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

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested comprehensive orthodontic treatment of adolescent dentition for treatment of the enrollees medical condition.  Findings:  The physician reviewer found that review of the submitted clinical documentation demonstrates the dental necessity for the requested services. The patient presents with a Class III malocclusion and crowding. The recommendation for interceptive treatment, while she is in the mixed dentition phase can help to improve her bite, anteroposterior position of the incisors, vertical positioning of the incisors, correction of the posterior crossbite (with expansion of the maxillary arch) which will improve intercuspation of the posterior teeth, help to correct the spacing issues which will lead to less crowding as the permanent teeth begin to erupt, as well as helping to prevent deleterious occlusion which could lead to periodontal issues. Early treatment in children with prognathnic lower jaw can also minimize the potential need for future orthognathic surgery. Based on the clinical documentation submitted for review, comprehensive orthodontic treatment of adolescent dentition is dentally necessary for treatment of the patients medical condition. Final Result: The reviewer determined that the requested services are dentally necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.  Credentials/Qualifications:   The reviewer is board certified in pediatric dentistry 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 54-year-old male enrollee requested 35 visits of enhanced external counterpulsation (EECP) for medical treatment of his angina.  Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested services.  This patient has known coronary disease but no hemodynamically significant stenosis identified on most recent angiography and no ischemia identified on most recent stress testing.  In this circumstance of no significant epicardial stenosis and no provokable ischemia during chest pain, EECP is not considered standard accepted practice.  The normal stress test and angiographic results support that the patients symptoms are more likely non-ischemic in origin and therefore not likely to benefit from EECP.  There is a lack of evidence indicating that repeated courses of EECP provide additional benefit.  All told, the requested 35 visits of EECP are not medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a two-year-old male enrollee has requested for speech therapy and occupational therapy for treatment of the enrollees global developmental delay. Findings:  The physician reviewer found that Schaaf and Miller report the effectiveness of sensory integration therapy by occupational therapists for children with multiple combinations of developmental sensory and motor delays. A controlled study demonstrated the effectiveness of sensory motor therapy in a childhood population (Miller, et al).  Although the study by Robert, et al. is a single case study, there was a dramatic improvement in behavior and attention when the child received occupational therapy utilizing sensory motor techniques. Given this patients medical records and the available peer-reviewed medical literature, it is indicated that this patient will continue to benefit from both occupational and speech therapies. It is therefore, medically necessary that this patient receive both speech and occupational therapy.
Appeal type: Medical Necessity
Decision: Upheld

A 54-year-old female enrollee requested authorization and coverage for the medication Celebrex. The health plan has denied this request indicating that the Celebrex is not medically necessary for treatment of the enrollees fibromyalgia, degenerative joint disease, and status post knee surgery.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

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for surgery to remove the benign seborrheic keratosis, on the right side of face. Seborrheic keratosis is a benign growth that can occur on the skin that may become inflamed when ruptured, especially with trauma, leading to superinfection, pain and itching. In this clinical setting, given that the patient reports a seborrheic keratosis that bleeds when shaved or scratched, the requested service is medically indicated. Therefore, surgery to remove the benign seborrheic keratosis, on the right side of face is medically necessary for the treatment of this patient.The California reconstructive surgery statute requires health insurers to cover reconstructive surgeries, defined as surgery performed to correct or repair abnormal structures of the body caused by congenital defects, developmental abnormalities, trauma, infection, tumors, or disease to do either of the following: (1) to improve function; or (2) to create a normal appearance, to the extent possible. In this case, the benign seborrheic keratosis is an abnormal structure of the body. The tumor, or seborrheic keratosis, is a benign growth that can occur on the skin. The requested service will improve function and prevent further inflammation, bleeding and pain. Accordingly, the requested surgery to remove the benign seborrheic keratosis, on the right side of face is reconstructive in nature for treatment of this patient.Final Result: The reviewer determined that the requested service is medically necessary for treatment of the patients medical condition and is reconstructive in nature. 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 32-year-old female enrollee has requested the replacement of the enrollees current spinal cord stimulator with an MRI-compatible stimulator for treatment of her back pain. Findings:  Three physician reviewers found that replacement of the patients current spinal cord stimulator with an MRI-compatible stimulator is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The documentation submitted for review fails to provide a rationale as to why MRI is required versus other traditional neuroimaging techniques. The peer-reviewed literature supports the use of imaging modalities such as traditional myelography, CT scan and/or CT myelogram for patients with a device or other contraindication to an MRI. Therefore, the request for replacement of the patients current spinal cord stimulator with an MRI-compatible stimulator is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested implant of a hypoglossal nerve stimulator for treatment of his obstructive sleep apnea.   The physician reviewer found that the submitted documentation fails to establish the medical necessity of the requested services. According to the documentation submitted for review, the patient has positional sleep apnea and CPAP and BiPAP are therapeutic as they each decreased his AHI to normal. The patient is not overweight and his OSA is related to sleeping in the supine position. There are less invasive ways to address positional sleep apnea, such as utilization of a vest with a tennis ball pocket in the back to avoid supine sleep. Utilization of this method would likely normalize the patients AHI. Based on the documentation submitted for review, the request for implant of a hypoglossal nerve stimulator is 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 internal medicine with sub-specialty 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: Experimental/Investigational
Decision: Upheld

