Persius/imr-appeals huggingface dataset:
Appeal type: Experimental/Investigational
Decision: Overturned

A 44-year-old male enrollee has requested an implanted neurostimulator electrode for treatment of his chronic headaches. Findings:  Two physician reviewers found that the requested services are likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The patient presents with a highly refractory chronic headache disorder with the failure to respond to a large number of standard therapies. The medical literature supports the requested services in the clinical setting. According to Magis and colleagues (2011), long-term follow-up confirms the efficacy and safety of occipital nerve stimulation in drug-resistant chronic cluster headaches. Given the high frequency of the patients disabling headaches and his failure to respond to standard therapies, the requested services are clinically indicated and likely to be more beneficial than other modalities.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for a Gallium-68 Dotatate positron emission tomography (PET) scan. The American College of Radiology (ACR) has recognized the use of Gallium-68 Dotatate PET in patients with suspected neuroendocrine tumors. Overall, this imaging technology has been demonstrated to be the most comprehensive physiologic test to detect neuroendocrine tumors, especially when conventional imaging is negative. The basis for the advantage of Gallium imaging is the positive binding of the compound with somatostatin receptors which are the basis of neuroendocrine tissue. In order to further evaluate this patients symptoms, when compared to standard alternatives including fluorodeoxyglucose (FDG) PET, the requested Gallium-68 Dotatate PET is likely to be more beneficial for evaluation of this patients medical condition. One reviewer found that the Gallium-68 Dotatate PET is not likely to be more beneficial for evaluation of this patients medical condition.Final Result: Two of the three 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:  One reviewer is board certified in diagnostic radiology and is actively practicing. One Reviewer is board certified in diagnostic radiology and is actively practicing.  One Reviewer is board certified in radiology and is 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: Experimental/Investigational
Decision: Upheld

A male enrollee requested a cooling/heating device for medical treatment of his medical condition.  Findings:  Three physician reviewers found that the submitted documentation fails to demonstrate the superior efficacy of the equipment at issue in this patients case.  Per the clinical notes, there was no documentation of a contraindication to an at-home local application of an ice/heat pack, as opposed to a motorized mechanical device.  All told, the cooling/heating device was not likely to have been of greater benefit than other treatment options.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/ Case Summary:  The enrollee requested authorization and coverage for Euflexxa injections. Findings:  The physician reviewer found that the enrollee has a history of bilateral knee pain and instability of the patella as well as subluxations and pain rated between 0/10 and 8/10.  Patella grind and patella apprehension are both positive.  Imaging is negative on x-rays for joint space narrowing. An MRI showed an anterior cruciate ligament (ACL) tear on the right knee, mild chondromalacia and patella alta.  An MRI of the left knee showed a degenerative meniscus tear and mild cartilage loss. Treatments for her patella instability include activity modification, and steroid injections.  She reports this has helped her, as has her physical therapy treatments.  The physical therapist recommended the enrollee stop physical therapy (PT) although she had made improvements, because she still had patella tracking issues consistent with her prior exams and history of patella instability. Euflexxa injections were recommended for pain relief with a determination of whether her knee pain is coming from cartilage loss or knee instability.  She was also assessed for meniscus debridement and underwent a partial medial meniscectomy of the left knee. Review of the record indicates this enrollees case is complicated by underlying anatomic challenges including a right knee ACL tear, left knee meniscus injury, and bilateral patella instability.  While there is some evidence of cartilage loss, there seem to be more sources of pain rather than early arthritis in this enrollee.  According to the medical literature, in general, the use of hyaluronic acid is not supported due to the fact that most studies do not show superiority over other treatments, including placebo.  According to the American Academy of Orthopedic Surgeons (AAOS), Euflexxa injections are not recommended for patients with symptomatic osteoarthritis of the knee and have not shown substantial improvement over a placebo treatment.  While it is noted that Euflexxa is US Food and Drug Administration (FDA)-approved for use in the treatment of osteoarthritis of the knee, current medical literature does not support use secondary to a lack of efficacy within the published medical literature.  The literature does not support the use of hyaluronic acid injections in symptomatic osteoarthritis of the knee.  Final Result: The reviewer determined that the requested service is not medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The physician reviewer is board certified in orthopedics and orthopedic sports 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 similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

