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

A 31-year-old male enrollee has requested abdominoplasty for treatment of her stated condition of pain in his abdomen, hip and rib areas.   Findings:  The physician reviewer found that abdominoplasty is a cosmetic procedure that involves placement of transverse suprapubic/lower abdominal and periumbilical incisions. The abdominal skin is then tightened by excising the caudal portion of abdominal skin and creating a new umbilical opening higher up on the skin that has now been stretched downward. In most cases tightening of the abdominal musculature is also performed by suture plication of the rectus sheaths. The result is frequently improved by liposuction performed at the same operation. It is not a medically necessary procedure unless the excess skin is required to close an open wound rather than being removed for cosmetic reasons.Panniculectomy is a lesser procedure that only involves removal of the lower abdominal skin without the muscle tightening or the supraumbilical skin tightening via periumbilical and lower abdominal incisions. It would be medically necessary rather than cosmetic in nature if the removed skin has a history of recurrent infections, is necrotic, etc. The pannus would have to be quite large to cause lower back pain. In this case, the patient is complaining of pain in his abdomen, hip and rib areas. It is highly unlikely that removal of the pannus would affect the patients symptoms. The mere presence of a pannus and/or its physical burden on the patient does not automatically make its removal medically necessary. There is no evidence in the reviewed materials that would support the medical necessity of either an abdominoplasty or panniculectomy in this case.Furthermore, the proposed abdominoplasty does not meet the requirements of reconstructive surgery as defined by California law. The submitted documentation does not demonstrate the patients abdominal pannus is an abnormal structure of the body caused by infection, trauma, tumor or disease. The excess tissue is not so great as to be considered a structural abnormality. In addition, the submitted records do not include evidence that the excess abdominal tissue is infected or compromised in any way. Thus, the requested abdominoplasty is not considered reconstructive surgery pursuant to California Health and Safety Code 1367.63.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary:  An enrollee has requested a separate anesthesiologist to administer anesthesia during a facet injection procedure for treatment of the enrollees upper thoracic pain. The physician reviewer found that based on the clinical documentation submitted for review, the medical necessity for a separate anesthesiologist to administer anesthesia during the facet injection procedure has not been established. In this case, the patient does not present with a significant history that would require monitored anesthesia care. The standard of care for administering monitored anesthesia care for a minimally invasive procedure is airway difficulty, large fluid shifts and co-morbid conditions that would put the patient at risk during the procedure. There is no documentation of co-morbid conditions that would place the patient at risk for complications requiring the need for monitored anesthesia care. Based on the documentation submitted for review and the peer-reviewed literature cited above, the requested services are not medically necessary for treatment of the patients medical condition. 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 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.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary:  An enrollee has requested authorization and coverage for Humira 80 mg per week.According to Alikhan and colleagues, treatment with biologics is currently one of the mainstays of therapy in the United States. Humira is currently the only U.S. Food and Drug Administration (FDA) approved medication for this disease. Humira is currently approved at 40 mg weekly. However, there is a study by Zouboulis and colleagues that shows that dose escalation to 80 mg weekly is more efficacious. Moreover, it has been proposed that obese patients may need higher dosing. In this case, the patient has done well on Humira 40 mg weekly but still has flaring symptoms, which may indicate that she needs alternative treatment. This can be initially accomplished by escalating her dosing of the Humira to 80 mg weekly. Given this patients BMI, since this patient is still flaring at the standard dose of Humira, it would be appropriate for this patient to have a trial of dose escalation to 80 mg weekly to see if this can control this chronic disease. Thus, Humira 80 mg per week is medically necessary for the treatment of the 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 dermatology 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 45-year-old female enrollee has requested thermography for breast cancer screening for evaluation of her medical condition.  Findings:  Three physician reviewers found that thermography appears nowhere in the National Cancer Institutes Physician Data Query on breast cancer screening where multiple modalities are discussed. Additionally, in 1990, the American College of Radiology concluded that, thermography has not been demonstrated to have value as a screening, diagnostic, or adjunctive imaging tool. Finally, thermography has many false positives and it has proven to be an unreliable screening test for breast cancer (Goldsmith). A modality such as this would need to be compared head-to head with the success of mammography before its efficacy and/or superiority can be shown. At this time, such studies are lacking.
Appeal type: Experimental/Investigational
Decision: Overturned

