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

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for panniculectomy. According to the American Society of Plastic Surgeons (ASPS), a panniculectomy involves the removal of hanging excess skin/fat in a transverse or vertical wedge but does not include muscle plication, neoumbilicoplasty or flap elevation. When surgery to remove extensive skin redundancy and fat folds is performed solely to enhance a patients appearance in the absence of any signs or symptoms of functional abnormalities, the procedure should be considered cosmetic in nature and not a compensable procedure. This patients medical records do not include documentation that the patients panniculus hangs below the level of the pubis, or that the panniculus causes chronic intertrigo that recurs over three months despite appropriate medical therapy. Further, the photograph does not reveal that the panniculus hangs below the level of the pubis. The patient complains of a recurrent rash underneath her abdominal pannus during the summer months, but there is no documentation of appropriate medical treatment of the rash or of failure of appropriate medical treatment of the rash. Moreover, the records do not report a functional problem with the rash that has been resistant to appropriate medical treatment. Based on these findings, the requested panniculectomy is not medically necessary for treatment of this patient. The California reconstructive surgery statute requires health insurers to cover reconstructive surgeries, defined as surgery performed to correct or repair abnormal structures of the body caused by congenital defects, developmental abnormalities, trauma, infection, tumors, or disease to do either of the following: (1) to improve function; or (2) to create a normal appearance, to the extent possible. An abdominal pannus is not a result of a congenital defect, a developmental abnormality, trauma, infection, tumor or disease. An abdominal pannus is not an abnormal structure of the body rather it is a normal structural change that is an accommodative response to gain or loss of body mass. The appearance of the patient is normal and consistent with the gain and loss of weight. The requested panniculectomy will not improve the patients function or provide a more than minimal improvement in the patients appearance. All told, the requested panniculectomy is not reconstructive in nature for treatment of this patient. Final Result: The reviewer determined that the requested services are not medically necessary and not reconstructive in nature 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: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for Helicobacter Pylori lab testing. Findings: Two of the three physician reviewers found that Helicobacter Pylori lab testing was not indicated under these circumstances. A recent study of the diagnosis of Helicobacter Pylori infection by researchers noted that the urea breath test or the stool antigen test can be used for non-invasive screening for Helicobacter Pylori in a test and treat strategy in younger patients presenting with dyspepsia without alarm symptoms. Serologic testing was not recommended, however, as it cannot distinguish between active disease and previous exposure. Antibodies to H pylori can remain elevated for a long time even after treatment, potentially increasing the number of false-positive results and thus unnecessary antibiotic exposure. Therefore, the services in issue 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 in issue were not likely to be more beneficial for treatment of the patients medical condition than any other available standard treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications:  One reviewer is board certified in internal medicine, with subspecialty certification in gastroenterology, and is actively practicing. One Reviewer is board certified in internal medicine, with subspecialty certification in gastroenterology, and is actively practicing. One Reviewer is board certified in gastroenterology, 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: Upheld

Physician 1: The patient is a 56-year-old female with degenerative disc disease. She had a herniated disc at L5-S1 and underwent subsequent microdiscectomy. Her provider is recommending artificial disc replacement. The Health Plan considers this procedure experimental.The Health Plan is correct that the proposed procedure is considered experimental. There is no evidence to support disc replacement surgery for this patient. The proposed procedure is still under investigation and is not considered standard of care. The long-term success rate and safety profile remain unknown. Because there is no evidence supporting the long-term safety and efficacy of the proposed procedure, I have determined the requested procedure is 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.Physician 2: The patient is a 56-year-old woman who has degenerative disc disease at L5-S1 and facet sclerosis. She underwent microdiscectomy in December 2004 and had temporary relief. She is now symptomatic and has requested an artificial disc replacement. The Health Plan has denied her request on the basis the requested procedure is considered investigational.The current clinical evidence regarding the artificial disc has allowed for Food and Drug Administration (FDA) approval that it is not inferior compared to fusion. Similarly, current studies appear to indicate it is not worse than fusion. Additional claims of efficacy are based upon a small number of short-term, non-randomized studies. A 300-patient FDA regulated investigational device exemption trial with long-term follow-up is underway. Without the results of this trial, artificial disc replacement remains experimental. Furthermore, it is not established as superior to fusion. Therefore, I have determined the requested procedure is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Plans denial should be upheld.Physician 3: The patient is a 56-year-old female with degenerative disc disease at L5-S1. The patient is status post a microdiscectomy. She is requesting authorization for artificial disc replacement. The Health Plan has denied authorization for the requested procedure.The proposed procedure is experimental without established long-term efficacy. The best published results reveal outcomes equivalent to fusion. However, the majority of studies show a failure rate of 35%. Furthermore, the long-term safety profile is unknown. In addition, there are other treatments available. For these reasons I have determined the requested procedure is 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.
Appeal type: Experimental/Investigational
Decision: Overturned

