchers reported that acupuncture has been found to be more effective than no treatment for short-term pain relief in chronic low back pain. Final Result: The reviewer determined that the requested services 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 oriental medicine and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for positron emission tomography (PET) (CPT 78815) with computed tomography (CT) for attenuation scans. Renal cell carcinoma most commonly metastasizes to the lungs, bone, liver, and brain. Metastatic bone lesions from renal cell carcinoma are typically lytic in nature. Bone scintigraphy has limited sensitivity in diagnosing lytic bony metastases in comparison to PET/CT, which has higher sensitivity and accuracy. In the peer-reviewed medical literature, it is noted that the utility of PET/CT is limited for renal cell carcinoma. However, the authors found that PET/CT has a specialized role for the prediction of the degree of tumor differentiation and allows for prognosis of the disease. The authors concluded that PET/CT has higher sensitivity and accuracy when compared with bone scan to detect renal cell carcinoma metastasis to the bone. Monitoring patients in this clinical setting with osseous metastases with PET/CT can therefore change management based on these results. In this case, the patients provider specifically stated that the PET/CT studies were performed to help guide treatment decisions. Given this support, the PET (CPT 78815) with CT for attenuation scans were likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Findings:  Three of the three physician reviewers found the PET (CPT 78815) with CT for attenuation scans were likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Final Result: The 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: Physician reviewers 1, 2, and 3 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: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: A male enrollee has requested authorization and coverage for Norco 10-325 mg, for six (6) pills per day. Findings: the reviewer found that The Centers for Disease Control and Prevention states that when starting opioid therapy for chronic pain, providers should prescribe immediate-release opioids instead of extended-release/long-acting opioids. when opioids are started, providers should prescribe the lowest effective dosage, use caution when prescribing opioids at any dosage, and carefully reassess evidence of individual benefits and risks when considering increasing dosage per day. However, in the documentation available for review, no objective treatment goals for pain and function are noted for the requested medication. Thus, the need to use this medical therapy as the primary treatment strategy for pain has not been established. Moreover, not all non-opioid medications classes have been optimized or tried. For all these reasons, the requested authorization and coverage for Norco 10-325 mg, for six (6) pills per day, is not medically necessary for treatment of this patients medical condition.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 anesthesiology with sub-specialty certification in pain medicine and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition. Findings:  The physician reviewer found that Findings:  The physician reviewer found that
Appeal type: Medical Necessity
Decision: Overturned

The parent of a 15-year-old male enrollee has requested growth hormone (GH) therapy for the treatment of the enrollees short stature. Findings:  The physician reviewer found that the patient exhibited obvious short stature, had a decreased annual growth rate and marginally low IGF levels before beginning GH therapy. His bone age study indicated the epiphyses were open. The patient began GH therapy and has had a positive response. The findings suggest a degree of GH deficiency in addition to short stature. It does not appear the patient would achieve his mid-parental height without GH therapy.
Appeal type: Experimental/Investigational
Decision: Upheld

A 41-year-old female enrollee has requested transcranial magnetic stimulation (TMS) for treatment of her major depressive disorder. Findings:  Two physician reviewers found that the services at issue were not and are not likely to be more effective for this patient than other available treatment options. This patient is on a maintenance regime of TMS for the treatment of depression. There is a lack of medical literature that supports TMS in maintenance form beyond the acute phase for the treatment of major depressive episodes. In addition, there is a lack of studies in the medical literature that have systematically evaluated the treatment parameters and benefits of maintenance TMS (Janicak, et al). Furthermore, acute phase treatment of TMS is still less powerful in treatment refractory depression than ECT, and still does not have a top ranking in the treatment algorithm of major depression as does ECT. In sum, the TMS services from the time period specified were not and are not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.
Appeal type: Medical Necessity
Decision: Overturned

