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

Nature of Statutory Criteria/Case Summary: Enrollee requested Orthovisc (hyaluronan) injections in both knees for treatment of osteoarthritis of both knees.  Findings:  The physician reviewer found that the requested services are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.At issue in this case is whether the requested Orthovisc (hyaluronan) injections in both knees is medically necessary for the treatment of the enrollees medical condition. The enrollee has a history of osteoarthritis of both knees with complaints of bilateral knee pain. Enrollee failed conservative treatment. Enrollee received Orthovisc injections with good benefit lasting one to one and a half year.Current evidence is limited, and guidelines from reputable organizations indicate that the evidence is inconclusive.  As such, the organization does not currently support viscosupplementation as the standard treatment for osteoarthritis of the knees. In light of the foregoing, viscosupplementation can be recommended in enrollees with a history of lasting benefit from prior injections and in carefully selected cases where the options are limited. The enrollee benefited from prior injections. Her options are limited, as the alternative is a total knee arthroplasty. 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: Medical Necessity
Decision: Upheld

A 30-year-old female enrollee has requested abdominal scar revision for treatment of her status post appendectomy.  Findings:  The physician reviewer found that the requested abdominal scar revision is not medically necessary for the patients medical condition.  The condition does not constitute an abnormal structure of the body, as this is not a pathologic scar.  The mere presence of a scar does not make its removal medically necessary.  In the absence of medical chart documentation of a pathologic scar (unstable scar prone to skin breakdown, impaired function, or symptoms) the proposed removal of this scar is not medically indicated.  The requested surgery is not being performed to improve function.  The submitted photographs show an excellent quality fine white line scar that is not likely to be improved by surgery and is not likely to be fixed to deeper structures.  All told, the requested abdominal scar revision is not reconstructive in nature and is not medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested 3T magnetic resonance imaging (MRI) for evaluation of the enrollees prostate cancer.  Findings: The physician reviewer found that in the peer-reviewed medical literature, Filson and colleagues reported that MR-ultrasound fusion biopsy allowed for the detection of clinically significant prostate cancer. Kuru and colleagues noted that MRI/transrectal ultrasound fusion has shown encouraging results for detecting clinically significant prostate cancer. Similarly, Valerio and colleagues compared the ability of standard biopsy to diagnose prostate cancer against a novel approach using software to overlay the images from magnetic resonance imaging and ultrasound to guide biopsies towards the suspicious areas of the prostate. The authors found consistent findings showing the superiority of this novel targeted approach, although further high-quality evidence is needed to change current practice. Further, Schoots and colleagues noted that they found evidence to suggest that MRI-guided targeted biopsy benefits the diagnosis of prostate cancer. Thus, the literature does support the use of the requested 3T MRI of the prostate as medically necessary for evaluation of this patients medical condition.Final Result: The reviewer determined that the requested diagnostic procedure is 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 diagnostic radiology 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 62-year-old male enrollee has requested a PET/CT scan (code 78815) for evaluation of his pancreatic carcinoma. Findings:  Three physician reviewers found that the PET/CT results provided necessary information for patient management. There was no other way to establish the diagnosis of tumor recurrence short of laparotomy or laparoscopy.  All told, the PET/CT scan performed was likely to have been superior over all alternative methods of evaluation.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for superior fornix reconstruction, symblepharon lysis, amniotic membrane graft, excision of left upper eyelid lesion, and wedge excision for lid notching. The records provided for review document that this patient sustained a fireworks injury resulting in significant scarring of the conjunctiva and cornea. Fireworks injuries can lead to significant chemical and thermal injury to the surface of the eye. Cheung and colleagues reported that in fireworks injuries, Despite total ocular surface failure, these eyes can achieve good postoperative visual results following limbal stem cell transplantation and subsequent keratoplasty with appropriate compliance. Before a patient can undergo surgical repair of the cornea, conjunctival disease must be surgically addressed. In this case, fornix reconstruction, symblepharon lysis, amniotic membrane graft, excision of left upper eyelid lesion, and wedge excision for lid notching were indicated to attempt to adequately treat this patients significant scarring of the conjunctiva and cornea. Therefore, the superior fornix reconstruction, symblepharon lysis, amniotic membrane graft, excision of left upper eyelid lesion, and wedge excision for lid notching were medically necessary for treatment of 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. Credentials/Qualifications: The reviewer is board certified in ophthalmology 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

