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

The patient is a 50-year-old male who had a sub-optimal flexible sigmoidoscopy in 2000. This was followed by a barium enema demonstrating diverticulosis. He has now requested a colonoscopy for screening purposes. He otherwise has no symptoms or family history of colon cancer. The Health Plan has denied authorization for the requested colonoscopy.The patients flexible sigmoidoscopy and barium enema occurred five years ago. The specificity and sensitivity of these exams is not equal to that of a full colonoscopy. A screening colonoscopy in an otherwise asymptomatic 50-year-old male is considered within standard of care and the appropriate diagnostic tool. Therefore, I have determined the requested colonoscopy is medically necessary for evaluation of the patients medical condition. The Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for bilateral breast reduction mammoplasty (CPT 19318).In this case, the patient complains of back, shoulder and neck pain. While there is mention of shoulder grooving as a complaint, it is not documented on physical exam or confirmed in the submitted photographs. The patient also complains of occasional rashes beneath both breasts that have been treated with over the counter medications, but there is no report of intertrigo that is unresponsive to medical management. There is also no report of chronic breast pain due to weight of the breasts, thoracic kyphosis, upper extremity paresthesia, headache, or congenital breast deformity. Because there less than two confirmed quality of life signs, the requested service would not be considered medically necessary according to ASPS criteria. In addition, the patients proposed resection of 200 and 250 grams per breast is below the 22nd percentile of 607 grams per breast at a body surface area (BSA) of 1.78 and below the 5th percentile of 272 grams per breast at the 5th percentile. This would qualify the procedure as cosmetic according to weight. Combining this lack of determination of medical necessity based on weight with the lack of determination of medical necessity based on ASPS criteria, the requested bilateral breast reduction mammoplasty (CPT 19318) is not medically necessary to treat the patients medical condition.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; or (2) to create a normal appearance, to the extent possible. In this case, the patient has breast ptosis, which is a normal structural change associated with aging. The patients appearance is normal, and the patients subjective complaints of functional disability from the weight of her breasts is not confirmed by any objective findings of significant breast weight for resection or photographic documentation of breast hypertrophy or shoulder grooving. Accordingly, the requested bilateral breast reduction mammoplasty (CPT 19318) is not reconstructive in nature for treatment of this patient.Final Result: The reviewer determined that the requested services are not medically necessary to treat 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 35-year-old female enrollee has requested  microdiscectomy at the lumbar L5-S1 level, performed using only regional anesthesia and without the need for pre-surgery x-ray for treatment of her back pain.   Findings:  The physician reviewer found that the patients in-network provider has recommended microdiscectomy under general anesthesia and requires two x-rays and inpatient hospital stay. This recommendation is not reasonable and not medically necessary in this clinical setting. Surgery on a pregnant female under general anesthetic, requiring two x-rays and inpatient hospital stay is not medically necessary and poses risk of harm to the patient and fetus. The requirement of two x-rays is not safe or reasonable as it exposes the patient and fetus to radiation. Moreover, surgery under general anesthesia is not the most appropriate form of treatment as it poses more risk of harm, compared to regional anesthesia. Thus, the patients out-of-network providers recommendation of microdiscectomy under regional anesthesia, without the requirement of pre-operative x-rays, and on an outpatient basis is medically necessary in this clinical setting as it poses the least risk of harm to the patient and fetus. Based on the documentation submitted for review and the peer-reviewed literature cited above, the requested services are medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld

The parent of a 13-year-old female enrollee requested revision eye surgery for medical treatment of the enrollees congenital ptosis of eyelid. Findings:  The physician reviewer found that surgical outcomes in congenital ptosis surgery are unpredictable, particularly if the patient has poor levator function. In these cases, a frontalis sling is indicated, and the functioning of the sling is incumbent upon the patient using the forehead muscle to elevate the eyelid. This is not always successful with unilateral slings because the patient will often times fall back on the better eye to see, and not utilize the frontalis muscle on the operated side to elevate the eyelid. The goal of the surgery is to clear the visual axis. However, absolute symmetry between the eyes is never achieved in these cases, and the patient and family are made to understand that multiple operations may be required over the patients lifetime to tighten the sling in order to simply clear the visual axis. Too much tightening leads to an inability to close the eye sufficiently as well as inappropriate lid margin rotation. This patients records do not demonstrate that revision surgery is medically necessary. The patients visual axis is cleared in the photograph showing her using the frontalis muscle. Despite asymmetry with the eyelids in repose, further surgery at present will cause more problems. Thus, the request for revision eyelid surgery is not medically necessary for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld

A 65-year-old male enrollee has requested Bicillin LA injections for the treatment of his chronic group B streptococcus infection.  Findings:  The physician reviewer found that there is a lack of evidence that group B streptococcal infection has been effectively prevented with antibiotics in non-pregnant adults. However, it is notable that Bicillin LA is not used for this purpose. This drug achieves relatively low levels in the blood, and group B streptococci are relatively resistant to penicillin. Doses several times higher than those recommended for group A streptococcal infection are recommended. Penicillin G or ampicillin is recommended by the CDC for prophylaxis. It is also unlikely the patient would still be carrying this organism after more than four years.
Appeal type: Experimental/Investigational
Decision: Overturned

