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

Nature of Statutory Criteria/Case Summary: An enrollee has requested a thigh lift for treatment of her medical condition.   The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested services.  The medical records do not include documentation of infections in the thigh folds, or photographs documenting cellulitis, ulcerations or rashes.  The patient reports a history of thigh infections, but problems with thigh infections are not mentioned in the primary care physician notes provided for review.  The medical records do not provide documentation in the form of frequent physician visits for the management of ongoing clinically significant dermatologic problems that have either never responded to topical therapy given or despite initial response, have recurred and caused significant functional impairment.  Surgical lipectomy should be reserved for patients that have failed optimal medical management for intertrigo, which is not the case for this patient.  The clinical notes do not provide sufficient documentation to confirm the failure of medically supervised care.  Additionally, the patients condition does not constitute an abnormal structure of the body.  The patient has excess thigh skin, which is an anticipated outcome following weight loss.  All told, the requested thigh lift is not reconstructive in nature and is not medically necessary for the treatment of this patient.  Final Result: The reviewer determined that the requested services are not reconstructive in nature and 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 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: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary:  An enrollee has requested breast tomosynthesis for evaluation of her medical condition.   Findings:  Two physician reviewers found that tomosynthesis is a technique that was developed several years ago as a problem solving adjunct to routine mammography. Applying the same basic concept as computed tomography (CT) scanning, the logic is that by separating the various layers of breast tissue, one can better detect abnormalities. For this patient, this is the specific clinical setting in which tomosynthesis has its greatest value.  The ability to separate overlapping structures enables visualization of an occult tumor which might otherwise have been missed. Therefore, breast tomosynthesis was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Final Result: Two 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:   All three reviewers are board certified in diagnostic radiology and are actively practicing. All three 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

The patient has requested authorization and coverage for Acute rehabilitation services including speech therapy and occupational therapy through telehealth conferencing, four hours per day, five days per week. In the present case, the patient has sustained embolic strokes. Functional impairments due to acquired brain insults such as stroke can range from mild to profound. While natural recovery evolves with time, many impairments are addressable by compensatory measures and directed rehabilitation efforts. The standard of care for this patients condition includes rehabilitation services, first in the inpatient setting, followed by rehabilitation in the community setting, based on impairments and the potential for achieving functional goals. Most of the significant neurological and functional recovery following a stroke occurs in the early stages after stroke and gains are slower in the subsequent stages. For this patient, further rehabilitation services can be provided on an intermittent basis in the community. There is a paucity of published data establishing the clinical effectiveness of the proposed telerehabilitation services for this patients condition. Moreover, the records do not support that the patient requires rehabilitation services for four hours per day, and there is no expectation that this volume of therapy would provide a marginal benefit for the patient over standard rehabilitative care. All told, the requested acute rehabilitation services including speech therapy and occupational therapy through telehealth conferencing, four hours per day, five days per week is 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 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: The patient has requested reimbursement for the esophageal pH monitoring. The records provided for review document that this patient had multiple symptoms consistent with laryngopharyngeal reflux, but these symptoms can be caused by other diseases which need to be ruled out. As noted in the medical literature, pH and impedance testing assess a patient for proximal acid and non-acid refluxes as a cause for symptoms. Impedance testing may be useful in evaluation of endoscopy-negative patients with complaints of heartburn or regurgitation despite proton pump inhibitor (PPI) therapy in whom documentation of nonacid reflux will alter clinical management. The American Society for Gastrointestinal Endoscopy (ASGE) states that when combined with pH testing, impedance can identify whether the refluxate is acidic, and can provide correlation between reflux episodes and symptoms to help guide management. This data can be useful in patients with persistent symptoms on PPI therapy who have nonacid reflux as a cause for symptoms. This patient has failed PPI therapy and had an unremarkable esophagogastroduodenoscopy in the past. Determination of whether the patients symptoms were caused by laryngopharyngeal acid or non-acid reflux was important in order to determine effective therapy and to avoid unsupported long-term use of PPI therapy. For these reasons, the esophageal pH monitoring was medically necessary for evaluation of this patients symptoms.Final Result: The reviewer determined that the services at issue were 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 internal medicine with subspecialty 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 Acthar Gel 80 unit/ml (15 ml). At this time, the guidelines do not support the use of Acthar Gel for the treatment of non-renal systemic lupus erythematosus (SLE) or patients with SLE-APS [antiphospholipid syndrome]. A study noted that repository corticotropin injection (RCI) has anti-inflammatory and immune-modulatory effects and is approved for multiple indications, including several rheumatologic conditions. This study revealed that, RCI was used primarily as late-line therapy in patients with rheumatologic diseases. Medical resource use was significantly lower in the three months after therapy compared with three months prior. The authors concluded that, this finding suggests that RCI may improve disease control and warrants further evaluation. However, no studies have been performed exclusively on patients with SLE-APS, with several studies excluding secondary APS due to lupus. Thus, with current knowledge, treatment of APS in the context of SLE should not differ from treatment of primary APS . The guidelines recommend rituximab for refractory non-renal disease. Rituximab has been shown to be safe and effective in the treatment of non-renal SLE, especially in terms of disease activity, immunologic parameters and steroid-sparing effect. 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 internal medicine with subspecialty certifications in allergy and immunology and rheumatology 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 an 11-year-old male enrollee has requested 20 hours per week (code H2019) of applied behavioral analysis (ABA) therapy and 2 hours per week of supervision (code H0032) for treatment of the enrollees autism spectrum disorder.  Findings:  The physician reviewer found that applied behavioral analysis has been shown to be effective in treating behaviors associated with autism spectrum disorder. Treatments based on operant principles of learning are more effective for reducing maladaptive behaviors than alternative treatments. Studies have shown that ABA methods continue to result in positive outcomes in individuals with autism and intellectual disability. A paper by Grey and colleagues notes that applied behavior analysis has a large evidence base in children with intellectual disability and behavioral concerns. Evidence-based studies also noted improvement of function in older children with autism spectrum disorders using intense ABA interventions (Granpeesheh, et al.). The goals for older children often are to identify and remediate particular deficits. Sallows and Graupner note that although substantial gains are made after one year of ABA therapy when compared to controls, further gains have been noted in subsequent years. Based upon the documentation provided, the behaviors in this patient include withdrawal, self-regulation, and atypical behaviors as well as the need for improving daily living skills, socialization and language skills. No recent evidence has been submitted from the patients treating therapists which demonstrates that the patient is no longer able to achieve additional gains with ABA therapy. As such, continued ABA intervention is clinically indicated and medically necessary for this patient. The requested frequency of 20 hours per week of direct therapy and 2 hours per week of supervision is necessary and should be authorized.
Appeal type: Medical Necessity
Decision: Upheld