The parent of a seven-year-old male enrollee has requested for a magnetoencephalography (MEG) and magnetic source imaging (MSI) for evaluation of the enrollees epilepsy prior to surgery.  Findings:  Three physician reviewers found that there are limited studies that allow proper localization of an epileptogenic focus. MEG has been shown in multiple studies to enhance the ability to determine the seizure focus through less invasive means.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested authorization and coverage for an additional five (5) hours per week (260 units) of direct applied behavioral analysis (ABA) therapy (Code 0365T) for treatment of the enrollees autism.Findings:  The physician reviewer found that in this case, the patient demonstrates significant delays in social skills and adaptive skillsets along with significant outbursts of self-injury and aggression. The patient continues to require a high level of behavioral support as evidenced by the treatment goals set forth by the treating provider. Failure to demonstrate progress in these areas puts the patient at an increased risk for injury, and makes it increasingly difficult to be successful in more generalized environments. 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 pediatrics with sub-specialty certification in developmental-behavioral pediatrics 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 51-year-old female enrollee requested authorization and coverage for gastric bypass surgery for the treatment of morbid obesity complicated by gastroesophageal reflux disease (GERD).  The health plan has denied this request indicating that the requested surgery 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: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested coverage for inpatient mental health services for treatment of the enrollees behavioral health condition.  Findings: The physician reviewer found that inpatient mental health services were not medically necessary for treatment of the patients behavioral health conditions. The patient was paranoid, labile and bizarre with thought blocking. However, the following day he dismissed the behavior and he was noted to be calm, appropriate and communicative. He was not paranoid. He was sleeping and eating well. He had a good visit with his parents and had plans to discharge to their home before moving to an apartment. The psychiatrist noted that the patient was taking and tolerating his medications. There were no medication changes as he continued lithium, bupropion, eszopiclone, propranolol and buspirone. He was neither violent nor aggressive on the unit. He was coherent, logical and goal directed. He was anxious and depressed, but he was not suicidal, paranoid or delusional. He was sleeping well at night. He had a supportive family. Although ongoing care is indicated, there was no evidence of an acute psychiatric syndrome and the patient had a safe plan for aftercare. As such, the services at issue were not medically necessary.Final Result: The reviewer determined that the services at issue were 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 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: Upheld

A 64-year-old female enrollee requested authorization and coverage of treatment with the medication thalidomide. The Health Plan  denied the request indicating that the requested medication is not medically necessary for treatment of the enrollees ovarian cancer.  One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer upheld the Health Plans denial on the basis that the requested medication is not medically necessary.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a two-year-old female enrollee has requested speech therapy (one hour sessions, one time per week) for treatment of the enrollees developmental language delay. Findings:  The physician reviewer found that the submitted documentation supports the medical necessity of the requested services.  Speech and language delay must be taken seriously in young children, because the long-term consequences may be substantial.  The current medical evidence supports the requested speech therapy in this clinical setting.  Bernhardt and Major noted that early phonological and metaphonological intervention can promote normalization of speech development for some children with severe phonological impairment.  Broomfield and Dodd noted the benefit of speech and language treatment compared to no treatment in children with primary speech and language impairment.  This patient has isolated expressive language delay, with difficulty with imitation of sounds and words.  The medical literature supports intensive speech and language therapy for expressive language delay.  All told, speech therapy (one hour sessions, one time per week) is medically indicated for the treatment of this patient.
Appeal type: Experimental/Investigational
Decision: Upheld

A 56-year-old male enrollee has requested for VitalStim therapy for treatment of his condition.   Findings:  Two physician reviewers found that there is very little information or support for the use of this in post-radiation patients who are likely to have severe fibrosis of the soft tissue and musculature of the pharynx, as opposed to incoordination or weakness of the swallowing apparatus.  The one group that studied post-radiation patients specifically looked at patients who had undergone therapy two to four months post-radiation. There were 12 patients studied.  As such, at this time, it is not possible to state that VitalStim therapy would be any more effective than any standard swallowing therapy for this particular patient.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a seven-year-old female enrollee has requested speech therapy services for treatment of the enrollees developmental delay.  Findings:  The physician reviewer found that this seven-year-old is mildly to moderately developmentally delayed, with significant speech delay. Barium swallowing studies have demonstrated that the patients oral pharyngeal glottal mechanism is congenitally dysfunctional, which combined with her congenitally derived developmental delay is the etiology of her speech delay. The medical literature strongly supports the utilization of speech therapy in the developmentally delayed child. A controlled study revealed the effectiveness of speech therapy services in patients with similar developmental delays as this patient (Goorhuis-Brouwer and Knijffs). Further, Law and colleagues discussed multiple studies including various research reports that demonstrated the success of speech therapy in developmentally challenged children. Therefore, continued individual speech therapy services are indicated for this patient from a medical standpoint.
Appeal type: Medical Necessity
Decision: Upheld

A 23-year-old male enrollee has requested for a tonsillectomy for treatment of his chronic tonsillitis.    Findings:  The physician reviewer found that clinical evidence does not establish the medical necessity of the proposed tonsillectomy. The Milliman Care guidelines are essentially similar and the records provided for review do not indicate the patient has either recurrent tonsillitis or obstructive symptoms which would support a finding of medical necessity for the requested surgical procedure.
Appeal type: Medical Necessity
Decision: Upheld

