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

A 59-year-old male enrollee has requested gastric bypass bariatric surgery for treatment of morbid obesity.  Findings:  The physician reviewer found that this patient clearly meets the criteria set by the National Institutes of Health for surgical treatment of obesity with a BMI of 47.4 and multiple comorbid conditions that would likely be ameliorated or eliminated by bariatric surgery. With regard to the Health Roads program, there is no scientific evidence demonstrating that structured diet or exercise plans have been successful in the treatment of the morbidly obese. In fact, the Swedish obesity study identified that even though there may be reduction or resolution of some symptoms with diet and exercise, surgery has the longest and best long-term outcome for the morbidly obese.
Appeal type: Urgent Care
Decision: Upheld

The parent of a 17-year-old male enrollee has requested  psychiatric emergency services for treatment of the enrollee's post-traumatic stress disorder.  Findings:  The physician reviewer found that the submitted clinical documentation fails to demonstrate that the patient had a psychiatric emergency medical condition that required the services at issue on an emergent basis. Based on the medical records submitted for review, although the patient had a history of suicidal attempts there is no clinical documentation demonstrating that the patient was actively suicidal upon admission to the treatment program. Further, the patients master treatment plan on the date specified does not indicate that the patient was homicidal or psychotic or a threat to others. Moreover, the submitted clinical records do not demonstrate that the patient was unable to attend to his daily needs. If the patient was experiencing a psychiatric emergency medical condition as defined above, he would have required treatment in acute inpatient hospital setting and would not have been an appropriate candidate for participation in a wilderness therapy program. Given that the patient did not meet the above definition of a psychiatric emergency medical condition, the services at issue were not required on an emergent basis.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The enrollee has requested authorization and coverage for nipple sparing, skin saving, total mastectomy without sentinel node resection. The current peer-reviewed medical literature states that sentinel lymph node biopsy (SLNB) is medically necessary for patients with ductal carcinoma in situ (DCIS) who are undergoing mastectomy. With regard to nipple sparing mastectomy (NSM), researchers reported that they disregard the tumor-to-nipple distance as long as the subareolar/nipple margin is pathologically negative. Researchers acknowledged that the decision to save the nipple is treated like a lumpectomy margin, with the presence of positive margins supporting further excision. In this case, sparing the nipple/areolar complex is not medically necessary. The Health Plan has approved total mastectomy with sentinel lymph node resection and skin sparing with subsequent breast and nipple reconstruction, which is appropriate in this clinical setting. Furthermore, the requested NSM is not reconstructive in nature. 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 either improve function, or to create a normal appearance, to the extent possible. In this case, DCIS is a malignant condition and an abnormal structure of the body caused by tumor. The purpose of breast reconstruction is to create a normal appearance, to the extent possible. However, skin sparing mastectomy, both with and without nipple sparing, will not improve function or provide a more than minimal improvement in the patients appearance. Accordingly, the requested NSM is not reconstructive in nature for treatment of this patients medical condition. Final Result: The reviewer determined that the requested services are not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in 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: Overturned

Nature of Statutory Criteria/Case Summary: A 40-year-old female enrollee has requested authorization and coverage for Botox for treatment of the enrollees chronic migraine. Findings:  The physician reviewer found that The U.S. Food and Drug Administration (FDA) has approved Botox for headache prophylaxis in patients with adult chronic migraine who experience headaches on 15 or more days per month, each lasting more than four hours. The available medical records provided for review indicate failure of multiple medications for prophylaxis of migraine. The medical records indicate chronic headache of migraine type that are occurring 15 or more days per month.  The headaches have not responded to first-line treatment options. As such, Botox is likely to be more effective than other treatment options in this patients case. Final Result: All three reviewers determined that the requested services are likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: Physician reviewer number one is board certified in 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.Physician reviewer number two is board certified in 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.Physician reviewer number three is board certified in 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: Upheld

