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

The patient is an HIV-positive 48-year-old male under the care of an HIV care physician who has requested recombinant human growth hormone (rhGH) to treat severe fat redistribution syndrome of HIV (also referred to as visceral adipose tissue accumulation or lipodystrophy). The patient has visceral fat accumulation (lipohypertrophy) as well as facial and peripheral lipoatrophy and has experienced improvement on growth hormone treatment. At issue is whether continued growth hormone therapy is medically necessary.Lipodystrophy is a recognized condition in patients with HIV. The cause is unknown; it is believed to be multifactorial, with HIV infection, insulin resistance and antiretroviral medications all playing some role. To date, there is no FDA approved treatment for this condition; however, results of clinical trials of human growth hormone have been promising. Liposuction is often ineffective and cannot be performed on intra-abdominal fat and the fat often quickly reaccumulates anyway. While diet and exercise may help, they do not reverse the condition. Metformin and testosterone replacement may also play a role, but have not been proven effective.The results of a placebo-controlled, double blind trial with 245 HIV patients testing rhGH in abnormal visceral adipose tissue accumulation show significant improvement in patients who received rhGH. There are also numerous pilot studies that suggest it may be the most effective treatment thus far, and there are many reports of dramatic improvement in certain patients with lipohypertrophy.The weight of the evidence in placebo-controlled trials published in peer reviewed journals, as well as expert opinions published in review articles and numerous preliminary abstracts, suggests that human growth hormone is likely to be effective for treatment of the patients severe visceral fat accumulation.Based upon the information set forth above, I have determined that the requested therapy is medically necessary for treatment of the patients medical condition. The Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Upheld

The parent of a 17-year-old male enrollee has requested growth hormone therapy (Genotropin) for the treatment of the enrollees short stature. Findings:  The physician reviewer found that the patients relatively advanced bone age indicates that his growth period is by now quite limited. The patient does not qualify for growth hormone therapy under the FDA guidelines for growth hormone therapy. Growth hormone therapy is not medically indicated for this patient. Furthermore, based on the patients relatively advanced bone age, growth hormone therapy is not likely to be of significant benefit.
Appeal type: Medical Necessity
Decision: Overturned

A 60-year-old female enrollee has requested for a neurology consultation for treatment of her dizziness.  Findings:  The physician reviewer found that per Milliman Care Guidelines, indications for a referral to a neurologist include unremitting vertigo and disabling vertigo and nystagmus, cerebellar symptoms such as marked ataxia and incoordination, focal neurologic symptoms and persistent vertigo or dizziness.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary:  The parent of an enrollee has requested Nature-Throid for treatment of the enrollees hypothyroidism. The physician reviewer found that neither Armour Thyroid nor Nature Throid is standard, U.S. Food and Drug Administration (FDA) approved treatment for hypothyroidism. In addition, the most recent guidelines of the major endocrine societies do not recommend use of thyroid hormone extracts to treat hypothyroidism. This patients records do not include laboratory results that suggest an adverse reaction to the Armour Thyroid was due to an inappropriate dose of the medication that may have resulted in high serum levels of T4 or T3. Therefore, the appropriate treatment for this patient would be levothyroxine with proper monitoring with thyroid function tests in order to titrate the patients dose. All told, the requested Nature Throid is not supported as medically necessary for treatment of this 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 reviewer is board certified in pediatric endocrinology 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 facial feminization surgeries (reconstruct entire forehead; reconstruction of nose; reduction of facial bones; and suction lipectomy head & neck).Medical literature has stated that facial feminization surgery is medically necessary for some patients and may be a more important treatment for gender dysphoria than genital surgery. This literature has stated that non-genital surgical interventions are often of greater practical significance in the patients daily life than reconstruction of the genitals and that these interventions are not cosmetic or elective or for the mere convenience of the patient. These reconstructive procedures are not optional in any meaningful sense, but are understood to be medically necessary for the treatment of the diagnosed condition. Furthermore, Ainsworth and Spiegel have demonstrated that facial feminization surgery, like genital surgery, is associated with improved mental health-related quality of life.In this case, the patient has submitted multiple documents that support her claim that the requested surgeries are medically necessary. A letter from the patients therapist states that the patient has clinically significant distress and functional impairment that could benefit from facial feminization surgery. The patients primary care provider also supports the medical necessity of the requested surgeries to treat the patients gender dysphoria. Under these circumstances, the requested facial feminization surgeries (reconstruct entire forehead; reconstruction of nose; reduction of facial bones; and suction lipectomy head & neck) are medically necessary to treat the patients medical condition.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 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: Upheld