A 46-year-old male with a history of metastatic colon cancer with progressive liver metastases is requesting authorization for SIRT with Sir Spheres treatment.  Reviewers Findings:Two out of the three physicians have determined that SIRT has shown good responses and outcomes in hepatic metastases in literature. Given the lack of available treatment options in this setting, SIRT is medically appropriate and should be authorized.
Appeal type: Medical Necessity
Decision: Upheld

An 18-year-old male enrollee has requested nasal septal/turbinate repair (rhinoplasty and resection inferior turbinate) for treatment of his medical condition.  Findings:  The physician reviewer found that The standard of care for symptoms of runny nose, sneezing and nasal congestion with findings of septal deviation and enlarged turbinates is to maximize medical therapy prior to recommending surgical intervention. The submitted documentation does not demonstrate that this has been done. The medical records do not specify the degree of septal deviation or the degree of anatomic nasal airway restriction.  Thus, the submitted documentation fails to establish the medical necessity of the requested nasal septal/turbinate repair (rhinoplasty and resection inferior turbinate). The available medical records do not demonstrate that the patients condition constitutes an abnormal structure of the body.  All told, the requested nasal septal/turbinate repair (rhinoplasty and resection inferior turbinate) is not medically indicated and is not reconstructive in nature.
Appeal type: Medical Necessity
Decision: Upheld

A 59-year-old female enrollee has requested for Xolair for treatment of her recurrent chronic sinusitis. Findings:  The physician reviewer found that there is no record of wheezing, coughing, shortness of breath, etc. Pulmonary function testing yielded normal results with no reversibility. Xolair is considered medically necessary for the diagnosis of allergic asthma. It is not indicated for the treatment of sinusitis and allergies.
Appeal type: Medical Necessity
Decision: Upheld

A 55-year-old male enrollee has requested Transfer Factor Therapy for treatment of his atopic dermatitis. Findings:  The physician reviewer found that there have been no randomized controlled trials to establish the efficacy of transfer factor for atopic dermatitis or contact dermatitis. A meta-analysis of all randomized controlled trials of the various treatments for atopic dermatitis found that there was reasonable evidence to support the use of oral cyclosporin, topical corticosteroids, psychological approaches and ultraviolet light therapy. There was insufficient evidence to make recommendations on maternal allergen avoidance for disease prevention, oral antihistamines, Chinese herbs, dietary restriction in established atopic eczema, homeopathy, house dust mite reduction, massage therapy, hypnotherapy, evening primrose oil, emollients, topical coal tar and topical doxepin. Finally, there are no randomized controlled trials to support the use of transfer factor in this setting.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested hypoglossal nerve stimulation surgery for treatment of the enrollees obstructive sleep apnea (OSA).  Findings: Two physician reviewers found that although the requested surgery is not considered standard, there is adequate data supporting its efficacy in well selected patients who have failed standard available therapies. This patient has OSA and has failed prior surgical management including uvulopalatopharyngoplasty, nasal reconstruction and other techniques in addition to therapy and failure with CPAP as well as mandibular advancement prostheses. The American Academy of Otolaryngology-Head and Neck Surgery (AAOHNS) considers upper airway stimulation via the hypoglossal nerve for the treatment of adult OSA to be an effective second-line treatment of moderate to severe OSA in patients who are intolerant or who are unable to achieve benefit with CPAP. The most recent long-term peer-reviewed publication of upper airway stimulation for OSA by Woodson and colleagues demonstrated that patients achieved a definitive benefit from the implantation and electrical stimulation of the hypoglossal nerve for treatment of OSA. Clinically, this patient has failed prior surgical attempts, has been intolerant of the use of positive pressure airway therapy and has reduced his weight to have a body mass index below 32. Thus, the requested hypoglossal nerve stimulation surgery is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: Two reviewers determined that the requested surgery is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: All three physician reviewers are board certified in otolaryngology 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

