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 panniculectomy.  Findings:  The physician reviewer found that according a study The abdominal panniculus may cause disabling rashes, pain, physical limitation, back strain, and cosmetic deformity, and symptoms are more marked the heavier the panniculus. Panniculectomy can treat these symptoms In this case, the patient presents with significant weight loss following bariatric surgery. She has evidence of a symptomatic abdominal pannus as a result of significant weight loss. Her symptoms have included chronic rashes, abscesses and worsening urinary incontinence.  She has attempted dermatologic treatment with topical measures which has not been able to control her rashes. The photographs submitted for review demonstrate functional impairment related to the pannus, as there is evidence of a significant lower abdominal pannus that hangs below the pubic bone. She also has evidence of abscess formation and skin breakdown. Based on the documentation provided for review, the requested panniculectomy is medically necessary for treatment of the patients medical condition. Final Result: The reviewer determined that the requested surgery is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: Physician 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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Lipiflow treatment (0207T, 0330T). Findings:  The physician reviewers found that the documentation provided does not support the superior efficacy of the requested services in this clinical setting. There is insufficient information to determine if this patients symptoms of decreased near vision and night vision are caused by MGD and dry eye syndrome. Refractive error should be ruled out as the cause for these symptoms and this has not been documented. While there is some support for Lipiflow treatment, it is unclear from the documentation provided if this patient has failed standard therapies, such a warm compresses, lid scrubs, artificial tears, and omega-3 supplementation. Although dry eye syndrome can cause visual symptoms, there is insufficient evidence to justify the use of Lipiflow for a condition that is commonly and effectively treated with conservative measures. Therefore, Lipiflow treatment (0207T, 0330T) is not likely to be more effective than other treatment options in this patients case. Final Result: 3 of 3 reviewers determined that the requested services are 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 physician reviewers are board certified in ophthalmology 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

A 42-year-old male enrollee requested Zohydro for medical treatment of his chronic pain due to lumbosacral spondylolysis. Findings:  The physician reviewer found that in 2014, the U.S. Food and Drug Administration (FDA) approved Zohydro as a new formulation of extended release hydrocodone for pain. In their statement with approval, the FDA noted that there is less chance of liver failure as it is not combined with a non-narcotic mediation. Common side-effects matching other narcotic medications are noted to be constipation, nausea, and somnolence. Finding the appropriate combination of medication short- and/or long-acting narcotic is not without risk due to side effects and risk of addiction and abuse. Providers have to independently evaluate every patient for risk evaluation and mitigation strategies (REMS). Argoff and Silvershein reported that a review of published studies found no data to suggest that either short acting opioids or long acting opioids are generally more efficacious for treating any particular chronic non-cancer pain condition. Given the current standard of care for this patients medical conditions, the requested Zohydro is not supported as medically necessary.
Appeal type: Medical Necessity
Decision: Upheld

A 63-year-old female enrollee requested carisoprodol 350mg, 180 tablets per 30 days for medical treatment of her back pain.  Findings:  The physician reviewer found that the current standard of care for chronic pain and spasms is treatment in a multidisciplinary practice to include physical therapy, massage therapy, behavioral therapy, and injections to help reduce pain.  Carisoprodol is a centrally-acting muscle relaxant associated with a high-risk of dependence and tolerance.  Therefore, long-term administration of this medication is not recommended.  In the study by Gatch and colleagues, the authors noted that carisoprodol treatment resulted in tolerance and antagonist-precipitated withdrawal.  Centrally-acting and addictive muscle relaxants are more likely to cause adverse outcomes.  All told, the requested carisoprodol 350mg, 180 tablets per 30 days is not medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld

A 31-year-old female enrollee has requested Norco for treatment of her pain. Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested medication.  The medical records indicate myofascial pain, especially in the upper and lower back.  The patient reportedly has had a number of conservative measures for her pain, including acupuncture, massage therapy and chiropractic treatment.  However, there is a lack of support for Norco in this patients case.  Per the current medical evidence, there are other modalities which have not been tried which may be of benefit, including trigger point injections.  The literature does not support long-term use of Norco with the current pain syndrome.  All told, the requested Norco is not medically indicated for the treatment of this patient.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for LINX Reflux Management System. The Health Plan has denied this request indicating that the requested services are considered investigational for treatment of the enrollees gastroesophageal reflux disease.Findings There is a lack of randomized controlled trials with long term follow up demonstrating that LINX is safer or more effective than Nissen fundoplication or other surgical anti-reflux procedures. American College of Gastroenterology guidelines for the management of reflux disease also state that more evidence is needed before LINX can be recommended. One best evidence review concluded that long-term comparative outcome data past 1 year are needed in order to further understand the efficacy of magnetic sphincter augmentation. Additionally, LINX (to a greater extent than surgical fundoplication) is associated with severe dysphagia requiring endoscopic intervention. Another evidence review concluded that the long-term safety and efficacy of LINX - both alone and in comparison to current GERD therapies - remains to be determined. There are 29 reports of LINX erosion through the esophagus in the publicly accessible U.S. Food and Drug Administration Adverse Events database, among other adverse events. The currently available peer reviewed literature does not definitively support the conclusion that LINX is likely to be more beneficial than standard treatment in this clinical setting. For these reasons, LINX Reflux Management System is not likely to be of greater benefit for the treatment of this patients GERD symptoms than any available standard therapy.Final Result: Two of the three reviewers determined the requested services are 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:  All three reviewers are board certified in internal medicine with sub-specialty certification in gastroenterology 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.
Appeal type: Medical Necessity
Decision: Overturned