This patient is a 56-year-old woman with a reported history of varied neurological and pain symptoms since 2000.  She has been evaluated by multiple physicians and a variety of diagnoses have been rendered at different times including systemic lupus erythematous (SLE), multiple sclerosis (MS) and transverse myelitis, among others. According to a review of the records her diagnosis remains unsure; spine and brain imaging were negative for significant pathology, VER and BAER were negative, a sedimentation rate (ESR) was normal and a cerebral angiogram was normal. The patients cerebral spinal fluid (CSF) protein was minimally elevated in 2000, but she has had prior spinal surgery.  The record indicates the patient had a more recent CSF exam in December 2005, but no results are noted. The possible diagnosis of transverse myelitis lead to a trial of plasmapheresis in April 2005.  The patient reports the procedure was beneficial, but there is no clear documentation of medical benefit (change in neurological function) evident from the record.  The most recent reports from her neurologist do not reveal a request for repeat plasmapheresis, nor is there a definite clinical diagnosis. A rheumatology consultation noted a concern about depressive symptoms.  The patients request for additional plasmapheresis was denied based upon the Health Plans determination that it was not medically necessary to treat her medical condition.A review of the record provided demonstrates that numerous diagnoses have been entertained, but no neurological diagnosis for which plasmapheresis is indicated has been clearly made.  Although plasmapheresis is appropriate for certain neurological diagnoses including acute transverse myelitis, it also carries certain risks such as sepsis and should only be used when the potential for benefit warrants the risk.  This patient does not have a clear diagnosis of such a condition. If indeed, she has transverse myelitis, it is not well documented and would not appear to be an acute condition.  The record also indicates the patient has been reevaluated for a second opinion and the report is pending at this time.  That information may lead to a more definitive diagnosis. Based upon the information set forth above, I have determined the requested procedure is not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The enrollee has requested authorization and coverage for Lyrica 50 mg. for the treatment of idiopathic peripheral neuropathy. Findings:  The physician reviewer found that the requested medication is not medically necessary for treatment of the enrollees medical condition. Therefore, the Health Plans denial should be upheld. Researchers concluded that Lyrica has strong evidence to support its use for post-herpetic neuralgia, diabetic neuropathy and post-traumatic neuropathic pain. The authors did not find strong evidence to support its use in the treatment of idiopathic peripheral neuropathy. Further, the U.S. Food and Drug Administration (FDA) has not approved Lyrica for treatment of idiopathic peripheral neuropathy. National Institute for Health and Care Excellence (NICE) Guidelines recommend that if one of the first-line agents fails to provide relief, to consider another agent, such as Duloxetine or a tricyclic acid. This enrollee has complaints of numbness involving the bilateral legs and feet. A nerve conduction study demonstrated findings of mild peripheral neuropathy. The enrollee's physical examination findings are notable for an unsteady gait and a positive Rombergs test. The enrollees sensory and motor examinations have documented as normal. A lumbar MRI demonstrated findings of lumbar degenerative disc disease without significant canal or foraminal stenosis. The enrollee has tried Gabapentin for the neuropathic pain, which was ineffective. The enrollee reported that treatment with Lyrica was beneficial. The medical records do not document a failed trial of Duloxetine or a tricyclic acid. Currently, there is no evidence in the medical literature to suggest that Lyrica is superior to Duloxetine or a tricyclic acid for treating idiopathic neuropathic pain. Therefore, Lyrica 50 mg is not medically necessary for treatment of this enrollee.Final Result: The reviewer determined that the requested medication is not medically necessary for treatment of the enrollees medical condition. Therefore, the Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld

