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

A 38-year-old female enrollee has requested for a bariatric surgical consultation for treatment of her obesity. Findings:  The physician reviewer found that two different heights are documented by the patients provider. The discrepant heights need to be reconciled before the appropriateness of a bariatric surgery consultation can be determined. Additionally, the medical necessity of bariatric surgery is not strictly determined based on minimum weight and co-morbid condition criteria to fulfill standard the definition of morbid or clinically severe obesity. If the patient is determined to have clinically severe or morbid obesity, in accordance with the standard guidelines for bariatric surgery such as the NIH consensus guidelines, there must also be clinical documentation of failed weight loss efforts in order to be considered for surgical intervention.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested discogram for evaluation of the enrollee who has a history of degenerative disc disease of the cervical spine and low back pain. Findings: The reviewer found that there is a lack of support in the medical literature for the requested procedure in this clinical setting. This patient has multiple non-localizing and non-specific symptoms. The patients neurological examination and electromyogram/nerve conduction velocity were normal. The cervical and brain MRI and computed tomography (CT) scans, after carotid surgery, were also normal. As such, there is a lack of correlation between her studies and with her symptoms except for the myelomalacia and bright cord signal at C5-6, the level of her ADR. Typical post of fibrosis has some tethering effect on the cord and is exacerbated by flexion/rotation of the neck, as she has experienced. In addition, the American Pain Society has noted that the evidence for cervical discography is limited. The American Association of Neurologic Surgeons also has noted that discography is not recommended to formulate treatment strategies for patients with pain. All told, the requested procedure is not medically necessary for the evaluation of this patient.Final Result: The reviewer determined that the requested procedure is not medically necessary for evaluation of the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is board certified in neurological 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 reimbursement for Afirma Gene Expression Classifier testing. Findings:  Three physician reviewers found that the cytopathology of the left thyroid nodule was consistent with Hurthle cell neoplasm, in the same category as follicular neoplasm, Bethesda Category IV. The risk of malignancy is 15 to 30% in this category. The Bethesda System recommends a surgical lobectomy for this type of nodule.  If the genetic test is suspicious, the risk of malignancy increases to 40%. The risk of malignancy decreases to less than 6% with benign findings by Afirma Gene Expression Classifier testing. The information from Afirma Gene Expression Classifier testing can assist providers in determining whether to perform thyroidectomy or not, and the extent of surgery. The test is in vitro, which confers no physical risk to the patient. The sample is obtained at the same time of the fine needle aspiration biopsy, and no additional procedure is needed. Thus, Afirma Gene Expression Classifier testing provided was likely to be superior over other available methods of evaluating this patient. Final Result: 3 of 3 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 physician reviewers are board certified in internal medicine with sub-specialty certification in endocrinology, diabetes and metabolism 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 50-year-old female enrollee has requested a keloid and scar removal procedure for the treatment of her condition. Findings: The physician reviewer found that the submitted clinical evidence does not establish that the procedure at issue was reconstructive in nature. This patient presented with keloid scars following breast reduction for macromastia. Thus, she had an abnormal structure caused by trauma, specifically, breast reduction surgery. However, the procedure at issue was not likely to result in more than a minimal improvement in the appearance of the patient as surgical excision of a keloid without postoperative steroid injections carries a significant chance of recurrence. Thus, the procedure at issue does not meet the definition of reconstructive surgery as defined by California law. With regard to the medical necessity of the procedure, a myriad of different interventions have been recommended for the treatment of keloids, ranging from simple pressure to surgery and radiation therapy. In general, more invasive treatments should be restricted to patients who have failed conservative treatment. Furthermore, there is a relatively high recurrence rate for patients who undergo surgical excision alone. For this patient, the records do not document a reasonable trial of more conservative treatments prior to proceeding to surgical management.  In the absence of a trial of less invasive treatment and given the likelihood of recurrence associated with surgical excision of the keloids, the procedure at issue was not medically necessary.
Appeal type: Medical Necessity
Decision: Upheld

