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

A 45-year-old female enrollee has requested a left knee replacement for treatment of her left knee pain.  Findings:  The physician reviewer found that the request for left knee replacement surgery is not medically necessary for treatment of the patients medical condition. In this case, the patient presents with morbid obesity with a BMI documented above standard level. The presence of morbid obesity increases the risk of postoperative infection (Cannada).  In addition, morbid obesity also increases the risk of venous embolism and it increases the technical challenges of the reconstructive procedure itself with an increased risk to ligamentous and neurovascular injury. In addition to obesity, the patients relatively young age will increase the likelihood of long-term complications of total knee arthroplasty leading to the need for revision. The long-term complications include bone resorption, subsidence due to chronic inflammation secondary to wear debris. The extent of inflammatory reaction to wear debris is variable from patient to patient but is present in all patients to some degree and the effects are duration of exposure dependent. For the reasons provided, the requested procedure is not medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld

A male enrollee requested an ultrasound guided caudal epidural corticosteroid injection for medical treatment of his back pain.  Findings:  The physician reviewer found that the patients physical examination and lumbar MRI do not show evidence of lumbar radiculopathy/radiculitis. The peer-reviewed medical literature provides evidence for epidural steroid injections in documented cases of nerve root compression or radiculitis. The patients chronic pain condition is not consistent with such a diagnosis. For the reasons provided, the requested services are not medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned

A 31-year-old female enrollee requested authorization and coverage of gastric bypass surgery. The Health Plan denied the request indicating that the requested procedure is not medically necessary for treatment of the enrollees morbid obesity. One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer overturned the Health Plans denial on the basis that the requested procedure is medically necessary depending upon the results of an endocrine evaluation and possible treatment.
Appeal type: Experimental/Investigational
Decision: Upheld

A 19-year-old male enrollee requested LINX Anti-Reflux Management System procedure for treatment of the enrollees gastroesophageal reflux disease (GERD).  Findings:  Two physician reviewers found that LINX Reflux Management System (LINX) is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The requested procedure is indicated for patients with diagnosed GERD as defined by abnormal pH testing, and who continue to have chronic GERD symptoms despite maximal medical therapy for the treatment of reflux. Based on the documentation submitted for review there is a lack of documentation demonstrating that the patient has failed maximum medical management to necessitate the requested procedure. In addition, the risk of exacerbating dysphagia with LINX procedure is not clear in patients who have previously reported pharyngeal dysphagia, such as in this case. Given these concerns, the requested procedure is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a five-year-old female enrollee has requested  for speech therapy for treatment of the enrollees delayed speech. Findings:  The physician reviewer found that it is clear that speech and language delay must be taken very seriously in young children, as the long-term consequences may be substantial. According to a Cochrane Database meta-analysis of 25 studies, approximately 6 percent of children have speech and language difficulties. The authors of this meta-analysis noted that children whose difficulties persist into primary school may have long-term problems concerning literacy, socialization, behavior and school attainment. Bernhardt and Major concluded that early phonological and metaphonological intervention can promote normalization of speech development and normal acquisition of literacy skills for at least some children with a history of severe phonological impairment.
Appeal type: Medical Necessity
Decision: Overturned

A 40-year-old female enrollee requested authorization and coverage of orthognathic surgery. The health plan denied the request, indicating that the requested surgery is not medically necessary for treatment of the enrollees dysfunctional dental malocclusion secondary to developmental maxillomandibular deformity.One oral surgical reviewer performed a medical necessity Independent Medical Review. The oral surgical reviewer overturned the health plans denial on the basis that the requested services are medically necessary.
Appeal type: Medical Necessity
Decision: Upheld

