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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for hour long weekly physical therapy appointments for treatment of the enrollees medical condition. Findings:  The physician reviewer found that there is a lack of support in the medical literature for the services at issue in this clinical setting. At present, treatment recommendations generally revolve around relative rest, stretching, strengthening exercises, and passive modalities for palliation and improved tolerance for exercise. Eccentric load training is generally considered an appropriate measure for relieving symptoms and improving outcomes. In this patients case, he has undergone surgery and extensive physical therapy. He continues to have some symptoms but is able to ambulate significant distances independently. He has undergone sufficient therapy to be educated on independent stretching and strengthening exercises, including training in eccentric exercises. The records show that he can predominately perform independent exercises, receive modalities independently and perform self-massage, with no anticipated marginal difference in clinical course or outcomes versus exercises, manual therapy and modalities received in frequent and long therapy sessions in a formal setting. The literature does not support a proven benefit of long-term, high-intensity therapies, including manual therapy, in the setting of Achilles tendinopathy or post-tendon repair with respect to health or functional outcomes. For these reasons, hour long weekly physical therapy appointments are not medically necessary for treatment of this patient. Final Result: The reviewer determined that the services at issue 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 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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Cuvitru 10 mg every seven days for treatment of the enrollees non-specified immunodeficiency disorder. Findings:  The physician reviewer found that Selective antibody deficiency with normal serum immunoglobulin concentrations is a deficiency of specific antibody response to polysaccharide antigens with intact response to protein antigens and normal serum level of IgG and IgG subclass. Immunoglobulin replacement therapy with intravenous immunoglobulin (IVIG) or subcutaneous immunoglobulin preparations is a treatment option for this group of patients with recurrent infections that persist after immunizing and providing antibiotic treatment. In retrospective, uncontrolled series of pediatric patients, immunoglobulin replacement therapy led to significant decreases in the number of infections. In these studies, immunoglobulin replacement therapy was discontinued after one to two years, and the antibody-mediated immunity was re-assessed four to six months after discontinuation.   The studies observed that responses to the polysaccharide vaccine sometimes improve after treatment. The mechanisms for this improvement are presently unknown. This patient has normal levels of IgG, IgA and IgG subclasses.  The patient does not have documented evidence of abnormal post-vaccination pneumococcal (polysaccharide) titers.  There is only one set of pneumococcal titer and it is unclear if it is pre or post-vaccine titer.  Furthermore, the patient has been receiving IVIG while these laboratory studies were performed which would affect the validity of the results. The lack of proper immunodeficiency workup including pre- and post-pneumococcal titer is acknowledged by her treating provider in the progress note. However, given that this patient is most at risk for infection in the winter, it is medically necessary to carry out the complete immunodeficiency workup until after the winter season. A complete immunodeficiency workup is required while stopping the therapy. Therefore, Cuvitru 10 mg every seven days is medically necessary for treatment of this patients medical condition. 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 allergy and immunology 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 38-year-old female who indicates her vision is significantly impaired because of excess skin. According to the Health Plan, the patient has been evaluated by three ophthalmologists who do not believe the patients visual field loss is related to excess skin. The Health Plan indicates the patients impaired vision is due to dry eyes. The patient has requested authorization and coverage for blepharoplasty. The Health Plan has denied this request on the basis the requested procedure is cosmetic in nature, and therefore, not medically necessary.The Health Plans denial should be upheld. The submitted visual field tests are not characteristic of visual field loss secondary to excess skin. There is no significant superior visual field expansion despite the patients eyelids being taped. It was also noted the patients eyelids do not rest on her eyelashes. Given the evidence provided, I have determined that the requested procedure is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld

The patient is a 50-year-old male who was hospitalized with intracranial hemorrhage and leukemia. He had dramatically impaired consciousness. The patient was receiving IV antibiotics and PE tube feedings. An intracranial shunt was placed. He remained at an acute inpatient level of care through August 2006. The Health Plan indicates the patient could have been transferred to a sub acute level of care as of July 2006.Review of the submitted clinical evidence indicates the patient was stabilized by July 2006 and off antibiotics by July 2006. As of July 2006, the treatment plan was to discharge the patient to a skilled nursing facility. There was no change in the patients condition in July 2006 warranting continuation at an acute level of care. He was transferred to a recovery floor and was no longer in an acute medical unit. All of the patients medical issues were chronic in nature as of the last authorized date of service. All acute conditions had been addressed and stabilized by July 2006 and therefore there was no indication for continued acute hospitalization.For the reasons stated above, I have determined the services at issue were not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld

Findings:  The physician reviewer found that an enrollee has requested authorization and coverage for Lupin levonorgestrel and ethinyl estradiol tablets USP 0.1mg for birth control due to a diagnosis of Polycystic Ovarian Syndrome. There is a place for deference to branded birth control pills and the American College of Obstetrics and Gynecology has addressed this issue. The medical issue for why the patient is on the pill, management of her polycystic ovarian syndrome (PCOS), does not specifically command a particular formation of birth control pill. However, generic oral birth control pills (OCPs) approved by the FDA have been shown to be bioequivalent and pharmaceutically equivalent to the branded product and are interchangeable. There is no evidence-based data to challenge this conclusion. In this case, the patients provider has offered the patient several different alternative formulations to Lupin (not just generic equivalents of the same formulation), but the patient has declined these. There was no medical documentation provided to support a failure of alternative medications. The request for the branded OCP is not medically necessary as alternative, equally efficacious generic OCPs are available which contain the same active ingredients. Therefore, the requested Lupin levonorgestrel and ethinyl estradiol tablets USP .1mg is not medically necessary.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 obstetrics and gynecology 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 female enrollee requested residential treatment services for medical treatment of her depression and anxiety. Findings:  The physician reviewer found that progress notes from the patients treatment indicate the patients primary problems stemmed from chronic relationship issues. She did present with some depressive and anxious symptoms, but these were mild to moderate in nature, and did not require the intensity of care provided at the residential level of care. She was going for visits outside the treatment center and reportedly had appropriate behaviors in public. For these reasons, the patient could have been safely and adequately treated in a less restrictive setting. Therefore, residential treatment services were not medically necessary for treatment of this patients medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for genicular nerve block and radiofrequency ablation for treatment of the enrollees right knee osteoarthritis. Findings:  Three physician reviewers found that in the peer-reviewed medical literature, researchers reported that there is a need for further high quality randomized controlled trials with larger patient samples evaluating the use of radiofrequency denervation of the spinal zygapophyseal joints for musculoskeletal pain disorders. In this patient, radiofrequency ablation specifically referencing the superior lateral genicular nerve, the superior medial genicular nerve and the inferior medial genicular nerve will not address the documented problems of joint surfacing changes, malalignment with varus deformity, and likely intraarticular changes to menisci within the patients knee joint. Given the lack of support, the requested genicular nerve block and radiofrequency ablation are not likely to be more beneficial than standard treatment interventions for treatment of this patients right knee osteoarthritis. Final Result: The 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: Reviewers 1, 2 and 3 are board certified in orthopedic surgery and are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

A male enrollee requested a computed tomography (CT) scan for medical evaluation of his prostate cancer.  Findings:  The physician reviewer found that the National Comprehensive Cancer Network (NCCN) guidelines do not support the use of CT of the abdomen and pelvis in this clinical scenario where there is low risk for lymph node involvement.  The requested CT of the abdomen and pelvis is not medically necessary as the yield of imaging in the setting of little clinical risk of metastatic lymph node spread is very low.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for genetic testing. This patient meets National Comprehensive Cancer Network guidelines for testing based on having close relatives diagnosed with breast cancer at age 50. The enrollee also has a family history of a grandmother diagnosed with lung cancer at age 40 and a father diagnosed with lymphoma at age 21. The largest studies reporting on the outcomes of multigene testing indicate that among women tested in clinical settings, about 5 to 10 percent have a BRCA1 or BRCA2 mutation, and about 4 to 7 percent have a harmful mutation in another gene associated with high to moderate risks of breast and/or ovarian cancer, or a mutation in a newer gene that may also be associated with increased risks for these cancers. Panel testing is now considered a standard of care. In sum, genetic testing was likely to be of greater benefit than other methods of evaluating this patient. Findings:  Two of the three physician reviewers found 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.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 internal medicine with sub-specialty certification in medical oncology 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 parent of a 13-year-old female has requested coverage for past residential care provided for treatment of her bipolar disorder.  Findings:  The physician reviewer found that modern psychiatric practice aims to place patients in the least restrictive treatment setting.  In general, community intervention settings are thought to offer optimization of treatment gains.  