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

Case Summary: The patient is a male with sickle cell trait and a sibling diagnosed with renal medullary carcinoma. He was last seen in August and was complaining of stomach aching. A renal ultrasound was ordered by the physician due to risk for renal medullary carcinoma. No other treatments or testing were done. MD Analysis: Renal medullary carcinoma (RMC) is a highly aggressive rare cancer seen primarily in patients with sickle cell trait. Often presenting symptoms include pain and hematuria. RMC is often diagnosed in late stages, and most patients succumb to the disease. Alvarez et al reported the crude unadjusted prevalence of RMC among individuals with sickle cell trait is around 1/39,000. If we take all patients reported with RMC and sickle cell trait from the United States (N = 149) since 1995, then the crude unadjusted prevalence of RMC among individuals with sickle cell trait is 1/20,000. Currently there are no guidelines for screening for RMC; however, a study discuss this in their conclusions given the high incidence of advanced stage RMC in patients with sickle cell trait. Therefore, in a child with abdominal pain with sickle cell trait, it is medically necessary to perform a renal ultrasound. Final Result: The reviewer determined that the requested service 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 pediatrics with subspecialty certification in pediatric hematology-oncology 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: Urgent Care
Decision: Upheld

A 19-year-old female enrollee has requested reimbursement for out-of-network services provided on 2/22/11. The Health Plan has denied this request indicating the services at issue were not required on an emergent basis.  Findings:  The physician reviewer found that the patient presented to an out-of-network provider with complaints of sharp abdominal pain for one week and brown vaginal discharge for four days. The patient reported the pain had worsened in the past two days. Her last menstrual period occurred four weeks prior to this evaluation. She denied fever, nausea, vomiting, diarrhea or constipation. Her pain level was noted as 0/10 on the pain scale. On physical examination, she appeared well and her vital signs were normal. She had abdominal tenderness on physical examination. Pelvic examination revealed some left adnexal tenderness. The patient was diagnosed with a vaginal infection and discharged home in stable condition with a prescription for antibiotics.  At issue in this case is whether a prudent layperson would have sought immediate medical attention. California law defines an emergency medical condition as a medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain) such that the absence of immediate medical attention could reasonably be expected to result in any of the following: (1) Placing the patients health in serious jeopardy; (2) Serious impairment to bodily functions; (3) Serious dysfunction of any bodily organ or part.Review of the submitted documentation does not demonstrate that this patient had signs or symptoms that would cause a prudent layperson to seek immediate medical attention. The patient had been experiencing abdominal pain for four days. Her pain level was documented as 0/10 on the pain scale at the time she sought medical care. There was no serious dysfunction to any bodily organ or part. The patient was able to eat and her bowel and bladder were functioning normally. A prudent layperson in this situation would not believe her health was in serious jeopardy.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested authorization and coverage for onabotulinumtoxinA. There is sufficient support for the requested medication in this clinical setting. The records document a history of hyperhidrosis affecting the palms and right axilla. The patient has tried and failed treatment with aluminum chloride solution. The requested medication is likely to benefit the patients hyperhidrosis affecting the axilla. The medical evidence supports the requested medication in this patients case. Thus, onabotulinumtoxinA is medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested medication is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in dermatology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for magnetic resonance imaging (MRI) of the left knee and lower leg. The submitted documentation supports the medical necessity of the requested services. There is significant evidence documenting severe osteoarthritis of the left knee. The patient experienced onset of severe pain and a lump in the popliteal area with radiation of pain down the calf and difficulty walking. The patient was evaluated by a primary care provider who recommended further evaluation with MRI. This patients popliteal pain, radiating severe calf pain resulting in difficulty walking is consistent with a leaking ruptured Bakers cyst. According to researchers, the current medical literature supports MRI as the imaging of choice for the evaluation of a possible Bakers cyst. As such, the requested MRI of the left knee and lower leg is medically necessary for the evaluation of this patient.Final Result: The reviewer determined that the requested services are medically necessary for evaluation 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: Medical Necessity
Decision: Upheld

A 52-year-old female enrollee requested authorization and coverage of Botox injections. The Health Plan denied the request indicating that the requested therapy is not medically necessary for treatment of the enrollees migraine headaches.Three physician reviewers performed a medical necessity Independent Medical Review. Two of the three physician reviewers concluded that the requested therapy is not medically necessary for treatment of the enrollee's medical condition. One of the three physician reviewers concluded that the requested therapy is medically necessary for treatment of the enrollee's medical condition. Because two of the three physician reviewers concluded that the requested therapy is not medically necessary for the treatment of the enrollee's medical condition, the Health Plans denial has been upheld.
Appeal type: Medical Necessity
Decision: Upheld

A 40-year-old female enrollee requested genetic testing for neurofibromatosis type 2/NF2 gene sequencing (CPT codes 81405 and 81406) for medical evaluation of his neurofibroma.   Findings:  The physician reviewer found that based on the available documentation, none of the individuals in this patients family independently meet the criteria for a diagnosis of NF2. The age of onset of the fathers meningioma does not suggest a hereditary cancer predisposition syndrome. The absence of vestibular schwannomas in any of the individuals presenting with tumors in this family makes NF2 highly unlikely. Given the current information, the requested genetic testing for neurofibromatosis type 2/NF2 gene sequencing (CPT codes 81405 and 81406) is not supported as medically necessary for evaluation of this patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld

