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

The patient is a 47-year-old female with a body mass index (BMI) of 41.7. She has multiple comorbid conditions. The patient wishes to undergo gastric bypass surgery. The Health Plan has denied this request indicating the patient has had a rapid weight gain over the past two years without any documented objective evidence of attempts at non-surgical weight management. At issue is whether gastric bypass surgery is medically necessary for treatment of the patients condition.The Health Plans denial should be upheld. The submitted documentation indicates the patient experienced a rapid rise in her weight over the past two years. It appears further workup is in order to investigate the etiology of the patients rapid weight gain. Furthermore, based upon the evidence provided, further attempts at non-surgical weight management should be attempted prior to consideration of gastric bypass surgery. Therefore, I have determined the requested surgery is not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Experimental/Investigational
Decision: Overturned

A 49-year-old female enrollee has requested radiofrequency ablation (RFA) for the treatment of her Chronic Regional Pain Syndrome (CRPS). Findings:  Two physician reviewers found that the National Guidelines Clearinghouse addresses the issue of sympathectomy and states that published data suggest that sympathectomy in properly selected RSD/CRPS patients may provide one of the most effective treatments for RSD/CRPS. The selection criteria for sympathectomy are critical in achieving long-term success. This applies to this patient who underwent successful anesthetic blocks and good long-lasting pain relief with radiofrequency treatments. Although the patients pain returned after several months, this is usually the case in chronic pain management due to its complex mechanisms and pathophysiology. Several months of good pain relief is a success and not a failure. The requested procedure has demonstrated efficacy for this patients condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for residential treatment center services provided and intensive outpatient program (IOP) services provided for treatment of the enrollees behavioral health condition. Findings:  The physician reviewer found that residential treatment center services provided were medically necessary for treatment of the patients behavioral health condition. According to the documentation submitted for review, the patient had mild to moderate post-acute withdrawal symptoms as well as intense cravings, erratic sleep, and requiring prompting to adequately attend to ADLs. For the reasons provided, the residential treatment center services provided were medically necessary.  However, there were no emotional, behavioral, or cognitive symptoms to warrant ongoing IOP. He was not a danger to himself or others. He was medically and psychiatrically stable. He was not agitated, nor was he manic or psychotic.  He verbalized motivation and appeared to be engaged and working the program. He was attending daily 12-step meetings and had secured a sponsor. There were no new problems that had arisen and he was working on issues with guilt and anxiety which could have continued on an outpatient basis. He no longer required recovery treatment that IOP provided. Based on the documentation submitted for review, the patient could have been treated at a lower level of care such as outpatient treatment in conjunction with a 12-step program and the support of his sponsor. For the reasons provided, the IOP services provided were not and are not medically necessary for treatment of 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 with sub-specialty certification in addiction medicine and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

The patient is a 64-year-old woman with a subacute onset of a painful asymmetric motor neuropathy. She has tried Darvocet, Percocet, Vicodin, and was placed on Actiq 800mcg as needed for pain control. She is also on Neurontin and Lidoderm patch. The patient has been treated with oral prednisone. There is no evidence she is taking long-acting narcotics. A request has been made for authorization and coverage for Actiq. The Health Plan has denied this request citing a lack of medical necessity for the drug.Based on the clinical information provided, it appears the patient has neuropathy of unknown etiology. She has severe pain associated with this condition. However, there is no evidence she is taking any long-acting opiates. Standard of care for patients such as this patient would include a long-acting opiate such as transdermal fentanyl or long-acting oxycodone or morphine. Actiq is typically used for breakthrough pain in patients with severe malignant and non-malignant pain. It is not indicated as primary pain management for neuropathic pain. Therefore, I have determined the requested medication is not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld

