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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Afrezza insulin. The Health Plan has denied this request indicating that the requested medication is not medically necessary for treatment of the enrollees diabetes, type I.There is support in the medical literature for the requested medication in this clinical setting. Afrezza is an inhaled insulin with ultra rapid pharmacokinetic-pahrmacodynamic (PK-PD) properties that enable improved postprandial glycemic control in adults with type 1 or type 2 diabetes. This inhaled insulin has a PK/PD profile with a rapid onset of action and a short duration of action that differentiates it from subcutaneous administered rapid acting insulin analogs and earlier inhaled insulins (Heinemann and Parkin). Afrezza is not intended as a substitute for traditional basal therapy with injectable long-acting insulin, but may be used to provide prandial insulin coverage. It must be used in combination with long acting insulin in patients with type 1 diabetes. Afrezza is more quickly absorbed than subcutaneous insulin therapies and has a shorter duration of action. It appears to be noninferior compared with subcutaneous insulin regimens, and is associated with less hypoglycemia. Thus, it may serve as an alternative insulin agent in patients reluctant to administer multiple subcutaneous injections of insulin daily or in patients who experience late postprandial hypoglycemia with subcutaneous insulin. The patient indicates a risk for nocturnal hypoglycemia, which is probably the result of late postprandial hypoglycemia. The risk of late postprandial hypoglycemia can be minimized with Afrezza. This type of insulin might help the patient address hyperglycemia without delayed hypoglycemic response. From the submitted record, the patient has risk of hypoglycemia with the current subcutaneous insulin regimen. Based on the documentation provided, Afrezza has been demonstrated as medically necessary for the management and treatment of this patients diabetes.  Final Result: The reviewer determined that 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 internal medicine with sub-specialty certification in endocrinology, diabetes and metabolism 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: The patient has requested reimbursement for fertility preservation services (evaluation of reproductive potential, ovarian stimulation, oocyte retrieval, oocyte fertilization, and storage of oocytes and/or embryos). Chemotherapy is a gonadotoxic treatment that can result in infertility. For reproductive aged patients with newly diagnosed cancer, it is within the current standard of care to counsel them about their options for preservation of fertility and, if appropriate, potential preservation of ovarian hormone production. Providers should discuss the risk of treatment-induced infertility as well as possible interventions to preserve fertility and hormone production prior to initiating gonadotoxic therapy, as was done in this patients case. Although there is a lack of large randomized clinical trials with long-term follow-up studies assessing the possible impact of fertility treatment on cancer patients, the current medical literature supports fertility preservation in this clinical setting.  Established techniques for fertility preservation include cryopreservation of embryos and oocytes, which is associated with the greatest likelihood of successfully generating offspring. Given these findings, fertility preservation services (evaluation of reproductive potential, ovarian stimulation, oocyte retrieval, oocyte fertilization, and storage of oocytes and/or embryos) 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 obstetrics and gynecology 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

A 54-year-old female enrollee has requested Synthroid for treatment of her hypothyroidism.  Findings:  The physician reviewer found the submitted documentation supports the medical necessity of the requested medication.  Although the active component of Synthroid is the same as the generic medication, the inactive ingredients and calibration may differ from one manufacturer to another.  More recently, the records indicate that the patient was prescribed Armour thyroid, and she reported excessive sweating.  The current medical evidence supports the requested medication in this clinical setting.  All told, Synthroid is medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Nurtec ODT. Findings:  The physician reviewer found that records provided for review document that this patient has been treated with several medications without appropriate relief of her migraines. The provider charted that the patient has failed to respond to treatment with Botox, celecoxib, pregabalin, gabapentin, and topiramate, among other agents. The patients current regimen including Nurtec has helped decrease the frequency of her migraines from 20 or more headache days per month, to about eight per month. The patients provider has recommended treatment with (rimegepant) Nurtec ODT. Migraine is a neurological disease with several treatment options. Nurtec is from the calcitonin gene-related peptide receptor (CGRP) antagonist family of medications. Several studies have demonstrated the safety and efficacy of Nurtec in the treatment of patients with migraine. Croop and colleagues found that Nurtec was more effective than placebo in the management of patients with acute migraine. In addition, the available evidence regarding Nurtec has garnered U.S. Food and Drug Administration (FDA) approval for the treatment of patients with migraine. Given this support, the requested Nurtec ODT is medically necessary for 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 neurology with subspecialty certification in vascular neurology 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 54-year-old female with a history of long-standing knee pain. She has tried numerous modalities to alleviate her pain. She received Synvisc injections a year ago with reported benefit. At issue is whether another course of Synvisc injections is medically necessary for treatment of the patients medical condition.The patient received a series of Synvisc injections in May 2005 with good results.  