A 60-year-old female enrollee has requested tongue suspension (glossectomy) for treatment of her obstructive sleep apnea (OSA). Findings:  Three physician reviewers found that this patient has been diagnosed with moderate to severe OSA but has become intolerant and claustrophobic with the use of medical therapy including nasal CPAP, which is a commonly recognized medical treatment for this condition. Surgical treatment in adults may be warranted and include UPPP and tonsillectomy as a part of surgical reconstruction of the soft palate. Currently, there are inadequate data in the peer reviewed medical literature that supports radiofrequency volumetric tissue reduction of the base of tongue. Specifically, Epstein and colleagues report that there are no clinical reviews and outcomes studies demonstrating significant improvement with use of the surgical technique despite the fact that patients may have significant retro-palatal obstruction and base of tongue obstruction. In addition, Kezirian and Goldberg documented little success with base of tongue radiofrequency for treatment of patients with OSA. Therefore, the requested procedure is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.
Appeal type: Experimental/Investigational
Decision: Overturned

A 60-year-old female enrollee has requested authorization positron emission tomography/computed tomography (PET/CT)for her moderately differentiated adenocarcinoma.  Findings:  Two physician reviewers found that this patient presents with biopsy proven adenocarcinoma of the descending colon with submucosal involvement discovered at routine screening colonoscopy. The patients provider has requested PET/CT for staging. On review of the medical literature and in practice, PET imaging is routinely the procedure of choice in the evaluation of potential distant metastases in colorectal cancer. Further, PET/CT is the most sensitive means with which to diagnose such spread of disease. Thus, PET/CT would be more beneficial and appropriate than any other test for the evaluation of this patient and should be approved.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary:  An enrollee has requested Cosentyx for treatment of the enrollees psoriasis.  The physician reviewer found that this patient has tried and failed numerous therapies, including UVB phototherapy, cyclosporine, Raptiva, Enbrel, and Stelara.  He did not tolerate anti-TNF agents due to neutropenia which lead to hospitalization.  The requirement that the patient first fail Humira prior to authorization for Cosentyx is not reasonable given the severe side effects in response to Enbrel.  In addition, he has been treated with multiple other systemic agents without sufficient control of his disease.  Recent studies have shown a superior control of psoriasis with Cosentyx over Stelara.  Given the number of systemic agents which have been tried and failed and the adverse effect of neutropenia in response to prior anti-TNF therapy, the requested medication Cosentyx is medically indicated 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 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 47-year-old female enrollee has requested sacroiliac joint injection for the treatment of her back pain. Findings:  Two physician reviewers found that according to the records provided, the patient had been diagnosed with left side SI joint pain prior to receiving the SI joint injection. Although the patient reports a trial of multiple standard therapies, the submitted medical records do not document which specific modalities were tried and the patients response to each treatment prior to therapy with SI joint injection. There is a lack of documentation showing chronic pain that failed to respond to conservative treatment for four-weeks as suggested by Pauza. Further, Hansen and colleagues suggest that there is limited data available for therapeutic SI joint injections. Moreover, SI joint injections are generally not performed as a prophylactic measure to prevent recurrence. Thus, for this patient who reported no pain during her visit, SI joint injections were not medically indicated and would be considered investigational.
Appeal type: Experimental/Investigational
Decision: Upheld

