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

A 24-year-old male enrollee has requested for acute inpatient substance abuse detoxification and treatment services for treatment of his cocaine dependence. Findings:  The physician reviewer found that there were no acute withdrawal symptoms noted in the records available for review and no evidence of vital sign instability.
Appeal type: Medical Necessity
Decision: Overturned

A 58-year-old male has requested neuromuscular electrical stimulation with a WalkAide device for treatment of hisspa stic paraplegia.  Findings:  The physician reviewer found that there is limited research on the benefits of functional electrical stimulation (FES) over use of a standard AFO for foot drop. In a small clinical trial, FES was shown to improve symmetry and speed of gait in 24 patients with chronic foot drop (Hausdorff and Ring). Another study performed compared the effects of an AFO versus a neuroprosthesis on gait mechanics in 15 patients with chronic foot drop. The researchers observed better balance control during ambulation with use of the neuroprosthesis (Ring, et al). A study in patients with multiple sclerosis revealed improved speed and efficiency of gait with use of the functional electrical stimulation (Paul, et al).In order to support the clinical need for a neuroprosthesis for foot drop, it is necessary to demonstrate that the device significantly improves gait mechanics or is significantly better tolerated than standard bracing techniques in a specific patient. In this patients case the records indicate his gait improved significantly with use of the WalkAide device. In addition, his provider reports that prior use of an AFO did not achieve the same results. Consistent with these findings, the WalkAide is medically necessary for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld

The patient is a 27-year-old woman with pain in the right leg associated with varicose veins. The pain interferes with her employment. There is no documentation of a trial of conservative therapy with compression stockings. A venous duplex exam showed no saphenofemoral reflux or deep system occlusion. On exam, there were two small varicose veins behind the right knee in the area of the patients complaints of pain. The patients provider requests authorization for surgical excision of the right leg varicose veins. The Health Plan has denied this request citing a lack of medical necessity.Saphenous vein reflux need not be demonstrated to warrant varicose vein surgery.  Symptomatic varicose branches certainly can exist without concomitant saphenous reflux. General practice guidelines in the specialty of vascular surgery dictate that symptomatic saphenous varicose veins warrant invasive treatment when the symptoms are severe enough to interfere with activities of daily living and are refractory to at least three months of conservative therapy including prescription compression stockings. In this patients case, there is no documentation of a trial of conservative therapy with compression stockings. A significant proportion of patients obtain adequate relief with compression alone. Thus, based on the evidence provided at this time, the requested surgery is not medically warranted. However, if the patient undergoes a documented trial of conservative therapy without adequate relief her request for surgical intervention should be reconsidered.As set forth above, I have determined the requested surgery is not medically necessary for treatment of the patients medical condition at this time. The Health Plans denial should be upheld at this time.
Appeal type: Medical Necessity
Decision: Upheld