A 36-year-old female enrollee requested authorization and coverage of a laparoscopic cholecystectomy for treatment of constant pain in abdomen.  The health plan denied the enrollees request indicating that the requested procedure is not medically necessary.One physician reviewer performed a medical necessity Independent Medical Review.  The physician reviewer overturned the health plans denial on the basis that the requested procedure is medically necessary.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: A 56-year-old female enrollee has requested authorization and coverage for occipital nerve block injection for treatment of the enrollees chronic intractable migraine without aura.  Findings:  The physician reviewer found that the records do not indicate the presence of occipital neuralgia as documented by physical examination findings. Occipital nerve blocks are not supported for the treatment of migraine or other type headaches. Dilli and colleagues noted that greater occipital nerve blocks do not reduce the frequency of moderate to severe migraine days in patients with episodic or chronic migraine compared to placebo. Thus, the requested occipital nerve block injection is not likely to be superior over other treatment options. Final Result: Two of three reviewers determined that the requested services are not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: Physician reviewer number one is board certified in neurology 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.Physician reviewer number two is board certified in neurology 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.Physician reviewer number three is board certified in neurology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: At issue is whether transoral incisionless fundoplication (TIF) with Esophy-X device is likely to be more beneficial for treatment of the patients condition than any available standard therapy. A review of the records indicates the patient was evaluated for a diagnosis of acid reflux. On this date, the provider documented that the patient has acid reflux and a Hill Grade 2 valve.Findings:  Three physician reviewers found that the 2013 American College of Gastroenterology guidelines for the treatment of gastroesophageal reflux disease (GERD) reported that the usage of current endoscopic therapy or TIF cannot be recommended as an alternative to medical or traditional surgical therapy. A study finds that in a meta-analysis of five randomized trials and 13 prospective studies, proton pump inhibitor use after TIF increased over time, and the satisfaction rate was only approximately 70%. There is a lack of large volume, long-term, peer-reviewed outcome studies to support the use of this procedure for this patient.Final Result: The reviewers determined that the requested procedure is 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: Physician reviewers 1, 2 and 3 are board certified in internal medicine with sub-specialty certification in gastroenterology 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 is a 63-year-old male with erectile dysfunction. Treatment with a vacuum erection device was ineffective. Treatment with Viagra led to side effects such as heartburn and headache. He has tried Cialis with good results and his provider has recommended continued treatment with Cialis. The Health Plan has denied authorization for Cialis in part because there is no documentation of an underlying medical condition causing the patients erectile dysfunction. At age 63 this patient most probably has some level of vascular disease, which is at least contributing to his erectile dysfunction. Regardless, the treatment of erectile dysfunction is results oriented and is not directed at the cause of the dysfunction. Medications such as Viagra and Cialis are considered appropriate first-line therapies for the treatment of erectile dysfunction. It is documented that Cialis has been effective for this patient where other treatments have failed. As such, it is evident that Cialis is an effective, medically necessary treatment for this patients erectile dysfunction. Therefore, I have determined the Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Overturned

