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

The patient is a 49-year-old female with an extensive history of treatment for fibrocystic disease of both breasts necessitating bilateral mastectomies in 1995. She subsequently underwent revisionary procedures for capsular contraction of the reconstructed breasts. It has been proposed by the patients surgeon that the patient again undergo removal of the contracted implants, capsulectomy, and replacement of the implants. Signs and symptoms documented by the surgeon in his records and the accompanying photograph are pain and deformation of the breasts.The patient has had bilateral mastectomies and is symptomatic. The requested procedure is medically indicated and appropriate given the patients clinical history. Bilateral capsulorrhaphy/capsulectomy and replacement of breast implants in a previously mastectomized patient is a medically necessary reconstructive procedure. The requested procedure is not cosmetic in nature and is considered reconstructive as defined by California law and the guidelines of the American Society of Plastic Surgeons. Therefore, I have determined that the requested procedure is medically necessary for treatment of the patients medical condition. The Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Victoza subcutaneously daily for treatment of the enrollees diabetes. Findings: The physician reviewer has found that adding Victoza to multiple daily insulin injections in people with type 2 diabetes has been shown to improve glycemic control without an increased risk of hypoglycemia, reduces body weight, and enables patients to lower their insulin doses. Studies related to use of liraglutide and type 1 diabetes have shown benefits. Victoza was associated with reductions in hypoglycemic events, bolus and total insulin dose, and bodyweight, and increased heart rate. Victoza is also safe for patients following bariatric surgery.  Victoza is an U.S. Food and Drug Administration (FDA) approved therapy for obesity at doses 1.2-3 mg per day. The records document that this patient is benefitting from Victoza given her food intake, weight and insulin requirements. Studies indicate that Victoza is safe for type 1 diabetes patients and it is approved for treatment of diabetes type 2 and for the treatment of obesity. Thus, the requested Victoza 1.8 mg subcutaneously daily is medically necessary for this patients medical condition. 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 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: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for CARIS Tumor Genetic and Antibody Testing.Findings:  Two of the three physician reviewers found CARIS Tumor Genetic and Antibody Testing is a type of molecular profiling. It has not been established if molecular markers are useful in treatment determination (predictive markers) and prognosis other than for KRAS, NRAS, and BRAF mutation testing and microsatellite instability (MSI) or mismatch repair (MMR) testing. Multiple clinical trials that are attempting to validate this personalized or precision medicine approach are in various stages of development and execution. Although preliminary data from some of these efforts have fueled excitement about the value and utility of these studies, their execution has also provoked many questions about the best way to approach complicating factors such as tumor heterogeneity and the choice of which genetic mutations to target. At this time, it is unclear if molecular profiling is beneficial in identifying potential targets for treatment. In sum, CARIS Tumor Genetic and Antibody Testing are not likely to be superior over other methods of evaluating this patient. Final Result: The 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: Physician reviewers 1, 2 and 3 are board certified in internal medicine with sub-specialty certification in medical oncology 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 63-year-old male enrollee has requested a PET scan for evaluation of his mental status. Findings:  Three physician reviewers found that the patient likely has a neurodegenerative dementing illness. The differential diagnosis includes Alzheimers disease, frontotemporal dementia and Lewy body disease. PET scanning is recognized by many as useful in evaluation of frontotemporal dementia. Peer-reviewed literature clearly supports the utility of PET imaging in the identification of dementing illness, especially in younger patients with atypical presentations. As frontotemporal dementia may have a hereditary component and a different clinical course than Alzheimers, it is important to diagnose early for optimal treatment. PET scanning is the best tool to assist in this diagnosis.
Appeal type: Experimental/Investigational
Decision: Upheld

An enrollee has requested authorization and coverage for transesophageal incisionless fundoplication (TIF) EsophyX device placement. Findings:  Three physician reviewers found that there is insufficient evidence the requested services are likely to be efficacious in this clinical setting. Upon review of the submitted documentation, it is not clear that the patient has acid reflux disease. The appearance of barium spontaneously reflux during an upper gastrointestinal (GI) series can be misleading and may occur in healthy individuals. Additionally, the patient has had a poor response to antisecretory therapy which is atypical in a patient with acid reflux. An interventional procedure for GERD is premature in the absence of formal esophageal manometry and pH testing. It is appropriate to undergo combined pH/impedance testing to look for weakly acidic/non-acidic reflux prior to consideration of a TIF procedure.  Furthermore, the efficacy and durability of TIF remains uncertain at this time. Although TIF is associated with fewer postoperative adverse effects such as gas, bloating and dysphagia compared with surgery fundoplication, the durability of TIF is less certain than that of surgery. In a meta-analysis of five randomized trials and 13 prospective studies, proton pump inhibitor use after TIF increased over time; the satisfaction rate was only 69% at six months. In another network meta-analysis of TIF versus fundoplication versus proton pump inhibitor therapy, fundoplication was associated with greater sphincter augmentation than TIF. All told, there is inadequate evidence to support the superior efficacy of the requested transesophageal incisionless fundoplication (TIF) EsophyX device placement at this time. As such, the requested services are not likely to result in superior benefit compared to available standard therapies.Final Result: The reviewers determined that 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: Physician reviewers 1, 2 and 3 are board certified in internal medicine with sub-specialty certification in gastroenterology 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