This patient is a 54-year-old woman with a history of multiple myeloma. There is also a reported diagnosis of amyloid heart disease. She developed a pneumonia that required hospitalization in August 2005. This followed several plasmapheresis treatments and the patient was said to have been markedly hypogammaglobulinemic at the onset of her pneumonia. As an inpatient, she was treated with vancomycin and levofloxacin. When discharged, she was given linezolid (Zyvox) and levofloxacin (Levaquin). Authorization for the Zyvox was denied because the Health Plan determined it was not medically necessary.Key to this case is the fact that no culture of sputum was performed although the patient was noted to have a productive cough. Zyvox is an excellent drug for methicillin-resistant staphylococcus aureus (MRSA) pneumonia. It is also a more desirable option than continuing vancomycin by outpatient IV administration. In this case however, the presence of staphylococcal infection was not documented.  Given the absence of documented evidence of staphylococcal infection, the use of Zyvox was not medically warranted. Therefore, I have determined the medication 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: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for ThyGenX services provided for evaluation of the enrollees thyroid nodules. Findings:  2/3 of the physician reviewers found that the report indicates that the cytopathology of the thyroid nodules was benign. The Bethesda System indicates that the risk of malignancy is 0 to 3% in benign nodules. The newest 2015 American Thyroid Associations guidelines state that nodules larger than 4 cm, like the dominant nodule in this case, might have larger risk for malignancy. The American Thyroid Association also recommends taking the patients history, ultrasound appearance and other clinical factors, including the institutions rate of malignancy, in consideration in order to make medical and surgical decisions. In this patients case, the provider recommended the ThyGenX test for the largest nodule. The result determined the management in this case, which was to perform radiofrequency ablation of the nodule to decrease its volume, rather than thyroidectomy. The study was indicated for the large thyroid nodule, in order to confirm benignity and determine management. Thus, ThyGenX services provided were likely to have been of greater benefit than other methods of evaluating this patient. Final Result: 2/3 of 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 reviewer number one is board certified in internal medicine with sub-specialty certification in endocrinology, diabetes and metabolism 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 internal medicine with sub-specialty certification in endocrinology, diabetes and metabolism 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 internal medicine with sub-specialty certification in endocrinology, diabetes and metabolism 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 reimbursement for intensive outpatient services. The progress notes during the disputed period indicate that the patient was minimally cooperative in treatment. Per the records, the patient had limited insight into her need for treatment. During the disputed timeframe, the patient was not expressing active suicidal ideation. She showed minimal commitment to therapy and also exhibited counterproductive behaviors. The patient continued to have symptoms of depression and anxiety. Overall, the submitted documentation indicated poor judgment and insight and impulsive behaviors. The records indicate that she was at continued risk for substance use as well as relapse. In cases such as this, an evidence-based, objective instrument such as the American Association of Community Psychiatrists Level of Care Utilization System (LOCUS) is indispensable in determining necessary and appropriate level of care for adults. In terms of risk of harm, the records support a score of 2 due to recent impulsive behaviors. With regards to functional status, the records support a score of 2 due to some problems in interpersonal interaction and school issues secondary to anxiety and substance use. In terms of medical, addictive and psychiatric comorbidity, the records support a score of 3. The records documented overall medical stability with mental health issues including anxiety and depression. With regards to level of stress of the recovery environment, the records support a score of 2 due to a stable living environment but strained relationship with family. In terms of level of support of the recovery environment, the records support a score of 2 due to supportive resources. With regards to treatment and recovery history, the records support a score of 3 due to minimal recent treatment response in the intensive outpatient program but consideration of continued depression and possible substance use. In terms of engagement and recovery status, the records support a score of 3 due to fair cooperation in treatment but limited ability to accept responsibility for recovery. Thus, the patient has a composite score of 17. This score correlates with intensive outpatient program level of care. Therefore, intensive outpatient services were medically necessary for the treatment of this patient.Final Result: The reviewer determined that the services at issue were 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 sub-specialty certification in child and adolescent 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

The parent of a female enrollee requested speech therapy for medical treatment of the enrollees medical condition.  Findings:  The physician reviewer found that the current medical evidence supports speech therapy in this clinical setting.  Law and colleagues noted a positive effect of speech and language therapy interventions for children with expressive phonological and expressive vocabulary difficulty.  All told, the requested speech therapy is medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld

A 62-year-old male enrollee has requested add-ons for the enrollees power wheelchair (K0108 TRX manual recline, K0108 power articulating leg rests, E2376 controller, E2313 electronic harness, E2300 elevating lift seat module 12 elevation and E2311 enhanced 5 function through joystick) for treatment of his medical conditions. Findings:  The physician reviewer found that the submitted documentation fails to establish the medical necessity of the requested equipment. The patient has a history of multiple sclerosis, primarily manifested by spastic hemiplegia and has been undergoing various therapy interventions, which have reported some beneficial effects on outcomes, including fatigue and spasticity, in this patients condition (Beer et al; Amatya et al). The request for manual recline is not medically necessary as the medical records provide no objective indications that the patient is unable to independently transfer to a bed, chair or other surface, even when using devices such as a sliding board. Moreover, the medical records submitted for review do not document testing of transfers in physical therapy. The request for power articulating leg rests is not medically necessary. The documentation submitted fails to provide evidence of a physical examination of the lower limbs demonstrating lower limb edema, including the degree of the edema and failure of basic interventions such as compression stockings. The elevating left seat module is not medically necessary. The documentation submitted for review fails to provide evidence that indicates the patient requires power seat elevation in order to accomplish transfers into and out of the wheelchair. Moreover, using power seat elevation to access items that are placed in high areas such as cabinets is a matter of convenience, and not medically necessity. These items can be resituated in areas that are more accessible to a person in a standard wheelchair. Finally, the request for a controller, electronic harness and joystick also are not medically indicated as the additional customized electronics for controlling the requested additional features are not medically necessary. Based upon the documentation submitted for review and the peer-reviewed literature cited above, the medical necessity of the requested equipment has not been established in this clinical setting.