This patient is a 42-year-old male with a several year history of pain and burning in the feet. He was evaluated by a neurologist who diagnosed polyneuropathy. Initially this was felt to be related to alcohol abuse, but subsequently the patient was diagnosed as having diabetes. He was on oral agents with poor control and is now on insulin with better control. The patient has persistent foot pain and was recently prescribed a TENS unit by the provider who has been managing his diabetes. It does not appear that the usual pharmacologic treatments have been attempted. The patients provider submitted a request for authorization of the TENS unit.  This request was denied by the Health Plan citing a lack of medical necessity.A TENS unit is not an accepted therapy for the treatment of diabetic neuropathy. Although there have been some small studies on this treatment approach, they have generally not been well controlled and the evidence regarding efficacy is mixed. This patient has never been treated with the usual pharmacologic remedies according to the information provided in the record. Medications such as amitriptyline, Lyrica, or Cymbalta are often effective in relieving this type of symptoms.  Additional consultation with a physician experienced in the treatment of diabetic neuropathy, such as a neurologist, may provide the patient with an opportunity to explore other appropriate treatment modalities.  Based upon the information set forth above, I have determined the requested device is not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned

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 a history of relief from prior injections received. The patient has tried and failed other conservative treatments, with the alternative being a total knee arthroplasty. Given the patients limited options and based on the current medical literature, the requested services are medically indicated. Therefore, Orthovisc 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: Overturned

A 30-year-old male enrollee requested the Medtronic Pump, E0784, A9277, and A9276 x 90 for medical treatment of his diabetes.  Findings:  Two physician reviewers found that the main advantage of continuous glucose monitoring is that it can help identify fluctuations and trends that would otherwise go unnoticed and can thereby help maintain tight glycemic control and prevent hyperglycemia and hypoglycemia.  It can be used to prevent potentially dangerous consequences of uncontrolled diabetes.  Continuous glucose monitoring systems have been shown to improve hemoglobin A1C levels of diabetic patients.  The requested device is likely to benefit the patients health and prevent complications from diabetes, including reduction of the frequency of hypoglycemic events.  All told, the requested Medtronic Pump, E0784, A9277, and A9276 x 90 is likely to be superior over other available treatment options.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for a consultation with an orthopedic surgeon for evaluation of the enrollee who has a history of multiple neurofibromatosis.  Findings:  The physician reviewer found that this patient presents with chronic neck pain located at the C7 level. Clinical examination findings are consistent with imaging evidence of local fibrotic changes and connective tissue changes at C7. Past medical history is positive for neurofibromatosis type 1 and 2 with known lesions in his neck. The lesion on the back of his neck at C7 has been diagnosed as a sarcoma.  A referral for surgical removal was recommended with an orthopedic spine surgeon who is now out-of-network. The patient has not established care with the orthopedic spine surgeon. Instead, the Health Plan has approved a referral to neurosurgeons within the patients geographic area for evaluation and treatment. As such, the documentation provides no compelling rationale to support the medical necessity of an orthopedic surgeon. Therefore, the requested consultation with an orthopedic surgeon has not been demonstrated as medically necessary for evaluation 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 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: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Synvisc One injectionFindings:  The physician reviewer found that there is adequate evidence that intraarticular hyaluronic acid injections reduce pain and increase function in knee osteoarthritis, and the benefits are long-lasting as compared with intraarticular corticosteroids. A study conducted a systematic review of overlapping meta-analyses comparing viscosupplementation with other non-operative treatment modalities for knee osteoarthritis. The authors reported that the current highest level of evidence suggests that intraarticular hyaluronic acid is a viable option for patients with knee osteoarthritis which results in improvements in knee pain and function that can persist for up to 26 weeks. Viscosupplementation has a good safety profile, and its use should be considered in patients with knee osteoarthritis. All told, the requested Synvisc One injection is supported as medically necessary for treatment of this patients knee osteoarthritis. Final Result: The reviewer determined that the requested service 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 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: An enrollee has requested authorization and coverage for hyperthermia treatments using ultrasound guided heat therapy (CPT codes 77605, 77427, and 77280). The provider has recommended hyperthermia. Based on the current medical literature, regional hyperthermia or combination with radiotherapy are not the standard of care for stage IV breast cancer. The standard therapy for stage IV breast cancer is some form of systemic therapy, usually chemotherapy. There is a lack of data supporting the addition of hyperthermia to the involved area, such as the lung or pleura. Therefore, hyperthermia treatments using ultrasound guided heat therapy (CPT codes 77605, 77427, and 77280) are not likely to be more beneficial for treatment of the patients condition than any available standard therapy.Findings:  Three of the three physician reviewers found the requested hyperthermia treatments using ultrasound guided heat therapy (CPT codes 77605, 77427, and 77280) are not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.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: 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