A 67-year-old female enrollee requested quarterly (every three months) Botox injections for treatment of the enrollees DiGeorge syndrome.   Findings:  The physician reviewer found that the patient has a rare genetic disorder that includes paralysis of the left lower lip.  While Botox is used in hemifacial spasm, symptomatic synkinesis, and facial dystonia, this patient only has an asymmetry in her lower lip movement. Botox is not likely to improve the patients speech, but rather would add to dysarthria and difficulty with drinking. All told, the requested Botox to be provided every three months is not medically necessary for the treatment of this patients facial asymmetry.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for RT300 functional electrical stimulation (FES) therapy system. Review of this patients records reports spasticity due to his spinal cord injury (SCI) and upper motor neuron injury. Recently published systematic reviews on the effects of FES in chronic SCI patients have demonstrated the beneficial effects of FES use on spasticity in the lower extremities and avoiding long-term complications of a severe SCI. Specifically, FES cycling has been shown to have positive effects on muscle size, strength, and function, as well as skin thickness, and cardiovascular and bone health. Sadowsky and colleagues evaluated a retrospective cohort of patients with chronic SCI and compared those performing long-term FES cycling to those involved in a standard protocol of range-of-motion and stretching exercises. The authors concluded that in the patients undergoing treatment with FES, muscle mass and strength were improved as well as quality of life and daily function measures. Overall, the current peer-reviewed medical literature supports RT300 FES use in this patient who is in the chronic phase after a complete SCI to improve overall health and potentially limit complications of the disability. For these reasons, the requested RT300 FES therapy system is medically necessary for 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 board certified in neurological surgery and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

The patients parent has requested authorization and coverage for a pediatric amplified pain rehabilitation (PAPR) program for treatment of the patients complex regional pain syndrome (CRPS). The American Pain Society (APS) recommendations for children with chronic pain state that intensive pain rehabilitation programs (several hours per day of treatment) using interdisciplinary treatment approaches are an option for children who are unable to receive or benefit from outpatient management. One study of a day hospital pediatric pain rehabilitation program, performed by colleagues, included pediatric CRPS patients who failed to improve with outpatient treatment. Treatment included daily physical, occupational and psychological therapy, for a median duration of three weeks. The authors found that statistically significant improvements from admission to discharge in pain intensity, functional disability, subjective reports of limb function and occupational performance, these functional gains were maintained or further improved at follow-up. Similarly, colleagues observed complete resolution of pain in children with CRPS after intensive inpatient rehabilitation, which consisted of physical, occupational, and psychological therapy, with no other medical intervention, followed by a home program. In this case, the patient was diagnosed with CRPS following a left ankle fracture sustained when a hockey puck struck her ankle. She has failed to improve with an intense multidisciplinary outpatient approach including physical therapy, aquatherapy and psychotherapy since. The provider noted that the patient has been compliant with her treatment plan and adherent to her home exercise program. She has also been treated with gabapentin 200 mg three times a day with no improvement in her symptoms. The notes from the provider express concern that if her CRPS continues to remain active and recalcitrant to intensive outpatient therapy it may progress to chronic CRPS. Based on the position statement from the APS, the requested intensive inpatient PAPR program is the next logical treatment step. Based on these findings, the requested PAPR program services are medically necessary for treatment of this patients CRPS.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 anesthesiology with subspecialty certification in pain management and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld

A 56-year-old male enrollee has requested the surgical implantation of a diaphragmatic pacing device for the treatment of his amyotrophic lateral sclerosis (ALS). Findings:  Three physician reviewers found that the provider has requested that the patient participate in a clinical trial.  The requested diaphragmatic pacing device is experimental and investigational and does not meet national Medicare criteria for medical necessity. There is no documentation to show the requested participation in the clinical trial for diaphragmatic pacing is safe and effective or superior to no treatment.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has been diagnosed with hemoccult positive stool. The patient underwent a colonoscopy with polyp removal. The patients height was 69 inches, his weight was 195.8 pounds, resulting in a body mass index of 28.9. He was given an American Society of Anesthesiologists (ASA) score of two. The patient has requested reimbursement for monitored anesthesia care (MAC - CPT 00811) that was provided. The Health Plan denied the request and reported the services at issue were not medically necessary for the treatment of this patient. At issue in this case is whether monitored anesthesia care (MAC - CPT 00811) that was provided was medically necessary for the treatment of the patients medical condition. The American Society for Gastrointestinal Endoscopy Guidelines for Sedation and Anesthesia in Gastrointestinal (GI) Endoscopy noted, We recommend that the combination of an opioid and benzodiazepine is a safe and effective regimen for achieving minimal to moderate sedation for upper endoscopy and colonoscopy in patients without risk factors for sedation-related adverse events. Researchers concluded, The overall risk of complications after colonoscopy increases when individuals receive anesthesia services. The widespread adoption of anesthesia services with colonoscopy should be considered within the context of all potential risks. In this case, the patient underwent a routine colonoscopy with polyp removal. The patient did not have any documented cardiac, pulmonary, kidney or liver disease. There was no previous history of difficulties with anesthesia or sedation. There was no history of alcohol or substance abuse. The patient was given an ASA score of two, which indicates a low likelihood of complications from anesthesia. The medical evidence does not support the services at issue in this clinical setting. Therefore, monitored anesthesia care (MAC - CPT 00811) that was provided was not medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested services were 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 anesthesiology 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 40-year-old female has requested reimbursement for emergency room services. The Health Plan has denied this request indicating that the enrollee's condition was not an emergent medical condition.  Findings:  The physician reviewer found that the patient presented to the emergency room (ER) with a chief complaint of tearing associated with swelling and pain in the region of the medial canthus of the right eye, present for one year, but worse since the prior day. She had been seen for this problem multiple times by her primary care provider. In the ER, her vital signs were unremarkable, and the emergency physician noted that she was in no apparent distress. No specific pain score was entered into the record by that physician.  Slight swelling was noted at the medial canthus and along the right side of the nose with tenderness to palpation.  There was no overlying skin erythema or increased warmth.  There was no exudative drainage expressed from the medial canthus area. The physician diagnosed the patient with dacryocystitis and recommended warm compresses. The patient was given a prescription for Norco for pain. She was referred back to her primary care physician for referral to otolaryngology or ophthalmology.At issue in this case is whether a reasonable and prudent layperson, taking into consideration the totality of the circumstances and the patients presenting history, would believe he or she was experiencing an emergency medical condition requiring emergency medical services. Under Health and Safety Code 1317.1, an emergency medical condition means 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 in bodily function; or 3) serious dysfunction of any bodily organ or part. Review of the submitted evidence indicates that the patient presented to the emergency room with complaints associated with a problem that had been occurring for a year.  At the time of her presentation to the ER, the patient was in no apparent distress. The examining physician noted only slight soft tissue swelling, with no evidence of infection.  A reasonable and prudent layperson with slight soft tissue swelling associated with a condition that had been present for a year would not believe that she was experiencing an emergency medical condition. The evidence provided does not support the patients contentions that she was in extreme pain, had severe swelling and had experienced significant worsening of her condition since being seen by her primary care physician earlier that day. As such, the patients condition did not meet prudent layperson criteria for emergency services.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has been diagnosed with synovial chondromatosis and degenerative joint disease. The patient reported left knee pain. The patient was noted to be status post open synovectomy for synovial chondromatosis. Physical examination findings included a mild left knee effusion and crepitation of the patellofemoral joint. An x-ray was noted to reveal significant synovial chondromatosis with joint space narrowing. A Celestone injection was administered to the left knee. The provider noted the Celestone injection did not provide the patient with pain relief. The patient has requested authorization and coverage for hyaluronan injections (CPT J7321) for the left knee. The Health Plan denied the request and reported that the requested services are not medically necessary for the treatment of this patient. At issue in this case is whether hyaluronan injections (CPT J7321) for the left knee are medically necessary for the treatment of the patients medical condition. Review of the current medical literature pertaining to viscosupplementation reveals mixed results. Although viscosupplementation may relieve knee pain in some patients with osteoarthritis, it is unknown which patients will benefit. Considering the foregoing, viscosupplementation can only be recommended for patients with a history of lasting benefit from prior injections and in carefully selected cases when everything else has been tried and the options are limited. In this case, the patients options are limited. The patient has tried and failed a corticosteroid injection with the alternative being a total knee arthroplasty. The medical evidence supports the requested services in this clinical setting. Therefore, hyaluronan injections (CPT J7321) for the left knee are 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 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.