A 49-year-old female enrollee has requested for a breast reduction and abdominoplasty for treatment of her low back pain, rash and other symptomatology. Findings:  The physician reviewer found that 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 so as to be considered a structural abnormality.Breast reduction surgery can be effective in relieving symptoms related to large breasts such as back pain, neck pain, skin breakdown, etc. To delineate which patients are likely to experience improvement in symptoms with breast reduction surgery, the Schnur scale was developed. It is a well-accepted guideline for differentiating medically necessary breast reduction from cosmetic surgery. The Schnur scale relates the amount of breast tissue removed to the pre-operative body mass surface area of the patient. It accounts for differing body masses among each patient and is not solely based on weight and height. In general, the greater the volume removed, the more likely the procedure is medically necessary. In this case, there is no documentation of the amount of breast tissue that is planned to be removed.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for dopamine transporter (DaT) single photon emission computed tomography (SPECT) scan.Findings:  Two of the three physician reviewers found while a DaT SPECT scan is not indicated for all patients with features of clinical Parkinsonism, it has been shown to be useful in cases where the diagnosis of idiopathic Parkinsons disease versus essential tremor is being considered. In this patients case, the exact diagnosis is not clear. It is imperative to provide a definitive diagnosis, as treatment for Parkinsons disease versus essential tremor is quite different, and placing the patient on an extended trial of dopamine therapy would place the patient at risk of significant side effects. In this case, the requested services may aid in the management of this patient. In sum, the requested DaT SPECT scan is likely to be more effective than other methods of evaluating this patient. Final Result: The reviewers determined that the requested services are 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 neurology 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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for cheek revision facial feminization surgery. The World Professional Association for Transgender Health (WPATH) Standards of Care (SOC) acknowledges that for certain patients, an intervention like a reduction rhinoplasty can have a radical and permanent effect on their quality of life, and therefore is much more medically necessary than for somebody without gender dysphoria. WPATHs SOC further states that facial feminization procedures in a patient with severe gender dysphoria can be considered medically necessary, depending on the unique clinical situation of a patients condition and life situation. Overall, facial feminization can improve the quality of life in transgender women. Social aggression and hostility towards transgender people is often based on the appearance of the person, and is mitigated by passing as the new gender publicly. The records provided for review document that this patient underwent facial feminization surgery. Postoperatively, the providers notes indicate the patient healed well and was satisfied with the outcome. However, once the post-operative swelling subsided, the patient expressed displeasure with the results. Further, the patient reports ongoing distress as a result of being misgendered within the community. The records document that this patients masculine facial features contribute substantially to her distress. Therefore, the requested cheek revision facial feminization surgery is supported as medically necessary to address this patients distress related to gender dysphoria. 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 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: Experimental/Investigational
Decision: Upheld

A 46-year-old male enrollee requested authorization and coverage of intradiscal electrothermal therapy (IDET). The Health Plan denied the request indicating that the requested therapy is considered experimental for the treatment of the enrollees back pain.Three physician reviewers performed an experimental/investigational Independent Medical Review. All three physician reviewers concluded that the requested therapy is not likely to be more beneficial for treatment of the enrollee's medical condition than any available standard therapy. Because all three physician reviewers concluded that the requested therapy is not likely to be more beneficial for treatment of the enrollee's medical condition than any available standard therapy, the Health Plans denial has been upheld.