A 42-year-old female enrollee has requested authorization and coverage for duodenal switch bariatric surgery.  Findings:  The physician reviewer found that the submitted documentation fails to establish the medical necessity of the requested procedure.  This patient is status post Roux-en-Y bypass surgery from several years ago and a subsequent revision three years after.  She is 58, and her current weight is 405 pounds, resulting in a body mass index (BMI) of 61.7.  The patient is now requesting coverage for a second revision.  Per the submitted medical records, there does not appear to be any technical failure of the two prior surgeries.  In addition, the long-limb revision adds a malabsorptive component to the operative, which is the primary mechanism of benefit for the biliopancreatic diversion with duodenal switch, compared to either gastric bypass or gastric banding, which are caloric restrictive procedures.  There is limited data regarding the benefit of the requested procedure in this clinical situation.  The current medical evidence does not support the requested procedure in this patients case.  All told, the requested duodenal switch bariatric surgery is not medically indicated for the treatment of this patient.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for autonomic nervous system function testing. Findings:  The physician reviewer found that Autonomic nervous system dysfunction may present with a myriad of symptoms including orthostatic intolerance, recurrent syncope, labile blood pressure, disorders of sweating and thermoregulation, neurogenic bladder, sexual dysfunction, gastrointestinal dysmotility, pupil abnormalities, and sleep disorders. These symptoms may be a consequence of genetic, neurodegenerative, autoimmune, or acquired disorders. Although autonomic symptoms may be among the most debilitating features of these progressive conditions, they are often treatable. According to the American Academy of Neurology (AAN), autonomic function tests are safe, noninvasive, and have an extremely high value-to-risk ratio. Postural tachycardia syndrome (POTS) is a clinical condition in which patients experience chronic symptoms of orthostatic intolerance. Head-up tilt (HUT) testing allows the laboratory to diagnose a patient with orthostatic hypotension. Autonomic laboratory testing is essential to make the diagnosis of POTS. In this case, the patient presented with symptoms suggestive of autonomic nervous system dysfunction. The patient underwent autonomic nerve function testing that revealed evidence of POTS. The patients treatment planning was initiated based on the POTS diagnosis. Based on the current medical literature, autonomic testing is safe, noninvasive, and appropriate for accurate diagnosis of this patients underlying autonomic system dysfunction and subsequent treatment of debilitating autonomic symptoms. For these reasons, autonomic nervous system function testing was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Findings: Three of the three physician reviewers found the services at issue were likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.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 reviewer 1 is board certified in neurology and is actively practicing. Physician reviewer 2 is board certified in neurology with subspecialty certification in vascular neurology and is actively practicing. Physician reviewer 3 is board certified in neurology with subspecialty certification in vascular neurology and is 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

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Ofev. This patient has multiple lung issues, including probable hepatopulmonary syndrome. The provider noted that the patients interstitial lung disease could be hypersensitivity pneumonitis, secondary to working in an aluminum factory. The computed tomography (CT) scan report does not describe the typical appearance of idiopathic pulmonary fibrosis, which is the U.S. Food and Drug Administration (FDA) approved indication for Ofev. The patients forced expiratory volume per one second (FEV1) and forced volume capacity (FVC) are close to normal range. The patients pulmonary function tests show a severe reduction in the diffusing lung capacity for carbon monoxide (DLCO), which is likely related to the shunting. The records do not rule out the patients PFO and pulmonary shunts as the causes of his persistent shortness of breath. Overall, there is a lack of data supporting Ofev in patients with fibrotic hypersensitivity pneumonitis, severe liver disease, and other causes of shortness of breath. All told, Ofev is not medically necessary for the treatment of this patients medical condition. Final Result: The reviewer determined that the requested medication is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in internal medicine with subspecialty certification in pulmonary disease 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 a 14-year-old female enrollee has requested partial hospital program services for treatment of the enrollees behavioral health condition. Findings:  The physician reviewer found that the partial hospital program (PHP) services during a specified time frame were medically necessary for treatment of the patients medical condition. The medical records submitted for review indicate that the patient was neither stable nor safe for discharge to a lower level of care. The patient remained very depressed and very conflicted over her relationship with her mother. The patient remained suicidal and cut herself during the treatment period in dispute. The medical records also indicate that the patient had not met her goals and was not safe for transfer during the services in dispute. Therefore the medical necessity for partial hospital program services has been established in this clinical setting.
Appeal type: Medical Necessity
Decision: Overturned

