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

A 45-year-old female enrollee has requested a panniculectomy and/or abdominoplasty for the treatment of her excess skin condition. Findings:  The physician reviewer found that the requested panniculectomy/abdominoplasty is not reconstructive in nature. The patients excess skin condition is not so severe as to constitute an abnormal structure of the body. The requested procedure would not be performed to improve function or create a normal appearance to the extent possible. The patient would still have obesity with cellulite and lipodystrophy and the preferred procedure would offer no more than a minimal improvement in the appearance of the patient. Thus, the patient does not meet the criteria of Californias reconstructive surgery law. Furthermore, there is no evidence to support the medical necessity of the proposed panniculectomy/abdominoplasty in this particular setting. The record lacks documentation of a stable weight for a period of at least six months. In addition, there is a lack of documentation of rashes, intertrigo, or skin ulcerations which have been diagnosed, treated with conservative management and failed conservative treatment over a period of time.
Appeal type: Medical Necessity
Decision: Upheld

A 49-year-old male enrollee has requested anterior endoscopic cervical foraminotomy, or in the alternative, artificial disc replacement for treatment of his cervical radiculopathy, low back pain, and lumbar facet arthropathy.  Findings:  The physician reviewer found that the first issue is the medical necessity of an anterior endoscopic cervical foraminotomy. Of the few case reviews, the only report on the anterior approach was a combined cadaver/case series study of 16 patients (Saringer, et al). Overall, the results of these 16 patients are insufficient to determine the safety or efficacy of this procedure. Therefore, the procedure should be considered not medically indicated. In an assessment of the safety and efficacy of cervical disc arthroplasty, Matz and colleagues performed a systematic review of the literature which yielded 280 references. After reviewing the abstracts and titles, the authors examined 10 studies that reported outcomes of arthroplasty compared to preoperative function or anterior cervical discectomy with fusion (ACDF). Of these 10 publications, there were no class I studies and only 4 class II studies. Overall, the authors concluded that total disc arthroplasty is still being evaluated for long-term outcomes in terms of durability and safety. Mummaneni and colleagues reported on their randomized, controlled trial of 541 patients, 276 of whom underwent arthroplasty, and 265 who underwent ACDF. When all criteria for success were used, the arthroplasty group had a superior outcome. However, multiple confounding factors such as the use of medications, cervical collar immobilization, and lack of blinding limit any conclusions from being drawn. More recently, published reports of randomized trials with longer term follow-up do suggest that artificial disc replacement may be beneficial, but the percentages of patients receiving 4-year and 5-year follow-up are exceedingly low and call into question the validity of the findings at this time (Burkus, et al). Given the lack of scientific data supporting the medical necessity of the requested procedures in this patients case, the denial should be upheld.
Appeal type: Experimental/Investigational
Decision: Overturned

A 55-year-old male enrollee has requested transcranial magnetic stimulation (TMS) therapy for treatment of his major depressive disorder.  Findings:  Three physician reviewers found that the patients treatment resistant major depressive disorder is well documented. Treatment strategies have included antidepressants, different classes, second generation antipsychotics, mood stabilizers, psychostimulants, and psychotherapy. Additionally, past treatment has included hospitalization and ECT with associated memory loss. Prior to beginning TMS, the patients symptoms included anhedonia and suicidal ideation. The patient received a course of TMS with positive response. TMS is currently in widespread use and there is strong support in the literature regarding both efficacy and safety of this treatment modality. High-frequency repetitive TMS has been found to be superior to sham in the treatment of depression (Schutter, et al.) and has been shown to be effective during the acute phase of depression (George and Post). Additionally, transcranial magnetic stimulation has been shown to be effective in treating major depression with minimal side effects and offers a novel alternative for the treatment of depression (Janicak, et al.). The American Psychiatric Association (APA) guidelines for the treatment of depression indicate that TMS is a safe and effective treatment option for depression that has been refractory to other treatments. In summary, TMS was likely to be more beneficial that any standard available therapy for the patients depression.
Appeal type: Medical Necessity
Decision: Overturned