A 58-year-old female enrollee has requested a heating/cooling device for treatment of her stated condition of arterial venous malfunction.  Findings:  Two physician reviewers found that there are few published articles reporting on the use of cryotherapy in the setting of musculoskeletal injury and post-operative care. In 2004, Hubbard and Denegar reported that, Many more high-quality studies are required to create evidence-based guidelines on the use of cryotherapy. These must focus on developing modes, durations, and frequencies of ice application that will optimize outcomes after injury. There are more data with regard to the use of an active cooling device in treatment of the knee during the early inpatient hospitalization period following knee surgery (Saito and colleagues). Overall, the studies do not indicate or suggest that the use of the cooling devices is indicated for use in the post-operative period outside of the hospital, or that such use results in better outcomes over the use of basic cooling measures such as regular ice bags. The device at issue in this case is an active cooling device. There is no high grade published literature supporting the clinical efficacy of this device in this patients clinical condition. Moreover, this device would not have been expected to significantly improve the patients health or functional outcome over cooling provided by topical ice packs and elevation.  Accordingly, I have determined the device at issue was not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.
Appeal type: Medical Necessity
Decision: Upheld

A 29-year-old female enrollee requested authorization and coverage of daily Vioxx 25 mg. The Health Plan denied the request indicating that the requested medication is not medically necessary for treatment of the enrollees systemic lupus erythematosus.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 at this time.
Appeal type: Medical Necessity
Decision: Overturned

The patient is a 26-year-old female with a long-term history of psoriasis involving 60-75% of her body. Her psoriasis has not improved with standard topical medications and UVB light therapy. In 2003, her psoriasis cleared almost completely after a trial of Enbrel. The patient had no side effects from the Enbrel. The patients provider is requesting authorization for Enbrel. The Health Plan has denied this request. In women of childbearing age, methotrexate and Soriatane are contraindicated. They are pregnancy category X medications. Methotrexate may cause bone marrow depression and liver damage and pretreatment usually requires a liver biopsy. Neither methotrexate nor Soriatane are widely used in women of childbearing age in the treatment of psoriasis. Cyclosporine is indicated for severe acute psoriasis  it is used for 6 to 12 months. There is a significant risk of kidney damage and hypertension with cyclosporine. Enbrel is a pregnancy category B drug. It can be safely stopped when a patient becomes pregnant. It is effective in the treatment of extensive psoriasis, including long-standing psoriasis. Enbrels safety profile is much better than the three medications described above. Additionally, a liver biopsy is not required. For these reasons, and the fact it has previously been effective, Enbrel is medically indicated and necessary for this patient. Therefore, I have determined the Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary:  An enrollee has requested an epidural steroid injection for treatment of his medical condition.    Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested services.  There is no mention of a home exercise program being done in the past or how long the patient had gone to physical therapy in the past, if at all.  The literature indicates that a home exercise program after physical therapy independent of an epidural can provide lasting results.  For these reasons, the requested epidural steroid injection is not medically indicated for the 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 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: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for a consultation for laparoscopic peritoneal pull-through vaginoplasty.The penile inversion method for vaginoplasty for transgender women is the gold standard method. The penile inversion method is the most commonly described technique for primary male-to-female transgender vaginoplasty. The technique has been widely researched and described.). The Medical literatures Standards of Care lists penile inversion, pedicled colosigmoid transplant, and free skin graft as means of vaginoplasty, but does not mention peritoneal vaginoplasty. While peritoneal vaginoplasty has been done for vaginal agenesis in cisgender woman, and recently has been tried for transgender women, there is no published evidence comparing outcomes to traditional methods for vaginoplasty in transgender women. As this outcome data is currently lacking, medical literature does not reflect whether peritoneal vaginoplasty is superior or inferior to penile inversion. Under these circumstances, the requested consultation for laparoscopic peritoneal pull-through vaginoplasty is not medically necessary to treat the patients medical condition.Final Result: The reviewer determined that the requested service 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 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

An 18-year-old female enrollee requested authorization and coverage of pulmonary rehabilitation therapy. The Health Plan denied the request indicating that the requested therapy is not medically necessary for treatment of the enrollees asthma.One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer upheld the Health Plans denial on the basis that the requested therapy is not medically necessary.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary:  An enrollee has requested breast tomosynthesis for evaluation of her medical condition. Two physician reviewers found that there is sufficient support for the services at issue in this clinical setting.  Tomosynthesis is a technique that was developed as a problem solving adjunct to routine mammography.  Breast tomosynthesis has been shown to be most useful in the evaluation of dense breasts.  There are several studies that support the use of breast tomosynthesis as a more accurate study than routine screening mammography.  Per Skaane and colleagues, the use of mammography plus tomosynthesis in a screening environment resulted in a significantly higher cancer detection rate and enabled the detection of more invasive cancers.  Rafferty and colleagues noted that the addition of tomosynthesis to digital mammography offers the dual benefit of significantly increased diagnostic accuracy and significantly reduced recall rates for noncancer cases.  In this patients, she has known heterogeneously dense breasts.  All told, breast tomosynthesis was likely to have been superior over other modalities for evaluating this patient.  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.