The patient is a five-year-old male with a history of developmental motor (fine) delay and a visual/sensory processing issue. The patient was evaluated by a neurologist who was not able to provide a specific diagnosis, but indicated the patient might have attention deficit hyperactivity disorder (ADHD) or a pervasive developmental disorder. The patient began receiving weekly occupational therapy in February 2003. A request has been made for continuing therapy. The Health Plan has denied the request.The submitted records document the patients occupational therapy sessions from June 2003 to February 2004. The goals documented are primarily behavioral in nature. Additionally, the patient has demonstrated only minimal improvement. Furthermore, the functional goals outlined have not been achieved. According to current literature the only treatment that benefits behavioral issues such as those exhibited by this patient is applied behavioral analysis. Continued occupational therapy is not likely to result in an improvement in the patients behavioral issues. Therefore, I have determined that the requested therapy 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 40-year-old male enrollee requested a computed tomography (CT) scan of the abdomen and pelvis for treatment of his abdominal pain.  Findings:  The physician reviewer found that the patient does not meet the American College of Radiology indications for abdominal or pelvic CT scans. The preliminary evaluation prior to CT scanning was limited, the patients physical examination was unrevealing, and there was no clinical sign or indication, or suspicion, of abdominal or pelvic masses or fluid collections, malignancies, inflammatory processes, infections, bowel obstruction or documented weight loss. In sum, there is a lack of clinical justification to warrant the CT scan of the abdomen and pelvis performed during the course of emergency treatment. Therefore, the medical necessity of the services at issue has not been established in this clinical setting.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The enrollee has requested authorization and coverage for a magnetic resonance imaging (MRI) of the lumbar spine. Findings:  The physician reviewer found that in patients with lower back and leg pain, lumbar foraminal stenosis is an important consideration, especially in the presence of radicular symptoms, such as this patients shooting leg pain and weakness. Foraminal stenosis can develop as a result of progressing degenerative disc disease and can cause low back and leg pain with extension of the lumbar spine. Oftentimes, there is a lack of critical clinical findings in these cases and imaging is needed. In patients with chronic low back and persistent leg pain, imaging to evaluate for lumbar spinal stenosis is the standard of care. Radiological diagnosis is performed using multiple radiological modalities, particularly the lumbar MRI. Electrophysiological testing can also aid diagnosis, but is not as specific as MRI. In the medical literature, the authors noted that MRI is instrumental in the diagnosis of ligamentum flavum thickening associated with facet degeneration, which causes spinal stenosis. In light of the foregoing, the requested MRI scan of the lumbar spine is medically necessary for evaluation of this patients low back and radicular pain.Final Result: The reviewer determined that the requested services are medically necessary for evaluation 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: Urgent Care
Decision: Upheld

A 61-year-old female enrollee has requested services for evaluation of a vaginal protrusion and vaginal burning.  Findings:  The physician reviewer found based upon the clinical documentation provided, the patients condition did not require immediate care as her symptoms and exam were identical to those she had at her exam by her in-plan physician in the United States about three weeks earlier. There is no evidence of vaginal bleeding supported by the medical records. The medical records state that the reason for the surgery was the vaginal prolapse, which the patient had already been assessed.  All told, the patients symptoms would not cause a prudent layperson to believe she was experiencing an emergency condition that required immediate attention.
Appeal type: Experimental/Investigational
Decision: Upheld

A 59-year-old female enrollee has requested biofeedback therapy for the treatment of her hemifacial spasm. Findings:  Two physician reviewers found that although there are several case reports of biofeedback for hemifacial spasm in the literature, there are no clinical trials of any magnitude that would suggest this modality of treatment is as effective or superior to the current treatment of Botox. Furthermore, there is insufficient data on the efficacy of biofeedback for other pain conditions to allow for extrapolation of the results to this setting. The submitted medical records do not document the exact nature of the trials and reported failure of Botox for this patients condition. In light of its proven results in this setting, additional attempts with Botox were likely to have greater efficacy than biofeedback, which has not been established as efficacious in this setting. All told, the use of biofeedback remains unproven for use in the disorder of hemifacial spasm, as determined by review of the relevant literature.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary:  An enrollee has requested authorization and coverage for cancer vaccine.Findings: Two out of three physician reviewers found that the requested cancer vaccine is not likely to be more beneficial for you than any available standard therapy.This patient has advanced neuroblastoma. There is insufficient evidence demonstrating the efficacy and safety of neuroblastoma vaccine for the treatment of advanced neuroblastoma. The current National Cancer Institute (NCI) guidelines do not support the use of a neuroblastoma vaccine as an accepted treatment option for advanced neuroblastoma. The current literature indicates that further studies are still needed to establish the efficacy and safety of the vaccine. Therefore, the requested cancer vaccine is not likely to be more beneficial than any available standard therapy.Final Result: The reviewers determined that the requested service is not likely to be more beneficial than any available standard treatment for the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer 1, reviewer 2, and reviewer 3 are board certified in internal medicine with sub-specialty certification in medical oncology. All reviewers 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: Experimental/Investigational
Decision: Overturned

A female enrollee requested endoluminal ablation of the perforator vein (CPT 36475 for medical treatment of her chronic venous insufficiency.  Findings:  Two physician reviewers found that endovascular treatment using either sclerotherapy or thermal ablation are presently recommended. According to the Society for Vascular Surgery and the American Venous Forum practice guidelines, We recommend treatment by percutaneous techniques that include ultrasound guided sclerotherapy or endovenous ablation [radiofrequency or laser] over open venous perforator surgery.  For these reasons, the request for endoluminal ablation of the perforator vein is likely to be more beneficial for treatment of this patients medical condition than the available standard therapy.