A 63-year-old female enrollee has requested Oncotype DX Assay for an evaluation of her risk for breast cancer recurrence. Findings:  The physician reviewer found that Oncotype DX Assay is a 21 gene assay that has been found to reliably predict the risk of recurrence of an individuals breast cancer within ten years. It also predicts the usefulness of chemotherapy in that individual. There is sufficient data in the literature that it is no longer considered investigational in appropriate patients, and it has been accepted by the National Comprehensive Cancer Network, the American Society of Clinical Oncology and Medicare. Oncotype DX Assay is appropriate for patients with negative nodes and positive estrogen receptors, as well as HER2 negative. Although the patient has a focus of cells in a node, it was less than 0.2 mm in size. By the current staging system, this is considered to be a negative node. Therefore, Oncotype DX Assay is appropriate for this patient, as it will provide unique biologic information with which the oncologist can make a recommendation about treatment.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested Sovaldi and Daklinza for treatment of his hepatitis C virus infection genotype 3.  Findings:  The physician reviewer found that according to joint guidelines issued by the American Association for the Study of Liver Diseases (AASLD) and the Infectious Diseases Society of America (IDSA), all patients with chronic hepatitis C should be treated except those with life expectancy less than 12 months due to non-liver-related conditions. This patient should be considered treatment-naive because he did not fail any appropriate or recommended therapies for hepatitis C patients with genotype 3. This patient is interferon-eligible as no medical contraindication is reported. Although the provider reports that there is concern about PEG-interferon side effects, the AASLD/IDSA recommendations were created with full knowledge of those effects, and the AASLD/IDSA specifies medical contraindications to PEG-interferon which are not reported in this case. If the patient is considered a Sovaldi/ribavirin failure rather than treatment-naive, Sovaldi/PEG-interferon and ribavirin are preferred over Daklinza regimens in interferon-eligible patients. All told, the requested treatment with Sovaldi and Daklinza is not supported as medically necessary for the treatment of this patients hepatitis C infection.  Final Result:  The reviewer determined that the requested medications 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 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: Medical Necessity
Decision: Overturned

The patient is a 14-year-old female with arteriovenous malformation in the left mandible. This was treated with embolization of the feeder vessels by an interventional radiologist followed by segmented resection of the mandible with immediate iliac crest and graft reconstruction. The segment of the mandible that was removed controlled teeth #18, #19, #20, #21, and #22. The graft reconstruction site is edentulous with the exception of impacted tooth #17. A request has been made intraosseous dental implants. The Health Plan indicates the requested procedure is not medically necessary.The first stage of mandibular reconstruction consisted of bone graft of the left mandibular continuity defect. Donor site was the anterior iliac crest. The second stage of mandibular reconstruction should consist of replacement of the missing dentition with intraosseous dental implants to replace teeth #22, #21, #20, #19, and #18. The requested procedure is medically necessary because there are no teeth that would serve as adequate abutments to support a partial denture. Furthermore, pressure from a partial denture would cause reposition of the grafted bone leading to failure of the entire reconstruction. Therefore, I have determined the requested procedure is medically necessary for treatment of the patients medical condition. The Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Upheld

Findings:  The physician reviewer found that The patient has requested authorization and coverage for RT300 functional electrical stimulation (FES) therapy system. In this case, the patient sustained a traumatic injury to cervical spinal cord. The mainstay of long-term management for this patient population focuses on surveillance and preventive clinical care related to the respiratory system, pressure injury prevention, neurogenic bowel and bladder management, tone issues, pain and monitoring for complications (Ong, et al.). Health and well-being in this patient population is promoted through optimizing medical care and the encouragement of participation in educational, social, recreational, avocational and vocational activities (Tweedy, et al.). While standard medical care and rehabilitation measures may not resolve a patients neurological impairments due to the underlying spinal cord injury, the requested FES cycle ergometer, has not been demonstrated to provide meaningful benefit for patients with this condition. Current studies reported in the peer-reviewed medical literature have not shown that the RT300 FES improve cardiovascular health, pulmonary health, bony health or other health parameters in a clinically significant manner (Nardone, et al.; Soleyman-Jahi, et al.; Phadke, et al.; Farrow, et al.). The RT300 FES may potentially help to improve or maintain muscle mass in weakened or totally paralyzed limbs, but this provides no significant health or functional benefit and does not obviate the need for pressure relief. All told, the requested RT300 FES therapy system is not medically necessary for treatment of this patient. Final Result: The reviewer determined that the requested device is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.
Appeal type: Experimental/Investigational
Decision: Upheld