In light of her previous response to the therapy, a repeat series of Synvisc is likely to be beneficial. The patient is relatively young to have severe arthritis and appears to be in eventual need of knee replacement. A repeat series of Synvisc injections is appropriate to alleviate pain and postpone surgical intervention. Therefore, I have determined the requested injections are medically necessary for treatment of the patients medical condition. The Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patients parent has requested authorization and coverage for laser hair removal. The records provided for review document that this patient presents with excessive hair about the buttocks and gluteal cleft. The patients age, gender, and hirsutism are all risk factors for the development and recurrence of pilonidal cysts. Pilonidal cysts are characterized by chronic and recurrent inflammation and infection surrounding hair on the buttocks and gluteal cleft. Surgical treatments have a high rate of recurrence and often require repeated surgical interventions and systemic antibiotics for the accompanying folliculitis and cellulitis (Kelati, et al.). There is evidence to suggest that laser hair removal decreases the risk of delayed healing and recurrence of pilonidal cysts following surgical treatment, and/or as an alternative to surgical treatment. Thus, the requested laser hair removal is medically necessary for 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. Based on the available documentation, this patients pilonidal cyst is an abnormal structure of the body caused by a secondary infection due to ingrown hairs. On review of this patients records, the requested laser hair removal is reconstructive in nature per the California reconstructive surgery statute. The patients pilonidal cyst is an abnormal structure of the body and the requested laser hair removal will improve the patients function and will create a more than minimal improvement in the patients appearance. Given these findings, the requested laser hair removal is reconstructive in nature for treatment of this patient. All told, the requested laser hair removal is medically necessary and reconstructive in nature for treatment of this patient. Final Result: The reviewer determined that the requested services are medically necessary and reconstructive in nature 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: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for chiropractic manipulative treatment services (CPT 98942), two sessions per month for three months. The requested chiropractic manipulative treatment services (CPT 98942) are for an adjustment of five different spinal regions. In this case, the patient has a diagnosis of right arm pain. There is no anatomical relationship between the lumbar spine, occiput, or coccyx to any nerves related to the arm. For chiropractic treatment, the spinal level must bear a direct causal relationship and symptoms should be related to the level of anatomic region that has been diagnosed. There is insufficient research on the effectiveness of chiropractic treatment on upper limb conditions. In this case, the patient does not have any spinal complaints. Given this patients diagnosis, chiropractic manipulation of five spinal regions is not medically indicated. Therefore, chiropractic manipulative treatment services (CPT 98942), two sessions per month for three months are not medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested 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 chiropractic 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: Experimental/Investigational
Decision: Overturned

A 34-year-old male enrollee has requested for high-dose chemotherapy with stem cell support (HDCSCS) triple-tandem transplant utilizing the TICE regimen (paclitaxel and ifosfamide followed by carboplatin and etoposide) for treatment of his testicular germ cell tumor.   Findings:  Three physician reviewers found that there is no established standard of care for relapsed germ cell tumors. Based on a thorough review of the available medical literature and historical data, tandem cell autologous transplantation appears to be superior to standard chemotherapy or single autologous stem cell transplantation. The above-cited literature demonstrates adequate support for a tandem transplant procedure for this patient. With regard to the requested triple-tandem transplant, the procedure has not been sufficiently studied to date to recommend its use over a tandem transplant procedure in this case.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for liposuction to remove the fat deposit from the spine. Lipo-accumulation of the dorsocervical fat pad can be a symptom of cortisone hormonal imbalance. Kairys and Schwell noted that, Physical manifestations of excess cortisol levels include moon facies, buffalo hump, easy bruising, abdominal striae, obesity, facial plethora, and hirsutism. The records provided for review document that this patient has a dorsocervical fat pad and she has a history of cervical radiculopathy. As noted in the medical literature, a dorsocervical fat pad is not likely to cause pain. This patients records do not support that the dorsocervical hump is related to pain from her cervical radiculopathy, or that the condition is related to a functional deficit. For these reasons, the requested liposuction to remove the fat deposit from the spine is not medically necessary for 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; (2) to create a normal appearance, to the extent possible. In the absence of a documented hormonal abnormality, a dorsocervical fat pad is not a result of a congenital defect, a developmental abnormality, trauma, infection, tumor, or disease. This patients condition is not an abnormal structure of the body. There is a lack of documentation that the requested procedure would improve the patients ability to function. In addition, the appearance of the patient is within normal limits. Based on the photographs provided for review, the requested procedure would not provide a more than minimal improvement in the patients appearance. Therefore, the requested liposuction to remove the fat deposit from the spine is not reconstructive in nature for treatment of this patient. Final Result: The reviewer determined that the requested services are not medically necessary and not reconstructive in nature for treatment of the patients medical condition. 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.