The patient is a 16-year-old-female with severe OCD symptoms for which treatment records begin in 2004. The possibility of a pediatric autoimmune neuropsychiatric disorder associated with streptococcal infection (PANDA syndrome) was also raised as an etiology due to the rapid onset of the disorder. The patient has been treated with traditional medications to control the OCD behaviors and has also been seen by a psychologist who has offered cognitive therapy. The patient, her therapist and her parent all request more intensive outpatient treatment since the patients OCD behaviors are such that she cannot drive a car and has difficulty with her academic and social functioning. Her current psychologist indicates his patient schedule cannot accommodate three to four sessions per week with the patient. The patient and her parent have expressed concerns that her severe OCD and major functional impairments will negatively impact her ability to prepare for college. The familys request for authorization for the intensive outpatient cognitive behavioral therapy program was denied by the Health Plan based upon a determination that the services are not medically necessary.The patient is unique in the severity of her symptoms and the lack of a significant response with the combination of medications and cognitive therapy. She is in a critical phase of her life and faces the challenges of continuing her education and possibly living away from home. Her symptoms are almost incapacitating and her treating psychologist does not have the available time to offer her the intensive treatment that was recommended. The patient has a fair to good prognosis for decreasing the symptoms with the intensive outpatient cognitive behavioral therapy program. Psychiatric follow-up will also be important for this patient to optimize medication management. The severity of the patients condition is uncommon and is creating significant social and functional impairments for her during the late adolescent period of her life. At present, the intensive outpatient program is medically appropriate and presents the least restrictive treatment alternative. Based upon the information set forth above, I have determined the requested services are medically necessary for treatment of the patients medical condition. The Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Upheld

A 54-year-old male enrollee requested authorization and coverage of a functional electrical stimulation (FES) ergometer. The Health Plan denied the request indicating that the requested equipment is not medically necessary for treatment of the enrollees quadriplegia.One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer upheld the Health Plans denial on the basis that the requested equipment is not medically necessary.
Appeal type: Experimental/Investigational
Decision: Overturned

A 56-year-old male enrollee has requested Harvoni (sofosbuvir in combination with ledipasvir (90/400mg)) for 12 weeks for treatment of his hepatitis C, genotype 4. Findings:  Two physician reviewers found that in this case, the requested medication is likely to be more effective than other treatment options.  The patient has cirrhosis of the liver and therefore is not a candidate for interferon-based therapy.  The requested medication has been demonstrated to be safe and effective in this clinical setting.  The SYNERGY trial studied 21 patients with hepatitis C, genotype 4 who were treated for 12 weeks with the combination of sofosbuvir and ledipasvir.  The results indicated a sustained virologic response of 95%.  In sum, the requested Harvoni (sofosbuvir in combination with ledipasvir (90/400mg)) for 12 weeks is likely to be superior over other treatment regimens.
Appeal type: Medical Necessity
Decision: Upheld

A 58-year-old female enrollee has requested a panniculectomy, bilateral thigh lift, bilateral hip lift and bilateral buttock lift for treatment of the enrollee, who is status post bariatric surgery. Findings:  The physician reviewer found that in regards to the panniculectomy, although the pannus hangs over the symphysis, there is insufficient documentation of a skin condition under the pannus and its failure to respond to non-surgical treatment. There is also insufficient documentation of a skin condition that would warrant breast surgery. With respect to the bilateral thigh lift, there is no evidence of any skin condition that would warrant this in the photographs. With respect to the bilateral hip lift and bilateral buttock lift, although this would address buttock rhytids, such improvement would only be cosmetic, as almost all of these are superior to the sitting area and are not sufficiently deep enough folds to cause a functional problem. All told, the proposed procedures are not necessary for treatment of this patients condition from a medical standpoint. Furthermore, the submitted evidence does not establish that the patient has a condition that constitutes an abnormal structure of the body caused by congenital defects, developmental abnormalities, trauma, infection, tumors or disease. While the patient has excess skin, this condition is not so excessive as to be considered an abnormal structure of the body. As such, the proposed surgery does not meet the expanded concept of medically necessary reconstructive surgery defined in California law.  In this patients case, the requested panniculectomy, bilateral thigh lift, bilateral hip lift and bilateral buttock lift are not indicated.
Appeal type: Medical Necessity
Decision: Upheld