A 46-year-old female enrollee has requested bariatric lap band surgery for treatment of her hypertension, sleep apnea, and acid reflux.   Findings:  Three physician reviewers found that this patients records do not document morbid obesity with a BMI of at least 35 and diagnosis of a serious co-morbid condition. This patient is being evaluated for hypertension, but is not being treated with medication. Currently, bariatric surgery for low BMI should only be performed as part of an IRB approved clinical trial. Consistent with these findings, the requested bariatric lap band surgery is not likely to provide this patient with an improved health outcome beyond that expected with standard non-surgical interventions.
Appeal type: Medical Necessity
Decision: Upheld

A 60-year-old male enrollee has requested authorization and coverage for a magnetic resonance imaging spectroscopic (MRIS) of the pelvic area, specific to the prostate for evaluation of his borderline prostate specific antigen. Findings:  The physician reviewer found that the diagnosis of cancer is made by examining cells under a microscope. In order to obtain a specimen from the prostate, the standard of care is ultrasound-guided biopsy. This patients provider has outlined a plan to take samples in order to rule out prostate cancer, or to determine the extent and location of disease. By contrast, MRIS is performed after a patient is diagnosed with cancer to look for metastatic disease. Currently, MRIS is not supported as a means to diagnose cancer in a patient without an established diagnosis. All told, use of MRIS in lieu of biopsy would be inappropriate for determination of an initial diagnosis. This patients provider detailed a sample biopsy approach, which is the standard of care for evaluation of this patients condition. As such, the requested diagnostic procedure is not medically necessary for evaluation and treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned

A 23-year-old female enrollee has requested continued residential treatment center (RTC) services for treatment of her eating disorder.   Findings:  The physician reviewer found that the residential treatment center (RTC) services provided from the date indicated and forward were and are medically necessary for treatment of the patients medical condition. According to the documentation submitted for review, this patient has a history of multiple, serious, well-constructed suicide attempts while receiving very high levels of care. In this particular case, brief periods of stabilization are often insufficient to insure the well-being of such a fragile patient. The odds ratio for recurrent successful suicide attempts in the context of an eating disorder overlapped with recurrent major depression becomes very high. As such, the additional time for stabilization in residential treatment becomes essential. The American Psychiatric Association (APA) guidelines, as well as most algorithms for the treatment of eating disorders, make allowances for such treatment refractory cases by the provision for longer term residential treatment. Based on the medical literature cited above and the documentation submitted for review, the services at issue were and are medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld

A 54-year-old female enrollee has requested lumbar spinal fusion for treatment of her back and leg pain.  Findings:  The physician reviewer found that this patient has chronic back pain. However, the records do not document that her pain generator has been identified. Her MRI scans did not show any evidence of canal or foraminal stenosis, and x-rays did not demonstrate any instability. A patient at 54-years of age is expected to have some degenerative disc disease, as well as a positive nuclear study, as with this patient at L5-S1. In the medical literature, Chou and colleagues noted that provocative discography is not recommended as a procedure for diagnosing discogenic low back pain due to the high rate of false positive results. Further, Resnick and colleagues noted that discography should not be used as the decision maker for lumbar fusion. Bambakidis and colleagues discussion on indications for spinal fusion include infection, tumor, fracture, spondylolysis with spondylolisthesis, and spinal stenosis. None of these indications for spinal fusion are present in this patients case. All told, the requested surgery exceeds the needs for this patient and therefore is not supported as medically necessary for treatment of her medical condition.
Appeal type: Medical Necessity
Decision: Upheld

A 39-year-old female enrollee has requested bariatric surgery consultation for treatment of her obesity. Findings:  The physician reviewer found that there is a lack of scientific evidence supporting weight loss surgery for patients who do not meet the minimum BMI with or without co-morbid conditions set forth by the National Institutes of Health Consensus Criteria for weight loss surgery. Such patients are not considered to have clinically severe obesity necessitating bariatric surgery. For patients such as this patient, conservative weight loss measures in lieu of bariatric surgery is the standard of care.
Appeal type: Medical Necessity
Decision: Upheld