A 61-year-old female enrollee requested bariatric surgery, gastric sleeve for treatment of her morbid obesity.  Findings:  The physician reviewer found that the submitted documentation demonstrates the medical necessity of the requested services in this patients case.  The current medical evidence supports bariatric surgery in this clinical setting.  The medical records document morbid obesity and comorbid medical conditions related to her obesity including diabetes, obstructive sleep apnea, hypertension, gastroesophageal reflux disease, asthma, and dyslipidemia.  She has tried and failed non-surgical attempts at weight loss.  She has been appropriately screened and cleared for bariatric surgery by numerous providers.  This patient meets generally accepted criteria for bariatric surgery.  All told, the requested gastric sleeve procedure is medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for administration of the authorized Remicade infusions at a hospital-based outpatient infusion facility.Belonephobia (fear of needles), trypanophobia (fear of injections), and aichmophobia (fear of sharp objects) can lead to phobias requiring specific management. In both pediatric and adult patients, these phobias can result in elevated levels of anxiety and fear leading to the avoidance of care, and to interference with clinicians ability to perform procedures. McMurtry and colleagues stated, Individuals with high levels of needle fear who also have chronic health conditions requiring injections are a particularly vulnerable group who require treatment of their fear to maximize adherence to their medical regimen and avoid negative health effects. Repeated exposure to traumatic experiences, including in pediatric patients, can establish nonadherence to medication, long-term avoidance of medical care and follow-up, and subsequent negative health effects; these can result in complications and long-term disability in high-risk diseases, such as Crohns disease. In this case, the patient has Crohns disease at a young age and severe needle phobia. Crohns disease requires chronic and uninterrupted therapy in order to prevent complications. The records indicate that the patient has been able to undergo infusions successfully due to needle phobia mitigation at a hospital outpatient facility, but has had difficulty at other facilities. The therapy he is stabilized on is likely to control disease and prevent severe disease complications. Thus, administration of the authorized Remicade infusions at a hospital-based outpatient infusion facility is medically necessary for the treatment of the patients medical condition.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 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: Experimental/Investigational
Decision: Overturned

A 59-year-old female enrollee has requested Botox injections at a frequency of every 3 months for treatment of her chronic migraine and cervicalgia.  Findings:  Three physician reviewers found that on review of the available peer reviewed, published, medical literature, the requested Botox injections are not likely to be more beneficial for the treatment of the patients chronic daily headaches than any available standard therapy. Overall, there is a paucity of medical literature supporting the efficacy of Botox in this patient population. Matthew and colleagues performed a randomized double-blinded, placebo controlled trial on Botox for the prophylactic treatment of chronic daily headaches and reported approximately seven more headache free days compared to baseline with Botox. However, the authors concluded that the primary time point difference for Botox when compared to placebo was not statistically significant. Similar results were achieved in the study from Silberstein and colleagues. In a more recent study by Aurora and colleagues, the safety and efficacy of multiple treatments of Botox as prophylactic treatment of episodic migraine headaches was assessed. The researchers found that there were no statistically significant between-group differences in the mean change from baseline in the frequency of migraine episodes per 30-day period. Thus, Botox injections for episodic, chronic, tension-type headaches or migraines has not been established as likely to be more beneficial than conventional modalities for management of this patients condition.
Appeal type: Medical Necessity
Decision: Upheld

The parents of a 15-year-old male enrollee requested authorization and coverage for continued residential treatment of the enrollees anxiety and depression.  The health plan denied this request indicating that the requested treatment is not medically necessary for treatment of the enrollees medical condition.One physician reviewer performed a medical necessity Independent Medical Review.  The physician reviewer upheld the health plans denial on the basis that the requested services are not medically necessary.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a 15-year-old female enrollee has requested for residential treatment for treatment of the enrollees behavioral health issues.  Findings:  The physician reviewer found that applying the Child and Adolescent Level of Care Utilization System (CALOCUS), this patient meets the criteria for this level of care. Specifically, the patient should be treated in a secure 24-hour residential facility with psychiatric monitoring. The records clearly document the patient to be at substantial risk of harm, have serious functional impairment, there was evidence that outpatient treatment and repeat acute hospitalizations had not resulted in optimal control of the patients symptoms. In addition, the residential level of care is consistent with community standards including the American Academy of Child and Adolescent Psychiatry (AACAP) practice parameters. Consistent with this support, the services provided this patient have been demonstrated to be medically necessary.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for the shingles vaccine, Zostavax for treatment of the enrollees history of shingles. Findings:  The physician reviewer found that the recommendations by the Centers for Disease and Control and Prevention (CDC) Advisory Committee for Immunization Practices endorse a single immunization for adults over the age of 60. In this case, the patient is younger than the recommended age for immunization and therefore he is not an appropriate candidate for the vaccine. In addition, prior episodes of shingles are not an indication for vaccine. Only highly immunocompromised patients with human immunodeficiency virus (HIV) infection are candidates for immunization under the age of 60, which is not the case for this patient. For the reasons provided, the request for the shingles vaccine, Zostavax is not medically necessary for treatment of the patients medical condition.  Final Result: The reviewer determined that the requested service is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in internal medicine with sub-specialty certification in infectious 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: Medical Necessity
Decision: Upheld