The enrollee is requesting reimbursement for periprosthetic capsulectomy breast (breast implant removal). This enrollee has a history of breast augmentation with saline implants. The enrollee was satisfied with the procedure, and was doing well until about four years ago, when she started to experience what she reported as breast implant illness symptoms. A plastic surgery consultation note indicates the enrollee was concerned about anaplastic large cell lymphoma (ALCL), bilateral breast pain, and decline in health. She attributed her hormonal issues, trouble losing weight, joint pain, brain fog, migraines, blurry vision, abnormal labs, possible autoimmune, rashes, skin sensitivities, and extreme fatigue to her breast implant illness related symptoms. The enrollee felt her breasts were pulling on her muscles and tissue and the right breast seemed to be decreasing in size and shape making her believe there might be a small leak in her breast implant. However, physical exam did not support this finding as laboratory results and breast exam were both within normal limits. The record indicated the capsulectomy was the enrollees preference to decrease breast size. There were no results of a mammogram in the record. Breast implant illness associated with systemic harms, such as autoimmune disease has been reported for silicone but not for saline implants. The medical literature for breast implant illness and this enrollees history of saline implant does not support the enrollee having illnesses related to her breast implants. The physician reviewer found that  records provide insufficient evidence of evaluation by internal medicine, rheumatology or neurology specialists for her symptoms.  Additionally there are not any results of imaging or laboratory studies.  The enrollee was concerned about anaplastic large cell lymphoma (ALCL), but the records do not document she had textured implants.  Smooth implants have not been implicated in ALCL.  Peer studies do no support capsulectomies to prevent or treat a systemic inflammatory condition in this enrollees case.Final Result: The reviewer determined that the requested service is not medically necessary for the treatment of the enrollees medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The enrollee has requested reimbursement for the hormone implants (CPT codes 11980 and J3490). Low testosterone can lead to such complications as reduced libido and erectile dysfunction, reduced muscle mass and strength, increased adiposity, osteoporosis, depressed mood, and fatigue (Dandona and Rosenberg). For these reasons, current data supports treatment of patients with hypogonadism when their testosterone level is less than 350 ng/dL (Nieschlag, et al). While topical gels and intramuscular injections are the most commonly prescribed formulations for testosterone replacement therapy, the short half-life of testosterone may be problematic for some patients. These modalities can often lead to highly variable levels of testosterone, resulting in poor patient compliance. Implantable testosterone pellets are an alternative therapy which provides a long-lasting effect (McCullough). For this reason, testosterone pellets may be of benefit to certain patients, such as this patient, who cannot achieve optimal clinical or biochemical results from the transdermal or intramuscular testosterone replacement therapy. Given these findings, the hormone implants (CPT codes 11980 and J3490) provided were likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.One reviewer found that the hormone implants (CPT codes 11980 and J3490) provided were not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: Two of the three reviewers determined that the services at issue were 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:  One reviewer is board certified in internal medicine with sub-specialty certification in endocrinology, diabetes and metabolism and is actively practicing. One Reviewer is board certified in internal medicine with sub-specialty certification in endocrinology, diabetes and metabolism and is actively practicing.  One Reviewer is board certified in internal medicine with sub-specialty certification in endocrinology, diabetes and metabolism and is 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: Experimental/Investigational
Decision: Overturned

A 56-year-old male enrollee has requested a PET/CT scan for an evaluation of his medical condition. Findings:  Two physician reviewers found that in the radiology literature PET scans for use in the diagnosis of head and neck cancer are far more accurate than MRI or CT scans alone. It is important to keep in mind that the oral pharynx and base of the tongue are very difficult areas to image well with conventional exams. The fact that head and neck tumors are metabolically PET-avid gives a definite advantage to the use of PET in cases where there is a strong clinical suspicion of head/neck tumor. In this particular patient, there was a high clinical suspicion of tumor based upon physical exam and history. The PET/CT scan guided the patients subsequent biopsy and was appropriate to fully evaluate his medical condition which would not have been possible with conventional exams.
Appeal type: Medical Necessity
Decision: Upheld