A 56-year-old female enrollee has requested an oral appliance for treatment of her obstructive sleep apnea.  Findings:  The physician reviewer found that this patients records support the diagnosis of mild sleep apnea. The patients treatment options include NCPAP and a dental appliance. Although the patient underwent numerous sessions of myofascial release and transcutaneous electrical stimulation, there is inadequate documentation regarding the level of patient compliance and the effectiveness of the NCPAP. If the patient was documented to be intolerant of the NCPAP, then consideration could be given to a dental appliance. Based on the records provided for review, the oral appliance at issue in this patients case was not medically necessary.
Appeal type: Medical Necessity
Decision: Upheld

The patient is a 74-year-old male who was hospitalized in July 2004 for dysphagia. At that time he was found to have perforation of his esophagus. He also had a past history of chronic lymphocytic leukemia for which he was not on any specific treatment. He was apparently transfused and started on Epogen, though his hemoglobin was 12.3. It appears Epogen was continued while the patient was in an extended care facility. It was noted that a hemoglobin on 8/2/04 was 12.5. The patient is seeking reimbursement for the doses of Epogen he received. The Health Plan has denied the patients request on the basis that Epogen was not medically necessary for treatment of the patients medical condition. Epogen is a bone marrow stimulant, which can increase hemoglobin and correct anemia. The Health Plan indicates hemoglobin must be below 11 and/or the patient must be receiving chemotherapy to qualify for Epogen use. The patient met neither of these criteria and in fact it does not appear he was anemic during the period at issue. The Health Plans criteria are medically reasonable and appropriate and consistent with community standards. As such, 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: Urgent Care
Decision: Upheld

A 46-year-old female enrollee has requested for an emergency room for treatment of her abdominal pain. Findings:  The physician reviewer found that an emergency medical condition is defined as acute symptoms of such severity that a prudent layperson would believe the absence of immediate medical attention would result in placing the members health in serious jeopardy. This patients symptoms were not acute in onset and had been present for one week. Her pain was not severe, but rated a 2 on a scale of 1 to 10. The patient did not require any medications in the emergency department.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has been diagnosed with Crohns disease. The provider noted that the patient had been treated with Remicade, Humira, Cimzia, Entyvio, and azathioprine. The provider noted the patient was status post small bowel resections and had failed treatment with Entyvio and Stelara 90 mg every eight weeks. The provider noted that the patient was taking Stelara 90 mg every four weeks. The patient reported that her symptoms, including diarrhea, had significantly improved. The patient has requested authorization and coverage for Stelara 90 mg every four weeks. The Health Plan denied the request and reported the requested medication regimen is not medically necessary for the treatment of this patient. At issue in this case is whether Stelara 90 mg every four weeks is medically necessary for the treatment of the patients medical condition. Researchers demonstrated the safety and efficacy of Stelara for induction and maintenance of remission in patients with moderate to severe Crohns disease that were resistant to anti-tumor necrosis factor (TNF) therapy. Researchers also performed a retrospective open-label study. The authors reported, The results of our study provide further evidence that subcutaneous ustekinumab treatment is associated with a sustained clinical response in the majority of anti-TNF resistant Crohns disease patients. In a study Patients received 90 mg of ustekinumab subcutaneously at weeks zero, one, and two during induction and 90 mg every four or eight weeks during maintenance. In this case, the patient has failed multiple biologic and conventional alternatives, and failed Stelara every eight weeks. She did have a response to Stelara every four weeks. Current medical literature supports Stelara 90 mg every four weeks in this clinical setting. Therefore, Stelara 90 mg every four weeks 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 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: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Hyalgan injections in the left knee. Guidelines from the American Academy of Orthopedic Surgeons indicate that the data on safety and efficacy of viscosupplementation remain inconclusive. As such, the AAOS does not currently recommend viscosupplementation as standard treatment. Hyalgan is not U.S. Food and Drug Administration (FDA) approved for treatment of a torn meniscus. Overall, the medical literature and AAOS no longer support the routine use of Hyalgan due to findings of poor efficacy. Therefore, the requested Hyalgan injections in the left knee are not medically necessary for treatment of this patient. Final Result: The reviewer determined that the requested services are 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 orthopedic surgery and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