A 62-year-old female enrollee has requested Avastin and RU486 therapy for treatment of her malignant melanoma with metastatic disease to the lungs and liver. Findings:  The physician reviewer found that meningiomas are brain tumors arising from the dura mater of the brain. They typically grow slowly and are amenable to resection if pathologically classified as grade I. However, grade II and grade III meningiomas have higher proliferative rates and are usually only partially resected. Radiation therapy after complete surgical resection is the standard of care for atypical meningiomas based upon the available medical evidence (Jaaskelainen, et al). Systemic therapy is indicated for patients in whom surgical resection is not possible and in those with high grade disease. The medical evidence to support various chemotherapy agents is primarily comprised of observational studies (Newton). Since the disease is uncommon, one cannot expect rigorously designed randomized clinical trials confirming the use of chemotherapy. This patient has received the standard of care and the tumor has progressed. The patient is not considered a candidate for radiation treatment, which supports the use of systemic therapy. The patients provider has recommended combination therapy with Avastin and RU486. Therefore, the requested use of Avastin and RU486 in this patient is supported as appropriate and medically necessary.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Lupron or leuprolide acetate 11.25 mg every three months. The Endocrine Society clinical practice guideline for the treatment of gender-dysphoric/gender-incongruent persons notes, We suggest maintaining physiologic levels of gender-appropriate hormones and monitoring for known risks and complications. The guidelines further state that serum testosterone should be less than 50 ng/dL in transgender females and that serum estradiol levels should be between 100 and 200 pg/mL. While these guidelines note that leuprolide and transdermal estrogen were as effective as cyproterone and transdermal estrogen in a comparative retrospective study, the cited study was based on a small sample of 40 patients, with 20 patients receiving Lupron. In guidelines for the primary and gender-affirming care of transgender and gender nonbinary people, Deutsch mentions the use of gonadotropin releasing hormone (GnRH)  analogs, noting that they are used routinely in the care of peripubertal transgender youth requiring pubertal delay and have also been described in the care of transgender adults. The author notes that drawbacks to the use of GnRH analogs include the need for either repeated injections, multiple daily nasal sprays, or surgical implantation. In this case, while the records document that the patient has failed to achieve the recommended serum testosterone and estradiol levels for transgender females, given the lack of large prospective studies in current medical literature supporting the use of Lupron in this population, the requested medication is not medically indicated. Therefore, Lupron or leuprolide acetate 11.25 mg every three months 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 experience in gender dysphoria and transgender 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

The patient is a 64-year-old male with a history of diabetes, hypertension, and Cushings disease. He uses a four-wheeled walker to assist with ambulation. He indicates he is having difficulty with his current walker because of its five-inch wheels. The patient believes eight-inch wheels are necessary. The Health Plan has denied the patients request for eight-inch wheels.A physical therapy note from 6/21/04 indicates the patient does not utilize a walker in the home and is able to ambulate independently in the home with an SPC. Furthermore, a physical therapy note from 8/11/04 indicates the patient is able to ambulate with a walker without difficulty. Based upon this information, there is no evidence the requested eight-inch wheels are medically necessary. Therefore, I have determined the requested equipment is not medically necessary for the patients mobility. The Health Plans denial should be upheld.
Appeal type: Experimental/Investigational
Decision: Upheld

A 51-year-old female enrollee has requested base of tongue reduction for treatment of her severe obstructive sleep apnea.  Findings:  Two physician reviewers found that although the medical literature is replete with studies regarding radiofrequency techniques for tongue base reduction, there is no standard as to which procedures and techniques are best. The medical studies indicate that there is some success with radiofrequency tongue base ablation in treatment of OSA and results are also favorable in patients with mild to moderate OSA and when combined with other site procedures. However, the use of tongue base reduction in obese patients with severe OSA is not supported by the literature. All told, the requested base of tongue reduction is not likely to be more beneficial for the treatment of the patients medical condition than other available modalities.
Appeal type: Medical Necessity
Decision: Upheld

A 45-year-old female enrollee has requested an off-the-shelf unloader knee brace and related items for the treatment of her left knee, status-post anterior cruciate ligament (ACL) reconstruction, meniscectomy, and chondroplasty. Findings:  The physician reviewer found that the utilization of braces of various varieties has been the subject of much discussion, but evidence of their efficacy following ACL surgery is lacking in the medical literature. A study by Brandsson and colleagues noted that there is some evidence of decreased swelling, pain and wound drainage with bracing in the early post-operative period but on later follow-up, no differences were found. McDevitt and colleagues also failed to find any difference in clinical outcomes between patients who used braces and those who did not, and this has been seen in younger patients as well. Wright and Fetzers randomized clinical trial reached the same conclusion, as have reviews of the literature (noted by Smith and Davies). In this case, an immobilizer was used in the post-operative period and there is support in the literature for that use. However, there is a lack of evidence for the efficacy of the later brace at issue and therefore the denial was appropriate.