enrollee has requested authorization and coverage for acupuncture treatment within five miles of the enrollees residence. Based on the current medical literature, acupuncture has been demonstrated to be effective in well selected patients with migraine, tension and episodic headaches. The recommended acupuncture frequency and duration is an initial trial of five to six sessions. Additional sessions may be performed when supported by improvement in objective measures with evidence of progressively greater, incremental objective gains. The literature suggests that care may be discontinued due to a lack of measurable improvements. In this case, the patient has undergone numerous acupuncture sessions with temporary reduction in symptoms. However, the provider failed to document the number of sessions completed as well as the specific, measurable, sustained, significant, objective functional improvement obtained with each acupuncture session to support future services. Moreover, there is a paucity of data supporting the medical necessity of acupuncture treatment within five miles of the patients residence for treatment of her medical condition.
Appeal type: Medical Necessity
Decision: Overturned

The patients parent has requested authorization and coverage for lifitegrast (Xiidra) 5% eye drops. Patients with Stuve-Wiedemann syndrome may require ocular treatment for conditions such as dry eye disease. Lifitegrast is an anti-inflammatory medication that has been shown to improve dry eye symptoms. In this case, given that the patients dry eye disease is not controlled with her current therapy, a trial of lifitegrast is medically indicated. Therefore, lifitegrast (Xiidra) 5% eye drops are medically necessary to prevent disease, disability, and other health conditions or their progression.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for bilateral periorbital/eyelid corrective surgery. De Jong and Holman state that in a thorough evaluation of blepharoptosis, Margin-reflex distance (MRD) is recorded. This is the distance measured from the corneal light reflex to the upper lid margin (MRD-1) or lower lid margin (MRD-2). MRD-1 less than two to three mm is indicative of blepharoptosis. Lee and colleagues explain that brow ptosis is defined as brows that rest below the supraorbital ridge and that may compromise vision via obstruction of the superior visual fields. In this case, the patient has brows that are at or just below the superior orbital rims bilaterally. Her MRD-1 is 4 mm bilaterally. A photograph showed an upper lid margin over the superior iris and clear of the pupil. The records did not include visual fields. While the patient has descent of her brows, given that her pupils are clear, her MRD-1 is 4 mm bilaterally, and the lack of documentation of blockage of the superior visual field, the requested service is not medically indicated. Accordingly, the requested bilateral periorbital/eyelid corrective surgery is not medically necessary for the treatment of this patient.The California reconstructive surgery statute requires health insurers to cover reconstructive surgeries, defined as surgery performed to correct or repair abnormal structures of the body caused by congenital defects, developmental abnormalities, trauma, infection, tumors, or disease to do either of the following: (1) to improve function; (2) to create a normal appearance, to the extent possible. In this case, the patients condition is the result of aging and does not constitute an abnormal structure of the body and does not cause a functional impairment. Therefore, bilateral periorbital/eyelid corrective surgery is not reconstructive in nature for this patient. Final Result: The reviewer determined that the requested service is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is board certified in 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: Overturned

A 31-year-old female enrollee has requested for the laparoscopic gastric banding procedure (Lap Band) for treatment of her morbid obesity. Findings:  The physician reviewer found that there is no scientific evidence that postponing weight loss surgery and requiring pre-operative diet plans predicts or improves outcome. From a technical point of view, a very short-term low calorie diet (1-2 weeks) reduces the size of the liver, thus making the operation technically easier. Given the patients BMI and comorbid conditions, the Lap Band procedure is medically appropriate.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary:  An enrollee has requested the Decision DX Melanoma Assay test for evaluation of his medical condition.  Findings:  Three physician reviewers found the Decision DX Melanoma assay was developed to help predict the risk of future metastatic spread of melanoma.  The assay tested gene expression in ocular melanoma, not cutaneous melanoma, and is not considered to be standard of care for the treatment of cutaneous melanoma.  The National Comprehensive Cancer Network guidelines indicate that genetic testing to predict metastatic risk, such as the Decision DX Melanoma Assay, should not be used outside of clinical trials.  Thus, Decision DX Melanoma Assay testing 15 was not likely to have been more effective 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 dermatology 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.