This case concerns a 48-year-old female who has requested reimbursement for epidural steroid injections and facet joint injections provided from June 2004 through August 2004. The Health Plan has denied this request indicating the therapy at issue was not medically necessary for treatment of the patients neck and low back pain.Review of the medical documentation indicates the patient has a past medical history of systemic lupus erythematosus (SLE) and fibromyalgia. She had ongoing neck and low back pain issues since a motor vehicle accident in April 2004. She underwent diagnostic studies including a brain CT, spinal x-rays, cervical MRI and lumbar MRI, which were all essentially normal. She underwent medical therapy with Duragesic patches, Lidocaine patches, Percocet, Ultracet, Vicodin, Flexeril, Klonopin, Effexor, and trigger point injections. She continued with significant pain and was referred to pain management. During the period of June 2004 through August 2004 she received cervical/lumbar epidural and facet injection therapy.Given the documentation provided, injection therapy was medically necessary and indicated for this patient. She had ongoing pain refractory to multiple medical therapies. Her PCP referred her to pain management for specific therapy. The pain management specialists felt that given her underlying medical conditions (i.e., SLE/fibromyalgia) and her poor response to multiple medical therapies, injection therapy was indicated and medically appropriate. The patient had not responded to medical therapy for a period of eight weeks following her motor vehicle accident and injection therapy was a viable option for pain control. The documentation indicates that the injection therapy provided prolonged pain relief. Based upon the information set forth above, I have determined the therapy at issue was medically necessary for treatment of the patients medical condition. The Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Overturned

The patient is a 17-year-old female who underwent anterior cruciate ligament reconstruction in February 2004. The patient received a course of physical therapy post operatively. She is highly active in athletics and has returned to playing basketball. Given the patients level of activity, the patients provider has recommended the patient receive a custom knee brace. The Health Plan indicates a custom knee brace is not medically necessary for the patient.Based upon the information provided it appears the patient participates in a high level of strenuous activity. As such, such is prone to injury and requires protection of the knee and graft post repair. Prefabricated braces are not comparable in function and protection to custom braces for patients such as this patient who are highly active. Therefore, I have determined the requested equipment is medically necessary for treatment of the patients medical condition. The Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Upheld

An enrollee has requested reimbursement for premium intraocular lenses. The Health Plan has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollees macular degeneration and cataracts. A review of the record indicates that the enrollee had right eye cataract surgery performed on 04/10/2018, and left eye cataract surgery performed on 05/08/2018. On these dates of service, the enrollee also had premium intraocular lenses implanted. The enrollee has stated that premium intraocular lenses were necessary to treat her macular degeneration.The submitted documentation does not support that the services at issue were medically necessary. Records of the patients history and physical reflect that the patient had macular degeneration and was found to have decreased visual acuity and cataracts on examination. The physician recommended cataract surgery with presbyopia correcting IOL implants. The patient has argued that premium intraocular lens implants were necessary in order to provide functional vision postoperatively. However, medical literature confirms that cataract surgery using a standard (monofocal) IOL is just as likely to correct a patients vision and provide functional improvement. The purpose of implanting presbyopia correcting intraocular lenses is to attempt to provide less dependence on glasses after cataract surgery. The additional benefits of the accommodating IOLs are for the patients convenience only. There is no evidence in the medical literature that presbyopia correcting IOLs would provide an additional benefit above standard IOLs and postoperative glasses or contacts. Therefore, although the cataract surgery itself was medically necessary, the use of premium intraocular lenses rather than standard monofocal intraocular lenses was not necessary. Accordingly, premium intraocular lenses were not medically necessary for treatment of the 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 ophthalmology 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 60-year-old male enrollee has requested for Provigil 100 mg (#60) for treatment of his treatment-resistant depression. Findings:  Three physician reviewers found that Modafinil is an FDA approved medication and it has shown promise in a variety of off-label indications in psychiatry including treatment-resistant depression as noted in the article by Minzenberg and Carter. This reference also notes that modafinil appears to be well-tolerated with a low rate of side effects and low liability for abuse. Another article by Vaishnavi and Gadde describes the benefit of modafinil for atypical depression in an open-label double-blind study. The authors found that modafinil significantly improved atypical depression symptoms during 12 weeks of open-label treatment and it was well-tolerated. A third reference in this same journal by Taneja and colleagues concludes that modafinil may have general mood-elevating effects and that these findings may have clinical implications for clinical practice, particularly for the adjunctive use of modafinil in the treatment of resistant depression.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary:  An enrollee has requested gene testing for evaluation of his medical condition. Findings:  Two physician reviewers found that there is a lack of support for the services at issue in this clinical setting.  While PCA3 testing may eventually have a role in reducing unnecessary biopsies, there are insufficient data on clinical outcomes to currently support routine use.  There is a lack of clear evidence that PCA3 is better than standard PSA testing with biopsies when indicated and some data that PCA3 may miss certain types of higher risk prostate cancer for which younger patients may be at risk.  In sum, gene testing was not likely to have been superior over other methods of evaluating this patient. Final Result: Two reviewers determined that the services at issue were 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 medical oncology 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: Upheld