A 32-year-old female enrollee has requested a knee ligament stabilizing brace for treatment of her left knee condition status post anterior cruciate ligament (ACL) surgery. Findings:  The physician reviewer found that a functional knee brace for the purpose of protection of the knee in high impact athletic sports injury for a period of one year after an anterior cruciate reconstruction has not been demonstrated to be beneficial in the medical literature. Wright and Fetzer noted that the use of bracing did not demonstrate improved outcomes in pain, range of motion, graft stability or protection from injury. Sterett and colleagues showed that high demand skiers who had had bracing after ACL reconstruction (compared with non-braced skiers) did receive protection from re-injury to a degree of statistical significance. However, the authors questioned whether these findings could be generalized to other high impact sports activities. McDevitt and colleagues studied a young, active population status post ACL reconstruction and found that no benefit could be detected from the use of functional bracing. The braced group was instructed to wear an off-the-shelf functional knee brace for all cutting, pivoting, or jumping activities for the first year after surgery. The conclusion was that post-operative bracing does not appear to change the clinical outcomes after ACL reconstruction.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for a panniculectomy performed for treatment of the enrollees pannus. Findings:  The physician reviewer found that the submitted documentation supports the medical necessity of the services at issue.  This patient had a well-documented history of a symptomatic lower abdominal pannus, and she had failed reasonable conservative management.  Specifically, she had chronic rashes underneath her overlapping pannus that had failed conservative measures of attempted weight loss, proper hygiene and specific/typical dermatologic medical management.  In this clinical setting, a panniculectomy was likely to have improved her functional deficit.  The current medical evidence supports the services at issue in this patients case. The Health Plans basis for denying reimbursement for the panniculectomy was that the pannus did not hang below the middle of the groin.  This appears to be an arbitrary cut-off point and is not supported by medical literature.  This also ignores the overall clinical picture of this patient.  All told, the panniculectomy performed was medically indicated for the 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 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: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested requested authorization and coverage for Xeljanz. Researchers noted that tofacitinib should be considered for the treatment of severe alopecia areata, alopecia totalis, and alopecia universalis. Researchers performed an open-label pilot study that included twelve patients with alopecia areata treated with Janus kinase (JAK) inhibitors. The authors found that only one patient demonstrated no regrowth. In this case, the patient has tried and failed standard steroid injections treatment, immunotherapy and methotrexate. Over the last three years, he has experienced rapidly progressing hair loss. Given the challenging pattern of this patients alopecia areata, and that he has tried and failed standard treatment, oral tofacitinib is the next step in on the treatment ladder. Therefore, Xeljanz is likely to be more beneficial for the treatment of the patients condition than any available standard therapy.Findings:  Three of the three physician reviewers found the requested Xeljanz 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 medication is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: Physician reviewers 1, 2, and 3 are board certified in dermatology 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: Experimental/Investigational
Decision: Overturned

A 60-year-old male enrollee has requested intensity modulated radiation therapy (IMRT) for treatment of his prostate cancer. Findings:  Two physician reviewers found that IMRT is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. In this patient with already transient and symptomatic bowel ischemia secondary to impingement of the inferior mesenteric artery by retroperitoneal lymphadenopathy, surgical palliation is not possible; and he has already progressed through multiple systemic therapies. Thus, palliative radiotherapy is the most beneficial treatment option to prevent further bowel ischemia at this time. IMRT would be critical in decreasing radiation exposure to the bowel, which in turn would lead to a decrease in bowel toxicity in someone with ulcerative colitis, severe enough to require a J-pouch. White and colleagues demonstrated that in patients with inflammatory bowel disease such as ulcerative colitis, abdominal/pelvic radiation delivered through IMRT decreased acute grade 2 or higher bowel toxicity from 100% to 28% as compared with 3D conformal radiation. Given the medical literature cited above and the documentation submitted the requested services are likely to be more beneficial than standard medical therapy.
Appeal type: Medical Necessity
Decision: Overturned