A 47-year-old female enrollee has requested for emergency services for treatment of her abdominal pain.  Findings:  The physician reviewer found that the symptoms  did not meet prudent layperson criteria for emergency care. A prudent layperson with an average knowledge of medicine and mild crampy abdominal pain of several months duration, anxiety, depression and flatulence would not reasonably expect the absence of emergency care to jeopardize their health. This patients symptoms could have been safely evaluated on a non-emergent basis.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the residential treatment center (RTC) services  for treatment of the enrollees alcohol abuse. Findings:  The physician reviewer found that there was no evidence of post-acute withdrawal symptoms. The patient was not a danger to self or others. There were no emotional, behavioral, cognitive, or impulsive issues to warrant further RTC level of care services. The patient was not manic, psychotic, or agitated. The patient was medically stable. The patient declined medications for his anxiety and depressive symptoms. The patient had come to accept that he must remain abstinent, and was engaged in the recovery process. The patient was cooperative and compliant, his family was supportive, and he had a sponsor with whom to work. He no longer required the strict supervision provided by residential treatment, and could have been stepped down to an ambulatory setting such as partial hospitalization program (PHP) or intensive outpatient program (IOP) to continue his recovery.Final Result: The reviewer 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 reviewer is board certified in psychiatry with sub-specialty certification in addiction 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

A 31-year-old enrollee has requested a duodenal switch conversion for treatment of her obesity.  Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested services in this patients case.  This patient is status post Roux-en-Y gastric bypass.  There is a lack of documentation of ongoing dietary or behavioral follow-up since this surgery.  Additionally, there is no documentation of any overt anatomic complication of the gastric bypass.  Although this patient has a body mass index of 47, there is no documentation that this patient was compliant with ongoing dietary, behavioral and exercise activity since her surgery.  All told, the requested duodenal switch conversation is not medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Overturned

A 59-year-old female enrollee has requested for the medication Aciphex for treatment of her gastroesophageal reflux disorder (GERD). Findings:  The physician reviewer found that proton pumps inhibitors (PPIs) continue to be the backbone of therapy for acid suppression, and they continue to be the standard of therapy for the treatment of gastroesophageal reflux disease. All PPIs decrease acid secretion by inhibiting parietal cell proton pumps, and all PPIs are essentially equivalent on healing control of intragastric pH over 24 hours. There are subtle differences in the adverse reactions of all the PPIs available in the market. The differences in the metabolites of various PPIs explain some differences in adverse reaction among various PPIs. This patient developed rash and difficulty breathing with Nexium, Protonix, Prevacid and omeprazole.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the digital breast tomosynthesis for evaluation of the enrollees risk for breast cancer. Findings: Two physician reviewers found that Tomosynthesis is a technique that was developed several years ago as a problem solving adjunct to routine mammography. Applying the same basic concept as computed tomography (CT) scanning, by separating the various layers of breast tissue, one can better detect abnormalities. Although the presence of breast implants is not an indication for tomosynthesis, in this patients case, her breasts have been described as dense, and it is specifically these patients who have dense breasts that can benefit most from tomosynthesis. In addition, the patient had a nodular area of asymmetry, which was another indication for tomosynthesis. The ability to separate out the overlapping structures enables the possibility of demonstrating an otherwise occult tumor. Thus, in this clinical setting, the use of the digital breast tomosynthesis was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Final Result: The reviewers determined that the service at issue was 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. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for tissue graft (CPT 20926). Findings:  The physician reviewer found that this patient sustained panfacial fractures as a result of an ATV accident.  Fat grafting has been proposed to help treat an external depressed scar causing chin asymmetry. No functional impairment has been adequately detailed associated with the external scar. Thus, the medical necessity of the requested services has not been established. However, the patients condition constitutes an abnormal structure of the body. A scar of the chin is considered to be an abnormal structure of the body. This abnormal structure of the body was caused by traumatic injury from the ATV accident. The records do not establish that the requested surgery will be performed to improve function. Rather, the requested services will be performed to create a normal appearance to the extent possible. The records demonstrate that the surgery will provide more than a minimal improvement in the appearance of the patient. Therefore, the requested services are reconstructive in nature. All told, the requested tissue graft (CPT 20926) is reconstructive in nature. Final Result: The reviewer determined that the requested services are reconstructive in nature. Therefore, the Health Plans denial should be overturned. 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: Upheld

Nature of Statutory Criteria/Case Summary: The patient has been diagnosed with palmar hyperhidrosis. The patient described that the sweating of his hands is intolerable and interferes with his ability to perform activities of daily living. Physical examination revealed that his skin was normal in temperature, turgor, and texture. No prior treatments have reportedly been tried for his palmar hyperhidrosis. Studies found that because of the potential complications of Botox injections in the palmar region, it is not considered first-line therapy for the management of palmar hyperhidrosis. Other potential treatments for hyperhidrosis such as over-the-counter antiperspirants, prescription strength or clinical strength antiperspirants, iontophoresis, or oral medications, have not reportedly been tried. The physical examination indicated that the patients skin was of normal temperature, turgor and texture and there was no documentation of increased moisture on the patients skin. Based on these reasons, the requested Botox injections are not medically necessary for treatment of this 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 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: Urgent Care
Decision: Upheld