The patient is a 10-month-old male with positional plagiocephaly diagnosed in September 2005. His provider also detected an associated torticollis, noting a loss of range of motion in the neck when turning to the left. The patients provider recommended a Dynamic Orthotic Cranioplasty (DOC) band. The Health Plan denied coverage for the DOC band based on their determination that it was not medically necessary, and the patients parents are now seeking reimbursement.Early review articles were indifferent as to the superiority of one treatment option for plagiocephaly over another. Recent research however, supports the superior benefit of orthotics such as the DOC band when compared to alternative treatment modalities. In this case, physical therapy was not performed, but the neurosurgeon clearly documented significant plagiocephaly and the patients mothers attempts at repositioning, without avail. Thus, the use of a DOC band was a medically reasonable and appropriate approach in the treatment of this patients plagiocephaly. Accordingly, I have determined the device at issue was medically necessary for treatment of the patients medical condition. The Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee underwent a total knee arthroplasty. She is requesting reimbursement for OxyContin 20 mg tablets that she received. The Health Plan has denied the request and reported that the medication at issue was not medically necessary. Per the Health Plan, OxyContin is a non-formulary medication. The Health Plan noted that there are other long-acting opioids, including fentanyl transdermal patch, methadone, tramadol extended-release, and morphine extended-release, with similar efficacy compared to OxyContin which were available. This denial is the subject of this appeal and determination. At issue in this case is whether the OxyContin 20 mg tablets that the patient received were medically necessary for her medical condition.In this case, the provider prescribed a non-formulary drug, a long-acting opioid, OxyContin. Long-acting opioids diminish the perception of pain and are used for chronic pain. Chronic pain is defined as pain that typically lasts over three months or past the time of normal tissue healing. Postoperative pain is acute and not chronic pain. In this case, the opioid medication was prescribed for postoperative pain control. As such, prescription of a non-formulary opioid such as OxyContin was not medically necessary. Therefore, OxyContin 20 mg tablets received were not medically appropriate and therefore not medically necessary 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 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: Upheld

Nature of Statutory Criteria/Case Summary: The patient presented to the emergency department (ED) via ambulance. He complained of waking up with epigastric discomfort with nausea, weakness, and diaphoresis. While in the ED, vital signs were stable and diagnostic testing was significant for negative findings. This patient underwent EKG, cardiac enzyme testing, CT angiogram of the coronary arteries, and an echocardiogram. All of these were unremarkable. This patients vital signs were normal on arrival. He was not experiencing unstable symptoms at the time of his admission. This patients symptoms did not meet criteria for the inpatient stay.Final Result: The reviewer determined that the requested services were not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is board certified in emergency medicine and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary:  An enrollee has requested laser hair removal for their arms, axilla, chest, face, neck, low back. The patient was born with genetics to grow the terminal hair in her arms, axilla, chest, face, neck and low back. It would be abnormal for a female to have terminal hair on the face, chest, neck and low back.  This hair growth in a woman is known as hirsutism. Hirsutism is a medical diagnosis where terminal hair grows in female body parts that are normally found in males. As such, the removal of terminal hair to the face, chest, neck and low back is within accepted standards of practice and clinically appropriate for treatment of gender dysphoria. These treatments will create a more feminine appearance for this patient and provide more than a minimal improvement in appearance. Moreover, removal of terminal hair to the face, chest, neck and low back will also improve this patients emotional function. However, females would be expected to have terminal hair in the axilla and on their arms. Therefore, removal of terminal hair to the axilla or arms is not medically necessary for treatment of this patient. Nor would removal of hair on the axilla and arms be considered reconstructive surgery, as the presence of hair in these areas is not considered an abnormal structure.Final Result: The reviewer determined that a portion of the requested services is medically necessary, and is reconstructive in nature for treatment of the patients medical condition. Therefore, the Health Plans denial should be partially 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: Medical Necessity
Decision: Upheld

A 28-year-old female enrollee requested authorization and coverage of continued chiropractic care. The Health Plan  denied the request indicating that the requested therapy is not medically necessary for treatment of the enrollees neck and back pain.One chiropractor reviewer performed a medical necessity Independent Medical Review. The chiropractor reviewer upheld the Health Plans denial on the basis that the requested therapy is not medically necessary.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for the computed tomography (CT) angiography (CPT 75574). Findings:  The physician reviewer found that as noted by the American College of Cardiology Foundation (ACCF), coronary CTA with contrast is often used to evaluate possible anomalous coronary arteries. Studies found that cardiac CTA provides excellent spatial and temporal resolution, allowing accurate anatomical assessment of these anomalies. Moreover, if the contrast coronary CTA was not done, another study such as a cardiac catheterization would have been indicated. Given this support, the CTA (CPT 75574) performed was medically necessary for further evaluation of this patients medical condition. Final Result: The reviewer determined that the diagnostic procedure at issue was 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 sub-specialty certification in cardiovascular 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: Overturned