However, due to multiple factors and unique considerations, determination of the appropriate level of care for adolescent patients with psychiatric conditions is a challenging endeavor.  In this patients case, residential care provided for the nine days at issue was medically indicated.  She had failed treatment at the initial residential treatment facility earlier in the year.  Considering the patients significant psychosocial stressors and the uncertain role or extent of the patients recurrent mood disorder, residential care was appropriate and medically necessary during the dates at issue.Per the medical records, the patient displays robust mood reactivity related to the pervasive parent-child relational conflicts.  In this clinical setting, intensive family therapy will be the central component in this patients treatment plan.  However, based on the records provided, the patient is not currently evidencing psychiatric symptomatologies that would justify placement at the residential level of care.  Given that community-based treatment facilitates more enduring and meaningful treatment gains, resumption of residential care is not medically necessary in this patients case.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for mastoplexy and fat grafting. The Health Plan has denied this request indicating that the requested services are not medically necessary and are not reconstructive in nature for treatment of the enrollees medical condition.There is support in the medical literature for the services at issue in this clinical setting. The patient is documented to have undergone medically necessary bilateral mastectomies followed by typical breast reconstruction. Based on the most recent evaluation, the patient has evidence of complications and deformities related to her medically necessary breast reconstruction. The patient has evidence of common complications associated with reconstructive breast surgery. Therefore, the recommended procedures for revision are consistent with standard procedures and standard of care. As such, mastoplexy and fat grafting are medically necessary for the treatment of this patients medical condition.With regards to whether mastoplexy and fat grafting are reconstructive in nature, the documentation supports that the requested services are reconstructive in nature. The patients bilateral mastectomies produced a severely abnormal appearance of the chest and breasts. The patient is documented to have continued breast deformities. The recommended surgical plan is aimed to produce relatively normal appearing breasts and would likely provide more than a minimal improvement in the patients appearance. For these reasons, mastoplexy and fat grafting are reconstructive in nature as defined by California law.Final Result: The reviewer determined that the requested services are medically necessary for treatment of the patients medical condition and are reconstructive in nature. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in plastic surgery and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Synvisc injections to the right knee. Per the medical literature, although viscosupplementation may relieve knee pain in some individuals with osteoarthritis, it is not known as to which individuals will benefit. The current evidence is limited, and guidelines from organizations such as the American Academy of Orthopedic Surgeons indicate that the evidence is not conclusive. In light of the foregoing, viscosupplementation can only be recommended in individuals with a history of lasting benefit from prior injections, and in carefully selected cases where everything else has been tried, and the options are limited. In this case, the patient has tried and failed other conservative treatments including arthroscopic surgery, NSAIDs, and cortisone injections, with the alternative being a total knee replacement. Given the patients limited options and based on the current medical literature, the requested services are medically indicated. Therefore, Synvisc injections to the right knee are medically necessary for the treatment of this patient.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 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: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested reimbursement for laboratory testing for allergies (immunoglobulin G (IgG) food sensitivity testing). Findings:  Three physician reviewers found that there is a lack of support for the services at issue in this patients case. Food-specific IgG testing does not predict true food hypersensitivity, and may actually be a marker of earlier development of food tolerance. Food-specific IgG tests typically yield multiple positive results and may represent a normal immune response to foods. Per the medical evidence, food-specific IgG testing should not be used as a tool to diagnose food allergy, and the positive food should not be eliminated from the diet based upon results of these tests. The standard evaluation of food allergy consists of blood immunoglobulin E (IgE) level for foods and skin testing. IgE immunoassays are in vitro assays used to identify food-specific IgE in the serum. These tests are widely available. Immunoassays have demonstrated very high positive predictive accuracy for several of the major food allergens. Skin testing for food-specific IgE is used in the diagnosis of IgE-mediated food allergies. A positive skin test to a particular food indicates the possibility that the patient has true allergy to that food. Therefore, laboratory testing for allergies (IgG food sensitivity testing) was not likely to have been superior over other methods of evaluating this patient.Final Result: The reviewers determined that the services at issue was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: Physician reviewer 1 is board certified in allergy and immunology and is actively practicing. Physician reviewers 2 and 3 are board certified in pediatrics and allergy and immunology 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.