A 60-year-old female enrollee has requested Supartz injections for treatment her bilateral knee osteoarthritis.  Findings:  The physician reviewer found that the records provided for review do not support the medical necessity of the requested Supartz injections for treatment of this patients bilateral knee osteoarthritis. Carefully conducted double-blinded studies have demonstrated a lack of any clinical effect from hyaluronan injection. In addition, there is a documented incidence of aseptic inflammatory reactions due to allergic response. Further, there is also a low but present risk of iatrogenic infection within the joint. Several studies evaluating repeated treatment protocols document adverse events including inflammatory changes within the knee joint after multiple injections. Given the limited benefit demonstrated in well designed, double blinded studies and the documented incidence of acute local reactions, it is not medically necessary for this patient to receive the repeated injection protocol recommended.
Appeal type: Urgent Care
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for emergency medical services provided.Findings:  The physician reviewer found that the medical services provided were not necessary for treatment of an emergency medical condition. In this case, the patient presented with eye redness and irritation that commenced the night prior. The patients condition was not sudden. The patient denied any sudden or serious symptoms such as trauma or decreased vision that would indicate complications such as kerato-conjunctivitis or corneal ulcer . The patients vital signs were normal without fever. The patient had a normal visual acuity. Other than conjunctival injection, the remainder of the patients eye exam was normal. Therefore, the services at issue were not necessary for treatment of an emergency medical condition. Thus, the patient did not receive emergency medical services on the date of serviceFinal Result: The reviewer determined that the patient did not receive emergency medical services on the date of service at issue. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in emergency medicine and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Cymbalta for treatment of the enrollees depression and back pain. Findings:  The physician reviewer found that the request for brand name Cymbalta is not medically necessary for treatment of the patients medical condition. A study compared patients initiating antidepressant therapy with a brand versus generic medication, found no significant difference in the likelihood of discontinuation of the initially dispensed medication during the first 180 days of SSRI [selective serotonin reuptake inhibitors] or SNRI [selective norepinephrine reuptake inhibitors] therapy. In addition, Cymbalta is well known to have significant side effects that include nausea. There is a lack of adequate studies to support the use of brand name versus generic in this clinical setting. Therefore, Cymbalta has not been established as medically necessary for treatment of the patients medical condition. 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 physician reviewer number is board certified in anesthesiology with sub-specialty certification in pain medicine and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested Gammaplex brand, intravenous immune globulin (IVIG) home infusions for treatment of her medical condition.   Findings:  Two physician reviewers found that there is a lack of standard guidelines in the treatment of autoimmune chronic urticaria. There are several published guidelines for suggestions on the treatment with most agreeing that maximal antihistamine therapy should be used followed by anti-inflammatory agents, omalizumab, and immunosuppressive agents.  Other therapies exist but have limitations.  In this case, the patient has failed two of the therapies. However, there is no documentation submitted that demonstrates she has failed or has a contraindication to other available therapies.  Although there are case reports and series of responses to IVIG, there is a lack of large studies or randomized controlled trials assessing its use. Given the lack of large studies, and no documentation of failure of more commonly used therapies, the request for IVIG is not likely to be more beneficial than standard therapy. Final Result: Two 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:  One reviewer is board certified in internal medicine and allergy and immunology and is actively practicing. Two reviewers are board certified in dermatology and is 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

The patient is a 36-year-old female with a body mass index (BMI) of 40 and comorbid conditions including urinary stress incontinence, gastroesophageal reflux disease, and depression. In addition, it has been noted that the patient has a history of migraine headaches. It does not appear the patient has obtained psychiatric clearance for weight loss surgery. The Health Plan has denied authorization and coverage for gastric bypass on the basis that it is not medically necessary.With a BMI of 40 and comorbid conditions, the patient meets accepted national medical necessity criteria for consideration of weight loss surgery. Roux-en-Y gastric bypass is medically indicated and medically necessary for treatment of this patients morbid obesity. Furthermore, scientific evidence does not show that structured weight management plans consisting of diet and exercise have been successful in the treatment of the morbidly obese. The study referenced above demonstrates that surgery has the best long-term outcome for the morbidly obese. However, although medically the patient meets criteria for consideration of weight loss surgery, there is no evidence that the patient has undergone a psychological evaluation to determine whether she is an appropriate candidate for weight loss surgery. Such an evaluation is considered standard of care prior to authorizing weight loss surgery and is particularly important in this case given the patients history of depression and migraine headaches. Based upon the information set forth above, I have determined that the requested procedure is medically necessary for treatment of the patients medical condition depending upon the results of a psychological evaluation. Therefore, the Health Plans denial should be overturned. If the psychological evaluation indicates the patient is an appropriate candidate for weight loss surgery, the procedure should be authorized. If the psychological evaluation indicates the patient is not an appropriate candidate for weight loss surgery the procedure should not be authorized.
Appeal type: Medical Necessity
Decision: Overturned

A fifty-four year-old female diagnosed with bilateral osteoarthritis and internal derangement in both knees is requesting reimbursement and prospective authorization for a series of Synvisc injections for the left knee.   Reviewers Findings:  The reviewing physician found that the patient has derived a benefit from previous Synvisc therapy, a repeat series of injections for the left knee should be authorized at this time.  The reviewing physician found that the Health Plan denial should be overturned.
Appeal type: Experimental/Investigational
Decision: Upheld

A 34-year-old female enrollee requested authorization and coverage of hepatic activation therapy.  The Health Plan  denied the request indicating that the requested therapy is considered investigational for treatment of the enrollees diabetes mellitus. Three physician reviewers performed an experimental/investigational Independent Medical Review. All three physician reviewers concluded that the requested therapy is not likely to be more beneficial for treatment of the enrollee's medical condition than any available standard therapy. Because all three physician reviewers concluded that the requested therapy 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.