A 45-year-old female has requested the medication Penlac for treatment of onychomycosis.  Findings:  The physician reviewer found that the submitted medical records do not document that the patients nail infection was painful or causing functional disability for the patient. Given the greater success rates of Lamisil, it is the preferred therapy in this clinical setting. Additionally, there is no evidence of contraindication of use of Lamisil in this case (e.g., abnormal liver function tests).
Appeal type: Medical Necessity
Decision: Upheld

The parent of a four-year-old female enrollee has requested lysis of labial adhesion surgery for the treatment of the enrollees labial adhesions.  Findings:  The physician reviewer found that labial adhesions typically responds to topical estrogen, topical steroids, gentle manipulation, and hygiene measures. In the absence of severe symptoms, (inability to void or severe pain), treatment should be limited to these measures. There is no clear indication from the records of an attempt at topical therapy other than Nystatin. Therefore, surgery is not currently necessary and is not the next appropriate step in the treatment of this condition.
Appeal type: Medical Necessity
Decision: Upheld

A 54-year-old female enrollee has requested for chiropractic services for treatment of her sciatica.  Findings:  The physician reviewer found that the American Chiropractic Association and CMS guidelines, the treating provider is expected to keep and maintain adequate case records clearly showing and indicating the progression of care (visit to visit), clinical impressions based on documented examinations/re-examinations, provocative and palliative responses to care and onset of exacerbations. The provider is expected to have a clear assessment of the patients condition and evaluation of treatment effectiveness (case management). The SOAP notes fail to follow progression, functional gains, type of chiropractic technique used, and what specific segments were adjusted at each visit.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested Norco for treatment of her medical condition.  Findings:  The physician reviewer found that based on the documentation submitted for review, the medical necessity for Norco has not been established. According to Peppin and colleagues, several prominent guidelines recommend that patients on long-term opioid therapy have periodic urine drug monitoring to ensure appropriate use. In this case, the patient presents with multiple medical issues including chronic low back pain, ADHD and fibromyalgia. She failed a recent urinary toxicology. Given the inconsistencies in urinary toxicology, enrollment in a pain management program, psychological follow-up is indicated prior to providing Norco. Given the above, the requested medication is not medically necessary for treatment of the 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-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.
Appeal type: Medical Necessity
Decision: Overturned

A 42-year-old female has requested breast implant removal for treatment of neck and shoulder pain.  Findings:  The physician reviewer found that based on review of the available records, the patient had undergone previous breast augmentation. She complains of chronic neck and back pain, which is well documented. These are functional complaints. She is undergoing multiple medical therapies including narcotics, non-steroidal anti-inflammatory drugs (NSAIDs) and muscle relaxants. She also has upper extremity parasthesias that could be related to her breast size. Her source for pain is most likely multifactorial. She has a history of traumatic injury, which is part of the etiology. However, her large implants have contributed to the worsening of her symptoms. Her examination and documented standard breast dimensions, nipple to inframammary distances, and notch to nipple distances are consistent with macromastia causing functional impairment. The patient has functional complaints related to her breast size and dimensions. This appears to be severe and significantly affecting her daily activities. She has attempted to treat her condition with medical therapy and physical therapy. This has not been successful. Work-up of her pain complaints has also been performed. Breast implant removal would therefore not be considered cosmetic treatment in this patient. The records document that she has a severe functional problem due to augmented breasts and would likely benefit from removal. With respect to capsulectomy, the patient has not been adequately documented to have capsular contracture and this should not be considered a separate procedure that is medically indicated. The source of the functional problem is weight and volume of the breasts but this is not a capsule related issue. In summary, breast implant removal is medically necessary, but capsulectomy is not medically necessary for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The parent of a 14-year-old male enrollee has requested authorization and coverage for orthodontic treatment including D0330 (panoramic x-ray), D0340/D0350 (cephalometric images), D0470 (diagnostic casts), D8080 (comprehensive orthodontic treatment), D8670 (periodic orthodontic treatment), D8680 (orthodontic retention) for treatment of the enrollees dental issues. Findings:  The physician reviewer found that as the need for orthodontic treatment can involve subjective assessments, there have been several objective tools developed as a means of comparing need for treatment. One such tool is the HLD. With the HLD, a score typically greater than 25 qualifies for treatment as a severe need. In this case, the corrected score was computed at 20, which is well under the threshold for treatment. There are several factors provided to exempt this score and qualify automatically based on medical or dental conditions. However, the documentation provided does not describe any conditions which would supersede and support an indication for the requested treatment. While this patient would benefit cosmetically and would show an improvement in chewing with orthodontic treatment, the records provided for review do not meet the threshold of medical necessity. For these reasons, the requested orthodontic treatment including D0330 (panoramic x-ray), D0340/D0350 (cephalometric images), D0470 (diagnostic casts), D8080 (comprehensive orthodontic treatment), D8670 (periodic orthodontic treatment), D8680 (orthodontic retention) has not been demonstrated to be medically necessary for treatment of the patients medical condition. Final Result: The reviewer determined that the requested services are 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 oral and maxillofacial 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: Experimental/Investigational
Decision: Upheld