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Wegovy (J3490). Findings:  The physician reviewer found that current medical evidence supports the requested medication in this clinical setting. While lifestyle modification is recommended as the cornerstone of obesity management, many patients do not achieve long-lasting benefits due to difficulty with adherence as well as physiological and neurohormonal adaptation of the body in response to weight loss. There are multiple pharmacologic therapies which are available for weight management. Wegovy (semaglutide) is a member of a class of medications known as glucagon-like peptide-1 (GLP-1) analogs. These medications improve glycemic control, reduce body weight, and decrease cardiovascular risk. Multiple studies have demonstrated this medications ability to promote weight loss, via reduced appetite and energy intake, and delayed gastric emptying. Additionally, the likelihood of health risks associated with this medication has been noted to be low. Therefore, the requested medication Wegovy (J3490) 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 endocrinology, diabetes, and metabolism and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for inpatient residential psychiatric services for treatment of the enrollees behavioral health conditions. Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the services at issue. The discharge summary from the wilderness program provided a good description of the condition of the patient just before she began receiving the services in dispute.  According to that information, she was cooperative.  She had developed insight into her problems as well as coping skills to be successful.  She had good peer relationships and was respected by her peers.  She did well in family therapy and re-established a good relationship with her parents.  There is no indication that she had any risk factors for harm of herself or others.  She did not require special medical or nursing care, or any type of therapeutic intervention that would require 24-hour treatment.  She did not meet criteria for admission to a 24-hour facility.  All told, inpatient residential psychiatric services were not medically indicated for the treatment of this patient.Final Result: The reviewers 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 physician 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: Urgent Care
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested enrollee has requested reimbursement for emergency services. Health and Safety Code section 1317.1, subdivision (a)(2)(A) notes Emergency services and care also means an additional screening, examination, and evaluation by a physician, or other personnelto determine if a psychiatric emergency medical condition exists, and the care and treatment necessary to relieve or eliminate the psychiatric emergency medical condition, within the capability of the facility. The patient was offered treatment within the facility but chose treatment elsewhere thus disqualifying himself from emergency treatment within the facility. The American Psychiatric Association (APA) treatment guidelines recommend that residential treatment or similar care higher than outpatient is indicated for patients who do not meet the clinical criteria for hospitalization but whose lives and social interactions have come to focus predominantly on substance use...lack sufficient social and vocational skills and drug-free social supports to maintain abstinence in an outpatient setting. In this patients case, the medical documentation does not indicate this patient met the criteria for a residential program as he was not previously treated in a less restrictive treatment setting such as IOP. Residential treatment was not in accordance with generally accepted standards of medical practice and not clinically appropriate for the patients illness. Thus, the emergency services provided from were not provided for treatment of a psychiatric emergency medical condition. Thus, the patient did not receive psychiatric emergency medical services on the date of service at issue.Final Result: The reviewer determined that the services at issue were not provided for treatment of a psychiatric emergency 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: Overturned

The patient is a 61-year-old female with visual field obstruction, heaviness of brows and upper eyelids. Surgical intervention was planned and the surgical consent included a brow lift and upper lid blepharoplasty. The patient indicates it was her expectation that the upper lid procedure would be performed during the July 2005 surgery. The Health Plan indicates the patients provider felt a brow lift and possibly an upper blepharoplasty were medically necessary. The patient added lower blepharoplasty and facelift to the reconstructive procedures. Surgery was performed in July 2005. No operative note was enclosed for review. Blepharoplasty of the upper eyelids was not performed as anticipated. The patient has requested authorization and coverage for an upper blepharoplasty for persistent visual field deficit not corrected by the brow lift. The Health Plan has denied this request on the basis that the requested procedure is not medically necessary for treatment of the patients medical condition.Although concerns were noted over the patients dry eyes, it does not appear this condition was significant as there is no evidence a Schirmers test was ordered following an ophthalmology evaluation performed in January 2005. Nor was there any follow-up to evaluate the success of a plug placed in the left lower punctum. Furthermore, it does not appear the right eye required a plug. A submitted visual field test was performed post-operatively, but without any evaluation of the lids or brow. The medial brows still rest well below the orbital rim. The patient still has redundant upper lids. The fact that visual fields performed one month postoperatively continue to show loss of upper visual field above 10 degrees of axis reflects the lack of improvement from her brow lift. As such, an upper blepharoplasty remains medically necessary and should be authorized.Based upon the information set forth above, I have determined the requested procedure is medically necessary for treatment of the patients medical condition. The Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Upheld

A 34-year-old female enrollee has requested for a bunionectomy and custom-made foot orthotics for treatment of her hallux valgus condition. Findings:  The physician reviewer found that there is no documented physician-directed, non-operative treatment. In addition, custom made foot orthotics would not be indicated in the absence of trial and failure of more conservative measures, such as the use of shoe modifications, which have not been documented.