The patient has requested authorization and coverage for left inguinal hernia repair surgery. The emergent need to repair inguinal hernias oftentimes arises in the setting of incarceration or small bowel obstruction. Otherwise, published literature supports observation of a patients symptoms. Refractory pain, large hernia, or a hernia increasing in size are also indications to consider repair. This patient has a longstanding known left inguinal hernia, which is increasingly symptomatic. A CT scan confirmed the presence of the inguinal hernia. The provider noted the surgery is contraindicated due to the patients history of smoking. Although smoking increases the risks associated with any surgery, there is no published guideline to mandate cessation as a condition of surgical repair. Therefore, the requested left inguinal hernia repair is medically necessary for treatment of this patient. 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 surgery and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for intravenous immunoglobulin (IVIG). Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested medication. This patient has demonstrated a clinical response to steroids. Additionally, the patient is not on the maximal dose of CellCept. Also, the records do not document contraindication to the use of Imuran or methotrexate, and the medical evidence supports trying these medications first in combination with steroids prior to the use of IVIG. The provider argues that the use of Cytoxan will increase risk of malignancy. Systemic sclerosis and chronic inflammatory conditions are associated with increased malignancy risk. Thus, aggressive therapy may actually decrease this risk and should not be a reason to avoid treatment with Cytoxan. All told, there are alternative treatments available for this patient. Therefore, the requested IVIG is not medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested medication 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 rheumatology 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 authorization and coverage for lumbar dexamethasone sodium injections. Researchers concluded that the accuracy of diagnostic facet joint nerve blocks and the efficacy of therapeutic facet joint interventions are supported by high-quality evidence for appropriately selected patients after failure of conservative treatment. Researchers also found that the evidence for long-term improvement is Level II for therapeutic facet joint nerve blocks in the cervical, thoracic, and lumbar spine. This patient presents with a longstanding history of chronic low back pain, significantly worsened over the past six months. The pain currently interferes with the patients ability to perform activities of daily living (ADLs) and sleep. She denied any radicular symptoms. Clinical examination findings are consistent with facet-mediated pain and imaging demonstrated bilateral facet arthropathy at the lower lumbar levels. The records document that the patient has failed several months of reasonable and comprehensive conservative treatment, including non-steroidal anti-inflammatory drugs (NSAIDs), physical therapy, and a home exercise program. Current evidence-based medical literature supports the use of therapeutic facet joint injections in this patients clinical scenario. Therefore, the requested lumbar dexamethasone sodium facet joint injections are medically necessary for treatment of this patient. Final Result: The reviewer determined that the requested services are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in orthopedic surgery and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld

The parent of a 2-year-old male enrollee has requested Synagis for the treatment of the enrollees current chronic lung disease and bronchomalacia. Findings:  Two physician reviewers found that RSV is a common cause of bronchiolitis and pneumonia in young children infecting almost all children at least once by two years of age. Infection does not provide life-long immunity and re-infection throughout life is therefore quite common. It is not practical or medically indicated to attempt to prevent RSV infection for children without significant underlying cardiopulmonary disease or in children past two years of age. The provided article by N. Sigurs indicating an increased risk of asthma and allergy following RSV infection involves infants, all less than one year of age, who were hospitalized due to severe RSV. This data does not apply to the patient who is already two+ years of age. There is not published medical literature that supports the use of Synagis in this clinical situation.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for a new ultralight manual wheelchair. The Health Plan has denied this request indicating that the requested equipment is not medically necessary for treatment of the enrollee who has a history of paraplegia and stage 4 pressure ulcer on the coccyx.The records forwarded for review do not support the medical necessity for the requested equipment in this patients case. A custom ultralight weight manual wheelchair is appropriate and necessary for optimizing this patients community level mobility, independence and health.  The lightest weight wheelchair with a rigid frame would increase independence in the community, especially on uneven surfaces such as ramps and, in the long-term, reduce injury to the shoulders due to wear and tear damage. However, the patient in this case already has an ultralight weight manual wheelchair and it is less than two years old.  It was assessed in the community by a physical therapist and noted to be repairable. Therefore, there is no indication of replacing the wheelchair with a new wheelchair. In general, a wheelchair that requires complete replacement after such a short interval would be due to a faulty or improper manufacture design of the wheelchair. The submitted records do not show that this is the case in this clinical setting. As such, a new ultralight manual wheelchair has not been demonstrated as medically necessary for the treatment of this patients medical condition.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 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: An enrollee has requested authorization and coverage for custom orthotics.Orthotics have long been utilized to help correct abnormal biomechanics of the foot, alleviating stress and strain from certain muscles, tendons, and ligaments. Custom orthotics have been a mainstay treatment for plantar fasciitis and posterior tibial tendinitis. Orthotics work by mechanically controlling the foot. They reduce overpronation, subtalar joint valgus, strain to the posterior tibial tendon insertion, and allow for increased arch support. The patient is noted to have a flatfoot structure with hyperpronation, which generally allows for increased strain and pain to the plantar fascia and posterior tibial tendon. The patients pain has been managed with custom orthotics in the past. The patients current orthotics are noted to be worn down and not supportive, allowing for breakthrough foot pain. It has been recommended that the patient receive new orthotics. There is sufficient support for the requested equipment in this clinical setting. Thus, the requested custom orthotics are medically necessary for the treatment of the patients medical condition.Final Result: The reviewer determined that the requested equipment 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 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 a similar medical condition.