A 35-year-old male enrollee has requested balloon sinuplasty for treatment of his chronic rhinitis, polyps/retention cysts, and chronic tonsillitis. Findings:  Three physician reviewers found that this patient has allergic rhinitis which generally responds to nasal steroid sprays. The minimal disease seen on computed tomography (CT) scan is most likely related to the allergic rhinitis and would not be substantially improved with surgical intervention. Based on the available peer-reviewed medical literature, balloon sinuplasty is a treatment option for well selected patients. However, this patients records do not document any indication for sinus surgery as the patients primary issue is allergic rhinitis. All told, the requested balloon sinuplasty is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.
Appeal type: Experimental/Investigational
Decision: Overturned

A 40-year-old male enrollee has requested for a UVB light therapy system for home use for treatment of his eczema. Findings:  Two physician reviewers found that the peer reviewed medical literature indicates that the treatment of atopic dermatitis typically includes the use of corticosteroids and phototherapy, including broad-band UVB-bb, which has been shown to be effective. Therefore, the use of a UVB light therapy system for home use is medically appropriate.
Appeal type: Medical Necessity
Decision: Upheld

A 43-year-old female enrollee has requested filler and/or Botox injections for the treatment of her medical condition. Findings:  The physician reviewer found that the submitted documentation including photographic evidence reveals that the appearance of the patients scar is within the range of what most observers would consider an acceptable result following a biopsy of a suspicious lesion. In this sense, it is not an abnormal structure following a biopsy. Furthermore, the collagen and/or Botox injections would not improve the patients function and would provide little or no improvement in her appearance. As such, the requested service does not meet the requirements of Californias reconstructive surgery statute. As to the medical necessity of the requested service, multiple physicians have evaluated the patient and have indicated that the outcome is good given her skin type and the procedures that have been performed. In addition, the photograph shows a relatively inconspicuous and well-healed scar. There is little likelihood that the patients appearance will improve with additional interventions. As several of the patients providers have indicated, there is concern about the probable outcome of more treatment to the area. Based on the submitted photograph which shows a good quality scar, this patient is unlikely to derive any significant improvement with additional interventions, and as such, the proposed service is not medically necessary.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a 12-year-old male enrollee has requested custom foot orthotics for treatment of the enrollees flexible cavus foot. Findings:  The physician reviewer found that in this patients case, the use of the requested custom foot orthotics is in accordance with the generally accepted standards of medical practice. The current medical evidence supports the use of the requested equipment in this clinical scenario. The submitted documentation has established the medical necessity of the recommended polypropylene custom orthotics. The requested equipment has been used extensively for decades to help control abnormal motion in the foot.  Their efficacy is supported in numerous scientific studies, and their use is standard of care in the medical community.  In this patients case, a pair of custom orthotics will help control the abnormal pronation and alleviate his arch pain.  All told, the requested custom foot orthotics are medically indicated for this patient.