The patient is a 63-year-old female with a body mass index (BMI) of 42 and significant comorbid conditions. Additionally, she has a large hiatal hernia and previous Nissan fundoplication. The record indicates the patient completed a bariatric surgery evaluation approximately three years ago and for various reasons did not proceed with surgical weight loss. At this time, the patient is requesting authorization for the Lap Band procedure. The Health Plan has denied coverage based upon their determination that the procedure it is not medically necessary for treatment of the patients morbid obesity.With the completion of a current, favorable psychological evaluation the patient would generally satisfy the nationally accepted medical necessity criteria for consideration of weight loss surgery. However, the Lap Band procedure is contraindicated. This procedure would require the take down of her Nissan fundoplication.  As such, the reversibility benefit of the Lap Band would be lost. The patient would also have an increased risk of esophageal injury under these circumstances. While it is highly likely that bariatric surgery would be beneficial for this patient, other procedures such as the duodenal switch would avoid the esophageal problem and may be more appropriate and safer for her. The bariatric surgery consultation and re-evaluation proposed by the Health Plan is a reasonable approach. However, the patient should not require further dietary workup or independent weight loss as 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 identifies 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. Based upon the facts as stated above, I have determined the requested procedure is not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for spine nerve treatment (radiofrequency neurolysis).Findings:  The physician reviewer found that Percutaneous neurolysis for chronic neck and back pain is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The majority of peer reviewed literature supports the efficacy of radiofrequency neurolysis in the treatment of chronic spinal pain due to facet pathology as long as the patients are appropriately selected. In reviewing the medical records, the MRI is significant for multilevel spondylosis. Per the providers notes, the patient had good but short term relief with cervical medial branch blocks. This patient meets the guidelines for radiofrequency neurolysis with two cervical medial branch blocks, which provided greater than 80% and greater than 90% reduction in pain. Radiofrequency facet neurolysis is, therefore, appropriate in treating the patient. In sum, spine nerve treatment (radiofrequency neurolysis) is likely to be more effective than the other available methods of treating this patients medical condition.Final Result: Two of the  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 reviewers 1, 2 & 3 are board certified in anesthesiology with sub-specialty certification in pain medicine 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

The patient is a 43-year-old female with an almost two-year history of persistent tinnitus. The patient states the onset of this problem coincided with a severe flu she had in November 2003. The tinnitus began as a small noise in the right ear that occurred only when the enrollee lay on her right side. It has since become constant and is a swooshing noise most prominent with each heartbeat. The patient also has pressure around her ears and upper neck. In March 2004, an audiometric evaluation demonstrated the presence of bilateral mild to moderate high frequency hearing loss. In May 2004, an MRI was within normal limits. In November 2004, the patient was evaluated by another otolaryngologist. At that time hearing thresholds were found to be normal on the right with mild high frequency loss on the left. Tympanograms were slightly negative but within normal limits. The patient has been treated with Flonase, Claritin, and Niacin and continues to be symptomatic. The patient has requested a referral to a sinus specialist. The Health Plan has denied this referral.Tinnitus is not a fully understood disorder, but it is not dangerous. It is unclear whether the patients tinnitus is pulsatile. In addition, although a bilateral vascular lesion would be rare, a CT scan of the temporal lobes would rule this out. In addition, although the patient is 43, bilateral pulsatile tinnitus can be secondary to carotid artery disease and a carotid doppler could rule this out as well. Furthermore, because of the discrepancy in audiograms a repeat audiogram would be helpful.The patient has requested a referral to a sinus specialist; however, tinnitus is not a sinus disorder and a referral to a sinus specialist is not indicated or necessary. Further testing and evaluation could be performed by the patients primary care physician or an otolaryngologist. Therefore, I have determined the requested referral is not medically necessary for evaluation of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned

The parents of an eight-year-old male enrollee have requested coverage for a circumcision revision for treatment of the enrollees redundant foreskin. Findings:  The physician reviewer found that this patient had an incomplete circumcision as a newborn and he is now having medical problems with the residual prepuce. By history, there have been multiple episodes of inflammation, evidenced clinically by the patients scratching of the area. This condition could reasonably be diagnosed as balanitis or balanoposthitis which is directly related to the redundant skin condition. Given the history of problems with the residual prepuce, the urologist has recommended re-doing the incompletely performed circumcision.
Appeal type: Medical Necessity
Decision: Overturned

A female enrollee requested reduction mammaplasty surgery for medical treatment of the enrollees hypertrophy of breast.  Findings:  The physician reviewer found that the patient reports back, shoulder and neck pain, as well as shoulder grooving.  Her examination documents findings consistent with significant macromastia.  Per the clinical notes, the patients macromastia is causing functional problems and she is likely to benefit from reduction surgery.  In this case, conservative management is unlikely to provide long-term benefit.  All told, the requested reduction mammoplasty surgery is medically indicated for the treatment of this patient.