Appeal type: Experimental/Investigational
Decision: Upheld

A 65-year-old female enrollee has requested plasma injections for treatment of her plantar fasciitis.  Findings:  Three physician reviewers found that the patient has failed conservative treatment consisting of stretching, icing, custom orthotics, night splints, immobilizing boot, physical therapy and steroid injections. The provider recommended an autologous platelet-rich plasma injection to the painful heel.    Most of the studies on platelet-rich plasma therapy note some efficacy.  However, these reports note that further investigation is necessary.  There is a lack of large, double-blind, placebo-controlled studies for this treatment modality.  Currently, the minimally invasive endoscopic plantar fasciotomy demonstrates a 90% cure rate.  At this time, the superior efficacy of the requested services has not been established.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for a power wheelchair, Group 3 Standard, multiple power option, sling/solid seat/back, patient weight capacity up to 300 pounds (CPT K0861); wheelchair component or accessory (CPT code K0108); power wheelchair accessory, Group 34 sealed lead acid battery (CPT E2359). The Health Plan has approved the patient for a basic group 3 powered wheelchair with occupied transit mounts and rehabilitation seating. The patient is noted to have good trunk control and is able to weight shift when needed. The requested wheelchair with tilt in space, powered elevating leg rests or custom seating would exceed the patients medical needs and are not necessary for this condition per the submitted documentation. All told, the requested power wheelchair, Group 3 Standard, multiple power option, sling/solid seat/back, patient weight capacity up to 300 pounds (CPT K0861); wheelchair component or accessory (CPT code K0108); power wheelchair accessory, Group 34 sealed lead acid battery (CPT E2359) is not medically necessary for treatment of this patient. Final Result: The reviewer determined that the requested equipment 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 physical medicine and rehabilitation with subspecialty certification in neuromuscular 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: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for percutaneous tibial nerve stimulation (PTNS). Findings:  The physician reviewer found that there is currently a lack of peer-reviewed medical literature supporting the superior efficacy of treatment with PTNS for interstitial cystitis, pelvic pain and associated symptomatology stemming from this pathologic pathway. A study concluded that intermittent PTNS is not a satisfactory treatment for refractory interstitial cystitis/bladder pain syndrome. Similarly, another study found that intermittent PTNS in patients with refractory interstitial cystitis has no significant clinical effect over 10 weeks of treatment. While it is possible that PTNS could benefit some symptoms including overactive bladder and incontinence, overall there is a paucity of data that the requested PTNS is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the requested service is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: Physician reviewers are board certified in urology 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: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for the residential treatment center level of care services  for treatment of the enrollees alcohol abuse. Findings:  The physician reviewer found that the patients withdrawal symptoms were mild-to-moderate in nature, and cravings were moderate. She was not a danger to herself or others. There were no emotional, behavioral, cognitive, or impulsive symptoms to warrant residential level of care. Her activities of daily living were intact. There was no evidence of a high degree of impulsivity, agitation, depression, mania, hallucinations, or any other significant symptom that would interfere with her care. She was medically and psychiatrically stable to the point that she could have been managed at an ambulatory level of care. She appeared to be engaged and working the program and had completed step I in Alcoholics Anonymous. She was cooperative and medication compliant. Given that the patient has had multiple prior substance abuse treatments at residential of care, she would have been educated regarding issues of relapse prevention and impulse control, thus already having a foundation from which to work. No new problems had arisen. The issues she was dealing with in therapy could have been addressed in an outpatient setting. Although she required further treatment to help her develop and solidify coping skills, this could have been accomplished in an ambulatory setting. She no longer required 24-hour residential monitoring and could have been stepped down to an ambulatory level of care. Thus, the residential treatment center level of care services provided from were not medically necessary for treatment of the patients medical condition. 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 30-year-old female enrollee has requested for a magnetic resonance imaging (MRI) scan of the bilateral shoulders for evaluation of her shoulder pain. Findings:  The physician reviewer found that an MRI of the shoulder can be of great value in the diagnosis or grading of many conditions, such as rotator cuff abnormalities, glenoid labral lesions, loose bodies, infections, and tumors.  It is of great value in the evaluation of instability, mechanical symptoms, and limited motion. It is not efficient as a screening procedure, but rather is most useful in concert with other modalities (see Nobuhara). It is necessary to be informed as to the anatomic and pathologic considerations to properly evaluate MRI findings (see Vahlensieck).