A 60-year-old female enrollee requested graft product services (homograft) for medical treatment of the enrollees burns.  Findings:  Three physician reviewers found that the homografting was likely to be more effective for this patient than any available standard therapies. It is well-established that cutaneous cadaver homograft is an effective dressing, which decreases exudate and water loss, inhibits bacterial growth, corrects hypoproteinemia, and ameliorates pain at dressing changes. According to Leon-Villapalos and colleagues, human deceased donor skin allografts represent a suitable and much used temporizing option for skin cover following burn injury. The main advantages for its use include dermoprotection and promotion of reepithelialisation of the wound and their ability to act as skin cover until autografting is possible or re-harvesting of donor sites becomes available. Finally, homografting has been proven to be helpful for many types of wounds, especially burns, and its application is the standard of care in this clinical setting. For the reasons provided above, the services at issue were likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Zepatier for treatment of the enrollees hepatitis C virus. Findings:  The physician reviewer found that according to the joint guidelines issued by the American Association for the Study of Liver Diseases (AASLD) and the Infectious Diseases Society of America (IDSA), all patients with chronic hepatitis C should be treated except those with limited life expectancy due to non-liver-related conditions. This recommendation applies to all patients, regardless of fibrosis stage. The guidelines recommend that treatment-naive genotype 1a patients should be treated with regimens including or Zepatier when NS5A resistance is not found. These guideline recommendations are based on clinical trial results showing a 99% cure rate when NS5A resistance is absent. AASLD/IDSA guidelines cite data showing reduced survival with delayed treatment. For these reasons, treatment with Zepatier is medically necessary for the treatment of the patients hepatitis C infection. 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 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: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Euflexxa injections for bilateral knees. Evidence from systematic reviews and randomized controlled trials indicate that although viscosupplementation may relieve knee pain in some patients with osteoarthritis, data has not established which patients will benefit. Guidelines from the American Academy of Orthopedic Surgeons (AAOS) indicate that the data on safety and efficacy of viscosupplementation remain inconclusive. As such, the AAOS does not currently recommend viscosupplementation as standard treatment for osteoarthritis of the knees. Viscosupplementation is reserved for patients with a history of lasting benefit from prior injections and in cases where the remaining options are limited. In this case, the patient has a history of osteoarthritis of both knees for many years. The available documentation reports bilateral knee pain, tenderness over the medial and lateral femoral condyles, and positive patellar grind test. The provider reported that the patient previously underwent viscosupplementation with excellent results. Furthermore, the options are limited with the alternative being bilateral total knee arthroplasties. Given these findings, the requested Euflexxa injections for bilateral knees 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: Medical Necessity
Decision: Upheld

A female enrollee requested magnetic resonance imaging (MRI) of the neck and spine without dye for medical evaluation of her cervicalgia.  Findings:  The physician reviewer found that there are no red flags to establish medical necessity for an MRI of the cervical spine prior to a conservative trial of therapy including physical therapy. In particular, there is no documentation of trauma, plain film findings requiring imaging clarification, tumor, infection or neurological deficit. These red flags provide indications for MRI without prior conservative treatment but no such documentation has been submitted in this case. In the absence of such evidence, the requested MRI is not medically necessary for evaluation of the patients medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld

A 34-year-old male enrollee has requested for transcranial magnetic stimulation therapy for treatment of his major depressive disorder. Findings:  Three physician reviewers found that the medical records do not demonstrate the superior efficacy of the requested transcranial magnetic stimulation therapy.  The medical records does not elaborate upon the specific psychotherapy plan.  Further, well-established medication management and augmentative strategies commonly used in the treatment of major depressive disorder have not been exhausted.  In sum, the requested transcranial magnetic stimulation therapy is not likely to be more beneficial than other treatment options.
Appeal type: Medical Necessity
Decision: Overturned

A 51-year-old female enrollee has requested for PET/CT scan  for evaluation of her breast cancer. Findings:  The physician reviewer found that it has been proven to be a useful tool in the evaluation of distant metastases. This is particularly important following this patients prior lymphadenectomy. PET/CT has proven valuable in the evaluation of distant metastases in breast cancer including the skeleton. This study is also useful in the restaging of patients with known malignancy after the completion of therapy.
Appeal type: Medical Necessity
Decision: Upheld