A 29-year-old male enrollee has requested emergency services for the treatment of his medical condition. Findings:  The physician reviewer found that at issue in this case is whether a reasonable and prudent layperson in the patients circumstances would have sought immediate medical attention for his complaint of right toe pain. California law defines an emergency medical condition as a medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain) such that the absence of immediate medical attention could reasonably be expected to result in any of the following: (1) Placing the patients health in serious jeopardy; (2) Serious impairment to bodily functions; (3) Serious dysfunction of any bodily organ or part. This patients symptoms had commenced gradually over the course of three days. He had a similar attack two weeks prior, and a known history of gout. Given that history, it is unlikely that one would reasonably believe his life or health to be in danger without immediate medical attention. While a flare of gout can be quite painful, the patient reported his pain as 5 out of 10 upon presentation to the emergency room. Although the patients symptoms warranted medical evaluation and perhaps modification to his prescribed pain medication regimen, they were not of sufficient severity to cause a prudent layperson to seek emergency medical attention.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for omeprazole DR 40 mg capsule. Since proton pump inhibitors do not correct the underlying pathophysiological motor abnormalities responsible for reflux, ongoing treatment at a sufficient dose is appropriate to maintain remission in patients with gastroesophageal reflux disease (GERD). Insufficient acid suppression can result in complications. Multiple studies show superior healing of erosive esophagitis with omeprazole 40 mg daily dosing rather than 20 mg daily. This patient has GERD and erosive esophagitis. Her symptoms are partially due to mechanical defects in esophageal motility. The records document that the patient has not experienced sufficient control with omeprazole 20 mg daily. Her provider recommended an increase in dosing to 40 mg, which is consistent with the current guidelines and medical literature. Given this support, the requested omeprazole DR 40 mg capsule is medically necessary for treatment of this patient. Final Result: The reviewer determined that the requested medication dosage 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 subspecialty certification in gastroenterology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld

A 59-year-old female has requested authorization for a wireless capsule endoscopy for evaluation of her medical condition.  Findings:  Three physician reviewers found that the patient has been under treatment for chronic hepatitis B with Baraclude for five years, and is status post treatment on three occasions for H. pylori. She presented with melenic stool on two separate occasions last year.  On each occasion, she underwent a non-diagnostic endoscopy.  There is no mention in her available medical record that she has undergone a colonoscopy.  The patients provider recommended a wireless capsule endoscopy for further evaluation of her medical condition. The Health Plan denied the requested procedure, indicating that colonoscopy is a procedure that is required as a pre-requisite in the work-up of occult gastrointestinal bleeding prior to covering a wireless capsule endoscopy. The medical literature strongly supports the use of capsule endoscopy (CE) in the evaluation of occult gastrointestinal bleeding. The data examining the efficacy of CE in the current peer reviewed medical literature, presupposes that results from upper and lower gastrointestinal endoscopy examinations were negative in all patients prior to the patient undergoing CE. There is some support for an early role of CE in the assessment of acute occult gastrointestinal hemorrhage (Mesink). However, such an emergency does not exist in this patients case. In accordance with the Health Plans pre-requisite diagnostic testing, the peer reviewed medical literature indicates the necessity for both upper endoscopy and colonoscopy procedures being performed prior to the use of CE in the work-up of a patient with occult gastrointestinal bleeding.  The documentation provided in this case does not demonstrate that the enrollee has undergone evaluation with a colonoscopy.
Appeal type: Experimental/Investigational
Decision: Upheld

A 57-year-old male enrollee has requested testing, cardiac computed tomography angiography (CCTA) for evaluation of his chest pain and shortness of breath.  Findings:  Two physician reviewers found that based on the records provided, the patient presents with some coronary risk, symptoms of atypical chest discomfort and an unequivocally positive stress test with jaw discomfort during exercise, ischemic appearing electrocardiographic changes and ischemia by nuclear perfusion imaging along with transient ischemic left ventricular dilation. In this circumstance, if assessment of coronary anatomy is thought to be necessary, then invasive coronary angiography is preferred due to its improved accuracy relative to coronary CT angiography and the ability to perform coronary revascularization during the same procedure if clinically appropriate. Current guidelines endorsed by several national organizations to not consider coronary CT scanning appropriate in symptomatic patients with unequivocally positive stress tests. Therefore, the requested coronary CT angiogram is not likely to be more beneficial than any available standard therapy including invasive coronary angiography.