A 57-year-old female enrollee has requested chiropractic services for treatment of her sinus pressure. Findings:  The physician reviewer found that based on the submitted documentation and in light of the patients medical history, chiropractic care is not medically necessary for this patients care. It is true that chiropractic adjustments do have significant effects on the body's biochemistry, connective tissue, vascular and neurological systems and physiological changes. However, in this patients case, there is not enough clinical information (e.g., a computed tomography scan) to rule out any further cancer metastasis or other conditions as a cause of her pain. Therefore, based on the lack of documentation of a medical follow-up and evaluation to rule out other causes of her pain, chiropractic care is not medically necessary for this patient at this time.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement and prospective authorization and coverage for transcranial magnetic stimulation (TMS) services. Per the recommendations of the Clinical TMS Society, TMS therapy can be reintroduced in patients who are relapsing into depression after initially responding to TMS treatment. A sham controlled study of four weeks of TMS with an additional 18 weeks of maintenance TMS showed benefit, specifically in patients who had some benefit in the initial four weeks. The authors reported on a subset of patients who required a much longer treatment course than the six weeks with six tapering treatments to reach remission. McDonald and colleagues found that some patients required up to nine weeks of TMS to achieve response. This patient showed benefit from TMS multiple times. She therefore meets the criterion specified in these recommendations to reintroduce TMS as a full course of therapy. However, she has experienced partial benefit over the most recent course of TMS and remains in a major depressive episode. Given this finding, she may be a slow responder and may require more treatment sessions. Accordingly, the TMS services were and are medically necessary for treatment of this patient.Final Result: The reviewer determined that the services at issue were and 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: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for abdominoplasty for treatment of the enrollees medical condition status post panniculectomy.  Findings: The physician reviewer found that as noted by the American Society for Plastic Surgeons (ASPS), cosmetic surgery is performed to reshape normal structures of the body in order to improve the patients appearance and self-esteem. The ASPS defined reconstructive surgery as performed on abnormal structures of the body, caused by congenital defects, developmental abnormalities, trauma, infection, tumors, or disease...generally performed to improve function, but may also be done to approximate a normal appearance. The ASPS noted that when an abdominoplasty or panniculectomy are performed solely to enhance a patients appearance in the absence of any signs or symptoms of functional abnormalities, the procedure should be considered cosmetic in nature. Based on the entirety of the documentation provided for review, this patient does not have a defined functional deficit that would be improved with abdominoplasty. She has not been documented to have functional problems related to the surgical outcomes. Her primary concerns are aesthetic from her previous abdominoplasty and subsequent revision. There can be cases in which an abdominoplasty can be considered reconstructive, if the level of deformity is significant enough to be considered significantly abnormal. However, this is not the case for this patient. Consistent with these findings, the requested abdominoplasty is not medically necessary.Final Result: The reviewer determined that the requested surgery is not medically necessary for treatment of the patients medical condition.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

Findings:  The physician reviewer found that The patient has requested reimbursement inpatient admission services. The records provided for review document that this patient presented to the emergency department with complaints of an erythematous rash that covered most of their body. The patient reported that they noticed symptoms following receipt of their second dose of the COVID-19 vaccine. The provider noted that the patient was afebrile due to treatment with Tylenol. The patient does not have a reported history of allergic reaction to vaccine or injectable. Overall, the patients presentation was concerning for delayed hypersensitivity reaction to the COVID-19 vaccine, which required evaluation and treatment at the inpatient level of care. The Centers for Disease Control and Prevention (CDC) recommend that patients with a history of an immediate allergic reaction to a vaccine or injectable or any history of anaphylaxis be observed for 30 minutes after COVID-19 vaccination while all other individuals should be observed for 15 minutes (Banerji, et al.). However, as noted by Sokolowska and colleagues, as is the case for any medication, anaphylaxis may occur after vaccination in the absence of a history of allergic disease. Considering the potential severity of some of this patients possible diagnoses and the need for treatment with IV steroids, the inpatient admission services were appropriate. Given this support, the inpatient admission services were medically necessary for this patient. Final Result: The reviewer determined that the services at issue were medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.