The enrollee is requesting authorization and coverage for the medication Tremfya. The enrollee has psoriasis on her abdomen, arms, and lower legs. The enrollee is consistent with her injections of Cimzia and would like to try adjuvant treatment with Xtrac. The provider noted that if the enrollee did not improve with adjuvant Xtrac in six months, a different biologic, such as an IL 23 molecule would be trialed. All other biologic classes and systemic therapies, including Cimzia, have failed to control or improve the enrollees symptoms without significant side effects. The provider is requesting Tremfya, which has been approved for use regulatory agencies for the treatment of plaque psoriasis. Literature describes biologic agents as the most effective therapies for moderate to severe psoriasis. The formulary-approved medications Taltz (ixekizumab) and Cosentyx (secukinumab) are supported in the studies to be appropriate treatment options for the enrollee.                                                          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 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 similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/ Case Summary:  The enrollee is requesting authorization and coverage for a custom right foot orthotic. Findings:  The physician reviewer found that according to the medical record, the enrollee has a history of scoliosis and leg length discrepancy with her left leg reportedly one cm shorter than her right leg. Podiatry notes indicate right knee, hip, and foot pain. She has hammertoe of the second toe with rubbing against her shoe and talar spur. In addition to a built in heel lift on the left, a custom right foot orthotic to assist with reducing pronation, pain, impact on the soft tissues and bones of the feet, reducing strain on the soft tissue, off-load deformities, prevent or delay surgery, and prevent ulceration was prescribed by her podiatrist. There is insufficient evidence in the record of the actual documented assessment of the limb length discrepancy. Although there is an estimate of a one cm difference for this enrollee, in actuality this number could be higher or lower; which could change the treatment options.  Per the medical literature, measurements performed by a clinician rather than imaging modalities, are not accurate as there can be a high level of inter-observer variability. Further, there is no evidence in the record of a trial of a simple over-the-counter heel lift on the left, which, literature indicates may resolve right knee and hip pain related to limb length discrepancy. Studies demonstrate that a limb length discrepancy of less than two cm seldom causes any issues and may addressed with an internal heel lift. Final Result: The reviewer determined the requested service was not medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The clinical reviewer is board certified in podiatry 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 parent of a 15-year-old female enrollee has requested acute inpatient psychiatric treatment for the treatment of the enrollees major depressive disorder. Findings:  The physician reviewer found that this patient was suicidal with plan and was unwilling to contract for safety. Her thinking suggested a possible psychotic element. The patient did improve in hospital, but she contracted for safely slowly and with some reluctance. Additional problems surfaced. An eating disorder with purging and possible drug use was also recognized. Family issues surfaced. The patient had improved somewhat. However, her improvements were not internalized sufficiently to allow her safe treatment at a lesser level of care. The patient continued to need 24/7 professional observation and supervision in the hospital setting. It was not established that her suicidal thinking was fully and safely resolved. Her eating disorder had only begun to be addressed. Her support system was only newly established. Acute inpatient psychiatric treatment provided was medically indicated.  It would have been unsafe and imprudent to discharge the patient earlier.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary:  An enrollee has requested advanced lipoprotein testing for evaluation of his medical condition.  Findings:  Three physician reviewers found that per the submitted documentation, this patient had increased coronary risk but no documented history of coronary disease.  In this circumstance, primary prevention guidelines for the management of cardiac risk and dyslipidemia have been established, are periodically updated by expert committees and are endorsed by several national organizations.  These guidelines currently do not recommend routine performance of specialized tests in the context of assessing coronary risk including lipoprotein-associated phospholipase A2, sub-classifications of low-density lipoprotein, high-density lipoprotein subclasses, lipoprotein (a), C-reactive protein, high sensitivity C-reactive protein, insulin, fibrinogen, genetic testing and homocysteine.  Treatment change or addition based on the results of screening with these specialized tests has not been shown to improve cardiac outcome incremental to that achievable by treatment based on standard risk factor profiling and basic lipid analysis.  All told, advanced lipoprotein testing was not likely to have been of greater benefit than other methods of evaluating this patient. Final Result: Three reviewers determined that the services at issue were 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:   All three reviewers are board certified in internal medicine with sub-specialty certification in cardiovascular disease 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.