A 60-year-old male enrollee requested monitored anesthesia care (MAC) during a colonoscopy for medical treatment of his medical condition.  Findings:  The physician reviewer found that the submitted documentation fails to establish the medical necessity of the services. The patient did not present with a significant history that would require monitored anesthesia care. In this case, conscious sedation was indicated. McQuaid and Laine compared the efficacy, safety, and efficiency of agents used for moderate sedation in esophagogastroduodenoscopy (EGD) or colonoscopy. The authors concluded that moderate sedation provides a high level of physician and patient satisfaction and low risk of serious adverse events with all currently available agents. The patient could have been provided with a combination of a benzodiazepine and narcotic intravenous. Based on the documentation submitted for review and the peer-reviewed literature cited above, the services at issue were not medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has been diagnosed with left foot pain and hallux limitus. The patient reported left big toe pain. The physical examination revealed a dorsal exostosis with slight pain and crepitus with first metatarsophalangeal (MTP) joint range of motion. The patient has requested authorization and coverage for a custom left foot orthotic. The Health Plan denied the request and reported the requested equipment is not medically necessary for the treatment of this patient. At issue in this case is whether a custom left foot orthotic is medically necessary for the treatment of the patients medical condition. A study by researchers reported that patients utilizing an orthosis, demonstrated increased ability of participants to bear weight on the arthritic hallux MTP joint and restoration of physiologic stance. Compared to existing products, the device was well-tolerated and did not require footwear modifications or impede normal gait. Overall, the orthosis offers an appealing solution to patients dissatisfied with existing treatment options as well as those who may be averse to or ineligible for surgery. Authors reported, Orthotics can be used to modify existing footwear. An extended shank or footplate made of spring-steel or carbon fiber can be used to stiffen the sole of the shoe thereby limiting dorsiflexion at the first MTP joint. A Mortons extension limits movement at the hallux in isolation and may be better tolerated by more active patients. In this case, the patient was noted to have pain and crepitus with first MTP joint range of motion. The patient was also noted to have a dorsal first MTP joint exostosis and hallux limitus. The medical evidence supports the requested equipment in this clinical setting. Therefore, a custom left foot orthotic is medically necessary for the treatment of this patient. 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 a board-certified podiatrist 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 representative of a 53-year-old male enrollee has requested for acute rehabilitation services for treatment of the enrollees medical condition, status-post cerebrovascular accident (CVA). Findings:  The physician reviewer found that the records do not outline specific and identifiable goals which would require such an acute rehabilitation environment, nor do they outline any goals which could not be addressed alternatively at a lesser level of care, including a skilled nursing facility. The lack of identifying acute rehabilitation goals is additionally supported by the patients past rehabilitation course, and by the patients ongoing dementia/delirium, which suggest that the patient would have a limited capacity for carryover in rehabilitation from one session to the next. Further, there is no medical evidence in the submitted documentation demonstrating that this patient regressed as a result of discharge to a skilled nursing facility. Additionally, the records do not document any specific care or supervision need which could not be met at a skilled nursing facility.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: A enrollee has requested authorization and coverage for three months of weekly one hour individual therapy sessions that include medication management and three months of one hour group therapy sessions, five times a week. Findings:  The physician reviewer found that the requested services are not medically necessary based on the clinical documentation and current practice standards. The records indicate that the patient has been stable on his psychotropic medications and has access to psychiatric care. Further, he has been approved for weekly psychotherapy visits, which are recommended. The records document that the patients most recent clinic visit was six months ago, save for a few discussions via telephone. Thus, the patients current clinical status, symptom inventory, degree of psychosocial stressors and extent of psychiatric, substance use and medical comorbidity, if any, are unknown at this time. Without this information, there is a lack of evidence supporting the requested services. Typically, in providing clinical and consultative services, psychiatrists function as valuable members of a health care team, and are not a sole provider. In this case, the patient has access to weekly visits with a therapist. The patient has been stable on trazodone, paroxetine and lorazepam for some time. There is no indication of poor tolerability, lack of efficacy, misuse or side effect. Under these circumstances, weekly psychiatric visits are not medically necessary. The patient should continue weekly psychotherapy and consider self-help groups and wellness-based activities in the community. Given these findings, the requested three months of weekly one hour individual therapy sessions that include medication management and three months of one hour group therapy sessions, five times a week are not medically necessary 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 psychiatry 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: A patient has requested authorization and coverage for chiropractic manipulation. The Health Plan has denied this request indicating that the requested services are not medically necessary for treatment of the patients back pain. The submitted documentation supports the medical necessity of the requested services. The patient has a history of chronic low back pain and has trialed nonsteroidal anti-inflammatory drugs, which resulted in gastrointestinal side effects. The patient has also received physical therapy. Research studies show moderate efficacy of spinal manipulation for chronic or subacute low back pain. There is sufficient support for the requested services in this clinical setting. Thus, the requested chiropractic manipulation is medically necessary for the 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 chiropractic 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

A 14-year-old female enrollee requested authorization and coverage of a custom molded knee brace for rehabilitation.  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 equipment is not medically necessary for treatment of the patients medical condition.