A 66-year-old male enrollee has requested AlloMap testing for evaluation of his status post orthotopic cardiac transplantation. Findings:  Two physician reviewers found that the testing at issue was likely to have been superior over other methods of evaluating this patient.  There is support for gene expression profiling using AlloMap testing for acute cellular rejection screening in appropriate low-risk patients who are between six months and five years post transplant.  The current medical evidence supports the testing at issue in this clinical setting.  In this patients case, AlloMap testing was consistent with well-established guidelines for postoperative management and follow-up.  Therefore, AlloMap testing was consistent with current standard of care and was likely to have been more beneficial for this patient than standard therapy.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary:  An enrollee has requested reimbursement for bone replacement graft for treatment of the enrollees dental condition. Findings: The physician reviewer found that the patient has requested reimbursement for code D7953, bone replacement graft for ridge preservation.  This procedure is typically done for facilitation of a future implant or to preserve the bone ridge in a case where aesthetics may be compromised.  The records show the patient to have a moderate smile line, indicating a graft was not necessary for aesthetics of the smile line. The submitted email correspondence noted that implant placement was not performed. The dental literature indicates that following extraction, the tooth socket will heal and regenerate bone on its own with no additional treatment.  Therefore, a graft would only be necessary if there was a large area of bone loss following extraction which would not be expected to heal. As there was no expectation of a large defect following extraction and there was no implant placed, the dental necessity of the services at issue has not been established. Therefore, bone replacement graft received was not dentally necessary for the treatment of this patient.Final Result: The reviewer determined that the services at issue were not dentally necessary for treatment of the patients dental condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in 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 53-year-old female enrollee requested authorization and coverage of a sliding transfer bench, a fully electric hospital bed, and a deluxe commode transfer chair for assistance with  Parkinsons disease.  The Health Plan denied the enrollees request indicating that the requested treatment is not medically necessary.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 for treatment of the patients medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for Guardant360 gene testing provided Findings:  The physician reviewer found that Guradant360 is a type of liquid biopsy that offers molecular profiling on tumor types. As human epidermal growth factor receptor 2 (HER2) testing was not able to be obtained on the patients pelvic washings, the testing at issue was performed to help guide therapy. However, molecular profiling of breast cancer is not supported by the National Comprehensive Cancer Network (NCCN) guidelines. For patients with clinical courses consistent with hormone receptor (HR) positive breast cancer, or with prior positive HR results, the panel has noted that a course of endocrine therapy is reasonable, regardless of whether the receptor assay is repeated or the result of the most recent HR assay. Further, it is possible to perform testing for HER2 on liquid specimens. Therefore, molecular profiling performed was not likely to be more beneficial than standard HER2 testing or using prior biopsy molecular markers to guide therapy. For the reasons provided, Guardant360 gene testing provided on the date of dispute was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the testing at issue was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: Physician reviewers 1, 2 & 3 are board certified in internal medicine with sub-specialty certification in medical oncology and are actively practicing. The reviewers are all 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 reimbursement for residential treatment center (RTC) services.  The Health Plan has denied this request, indicating that the requested services were not medically necessary for treatment of the patients behavioral health condition. The submitted documentation supports the medical necessity of the requested RTC services. The patient was experiencing a disturbance in mood (comorbid condition), and disordered eating, which manifested in many ways as described, but included worsening suicidal ideation. This could not be safely managed in a less restrictive setting. Her isolation, recent breakup, and feeling that she is a burden to others put her at risk for not being able to seek help from others. All of the RTC services provided were medically necessary and in accordance with generally accepted standards of medical practice. Final Result: The reviewer determined that the requested RTC services were all clinically appropriate for the patients behavioral health condition and 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 gynecomastia reconstruction surgery.In this case, malignancy is not suspected. Furthermore, records reflect that the patient has breast enlargement due to residual fatty tissue in the breast area from exogenous obesity rather than true gynecomastia. He does not have unilateral or bilateral grade III or IV gynecomastia present, and there is no complaint of pain and discomfort due to distention and tightness from hypertrophied breasts. Under these circumstances, the requested gynecomastia reconstruction surgery is not medically necessary to treat the patients medical condition.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, fatty tissue in the breast area is not a result of a congenital defect, a developmental abnormality, trauma, infection, tumors or disease. It is not an abnormal structure of the body. It is a normal structural change that is an accommodative response to the gain or loss of body mass. In addition, no functional loss is present, and the appearance of the patient is normal and consistent with the gain and loss of weight. Accordingly, the requested gynecomastia reconstruction surgery is not reconstructive in nature for treatment of this patient.Final Result: The reviewer determined that the requested services are not medically necessary to treat the patients condition and are not reconstructive in nature. 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.