The patient is a 31-year-old female who has a history of excessive daytime sleepiness, depression, and anxiety. It appears the patient has been on antidepressant therapy. The patient received Provigil to control her fatigue with apparently good results. There is no evidence other psychostimulants have been tried by the patient. The Health Plan has determined Provigil is not medically necessary for treatment of the patients medical condition.Although there is evidence supporting the use of Provigil as an antidepressant adjunct and for treatment of residual fatigue, no objective evidence has been submitted demonstrating Provigil is necessary or indicated for this patient. There are other approved psychostimulants available for treatment of the patients condition that have not been attempted. Furthermore, based upon the information provided, it appears other causes of the patients fatigue have not been ruled out. Because of the need to rule out other causes of the patients fatigue and the availability of other approved psychostimulants, which apparently have not been tried, I have determined the requested medication 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

An enrollee has requested reimbursement for the Autonomic Nervous Function Testing - autonomic reflex screen (CPT 95924) and Endopat study (CPT 95923). The autonomic nervous system is responsible for various functions including heart rate, body temperature, breathing, digestion, and sensation. The autonomic nervous system is composed of the sympathetic and parasympathetic nervous systems and their interplay. Disease occurs when there is the parasympathetic and sympathetic are unbalance or when there is direct damage to the autonomic nervous system in various disease states. Some symptoms linked to autonomic nervous system disease is dizziness, sweating abnormalities, and loss of appetite. The autonomic system can be evaluated using several tests including tilt table test, monitor of heart rate and blood pressure during specific situations, gastric emptying studies, quantitative sudomotor, axon reflex test, thermoregulatory sweat test, and urodynamics. Based on the medical literature, there is limited data showing that autonomic nervous function testing provides patients with improved health outcomes when compared to standard modalities for evaluation in this clinical setting. Thus, the Autonomic Nervous Function Testing - autonomic reflex screen (CPT 95924) and Endopat study (CPT 95923) provided were not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Findings:  Three physician reviewers found the Autonomic Nervous Function Testing - autonomic reflex screen (CPT 95924) and Endopat study (CPT 95923) provided were not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the Autonomic Nervous Function Testing - autonomic reflex screen (CPT 95924) and Endopat study (CPT 95923) provided were not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Credentials/Qualifications: Physician reviewers 1, 2 and 3 are board certified in neurology 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 bilateral mastectomy with male chest reconstruction for treatment of his gender dysphoria.  Findings: The physician reviewer found that the surgical concept of bilateral mastectomy for purposes of female-to-male gender reassignment is well established and documented within the community of plastic surgeons. Each patient must be reviewed on a case-by-case basis to determine medical necessity. In this patients case, medical necessity has been adequately established based upon the medical documentation provided. The patient has identified as a male for a significant amount of time and is under the care of a therapist, who is supportive of the treatment plan. This patient is noted to have significant female breast development. Thus, based on the entirety of the record the patient meets medical necessity criteria for bilateral mastectomy with male chest reconstruction.  The proposed procedure also meets criteria for reconstructive surgery in this case. His female breast development would be considered an abnormal male structure. The abnormal appearance is the result of the patients gender dysphoria and any appropriate surgical correction would attempt to obtain a more normal male appearance. Final Result: The reviewer determined that the requested services are medically necessary for treatment of the patients medical condition and 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: Overturned

The patient is a 41-year-old female with severe rectus diastases documented by multiple physicians and therapists. She has had three successful pregnancies since June of 1999 and reports constant lower back pain resulting from weak stomach muscles and strain on her back. The patient had weekly chiropractic adjustments which did not help her condition.  She reports constant back strain and pain in her abdomen and she had to wear a support belt for her lower back and stomach; lifting even small items was difficult. The patient also worked with a personal trainer but the exercise program was ineffective in relieving her lower back pain. A recent examination revealed weak rectus abdominal muscles with protrusion of the anterior abdominal wall. No definite bowel herniation was present. Her chiropractor reported the patient had been unable to reestablish normal abdominal muscle tone and strength leading to spinal instability and recurrent pain.  The patient was noted to be 145 pounds and 51 tall. She proceeded with abdominoplasty in Ocotober 2006 and is now requesting reimbursement. The Health Plan denied her request citing a lack of medical necessity.There is no other diagnosed medical condition to explain the patients persistent lower back pain except her rectus diastases. The Health Plan identifies three criteria which must be satisfied for authorization of abdominoplasty: the patient must (1) provide photographic documentation of her condition; (2) show signs and symptoms associated with significant rectus diastases and or hernia; and (3) provide documentation of extensive diastases of the rectus abdominis muscles along with notes showing the types, duration and responses to various medical therapies. The patient has satisfied these three criteria and the American Society of Plastic Surgeons (ASPS) position paper supports the reconstructive nature of abdominoplasty in this instance. The ASPS indicates that `abdominoplasty is considered reconstructive when performed to correct or relieve structural defects of the abdominal wall and/or chronic low back pain due to functional incompetence of the anterior abdominal wall. The position paper further indicates that pregnancy may cause this condition, as it has in this case. Abdominoplasty was an appropriate intervention for the treatment of the patients lower back pain.Based upon the information set forth above, I have determined the procedure at issue was medically necessary for treatment of the patients medical condition. The Health Plans denial should be overturned.
Appeal type: Experimental/Investigational
Decision: Upheld

A 35-year-old female enrollee requested authorization and coverage of gastric bypass surgery with duodenal switch. The Health Plan denied the request indicating that the requested procedure is considered experimental for treatment of the enrollees morbid obesity.Three physician reviewers performed an experimental/investigational Independent Medical Review. Two physician reviewers concluded that the requested procedure is not likely to be more beneficial for treatment of the enrollee's medical condition than any available standard therapy. One physician reviewer concluded that the requested procedure is likely to be more beneficial for treatment of the enrollee's medical condition than any available standard therapy. Because two of the three  physician reviewers concluded that the requested surgery is not likely to be more beneficial for treatment of the enrollee's medical condition than any available standard therapy, the Health Plans denial has been upheld.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for anesthesia (CPT code 00812) that was provided for a lower intestinal endoscopic procedure. The American Society for Gastrointestinal Endoscopy (ASGE) Standards of Practice Committee noted that anesthesia provider assistance should be considered in cases of prolonged or therapeutic endoscopic procedures, anticipated intolerance to standard sedatives, increased risk for adverse events due to severe comorbidity (American Society of Anesthesiologists class IV or V), or increased risk for airway obstruction due to anatomic variant. In this case, the documentation did not show the patient met any of these criteria. Therefore, anesthesia (CPT code 00812) that was  provided for a lower intestinal endoscopic procedure was not medically necessary for the treatment of this patient.Final Result: The reviewer determined that the service at issue was 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: Upheld

The parent of a five year-old female with a history of stuttering is requesting reimbursement for speech therapy services.  Reviewers Findings:The reviewing physician found that the medical literature for this patient suggests that although much time is spent on speech therapy for dysfluency/stuttering, there is little evidence that the therapy improves recovery over natural recovery rates. Therefore, the reviewing physician found that the Health Plan denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld

The patient is a 48-year-old female with back pain and major depression with associated fatigue. She is under the care of a pain management specialist. She has been treated with multiple medications including Prozac, Cymbalta and Provigil. The patient reports that Provigil has been very effective in relieving her pain, depression and fatigue and therefore she has requested authorization and coverage for the drug. The Health Plan has denied this request on the basis that Provigil is not medically necessary for treatment of the patients medical condition.The Health Plans denial should be upheld. Provigil is not generally utilized as a first-line agent in the management of major depression and its associated somatic complaints. Such use does not fall within the FDA-approved indications for the drug. Although the patient indicates she has been tried on multiple anti-depressants in the past, no objective evidence of the patients previous regimens or her response to these medications has been provided. Furthermore, there are no peer-reviewed studies advocating the use of Provigil for the treatment of fibromyalgia. While a few small studies showed a short-term positive effect, no long-term outcome data is available. Therefore, I have determined the requested medication is not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned

The enrollees parent is requesting authorization and coverage for AUVI-Q epinephrine injector for infants 0.1mg. The enrollee experienced an allergic reaction. The progress note from that incident reported the enrollee experienced lip and facial swelling, and tachypnea. The enrollee was administered an Epi junior pen, and vomiting followed. Physician orders instructed the parents to keep two Epi-pens available at all times. The enrollees mother requested an order for AUVI-Q for babies. The request is appropriate, as a governmental body has approved a 0.1 milligram dose for infants 7.5 to 15 kilogram. The current literature indicates this is the only approved medication in this age/weight group.  Also, the needle length is shorter in this device to be safely administered to infants.  This enrollee has a history which includes a prior allergic reaction, with severe systemic reactions. Therefore, the requested medication is appropriate.Final Result: The reviewer determined that the requested medication is medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The physician reviewer is board certified in immunology 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: Urgent Care
Decision: Upheld

A 40-year-old male enrollee has requested emergency services for the treatment of his medical condition. Findings:  The physician reviewer found that an emergency is the sudden onset of symptoms of such severity that a prudent layperson would believe his health to be in jeopardy without immediate medical attention. This patients upper respiratory symptoms had commenced gradually over five days. On the day he sought treatment, he had a transient episode of shortness of breath. The patient was not experiencing fever or chest pain. He was described as comfortable, without distress. The patients examination was unremarkable, as was a chest x-ray and EKG. He was advised to use over-the-counter medications for relief and did not require any medical interventions in the Emergency Department. While the patients symptoms may have warranted a medical evaluation, that service did not need to be provided on an emergent basis. This patients symptoms did not meet prudent layperson criteria for emergency care. A prudent layperson with an average knowledge of medicine would not reasonably expect the absence of emergency care to jeopardize his health.
Appeal type: Medical Necessity
Decision: Upheld

A 17-year-old male enrollee requested authorization and coverage of a CT scan for the treatment of   congenital hearing loss .  The Health Plan denied the enrollees request indicating that the requested treatment is not medically necessary.One physician reviewer performed a medical necessity Independent Medical Review.  The physician reviewer upheld the health plans denial on the basis that the requested services are not medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patients parent has requested authorization and coverage for Xolair 300 mg every two weeks for six months administered in the doctors office. This patient has a history of poorly controlled allergic rhinitis and mild persistent asthma. Based on current data and U.S. Food and Drug Administration (FDA) approval, Xolair is not indicated for the treatment of allergic rhinitis or mild persistent asthma. Xolair is supported for the treatment of moderate to severe persistent asthma uncontrolled on inhaler therapy. The records provided for review document that treatment with inhaled corticosteroids has adequately controlled this patients asthma. For these reasons, the requested Xolair 300 mg every two weeks for six months, administered in the doctors office, is not medically necessary for treatment of this patient.Final Result: The reviewer determined that the requested medication and 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 internal medicine with subspecialty certification in allergy and immunology 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 64-year-old female enrollee has requested automated percutaneous discectomy for treatment of her low back pain.  Findings:  Three physician reviewers found that at this time, there is a lack of large, randomized, scientific studies noting the safety and efficacy of the requested procedure. Goupille and colleagues noted that percutaneous discectomy cannot be validated for disc herniation associated with radiculopathy resistant to medical therapy. Gibson and Waddell noted that there is insufficient evidence to draw any conclusions regarding percutaneous discectomy. Boswell and colleagues also noted the limited evidence for any long-term results of percutaneous discectomy. The consensus based on the available literature is that there is a lack of long-term outcomes from appropriately designed clinical trials showing the safety and efficacy of percutaneous discectomy compared to standard treatment modalities (Gibson and Waddell). All told, the superior efficacy of the requested automated percutaneous discectomy has not been established in this setting.