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

A 51-year-old female enrollee has requested bilateral breast implants for the treatment of her breast asymmetry. Findings:  The physician reviewer found that although symmetry is the surgical objective of breast reduction surgery, perfect symmetry of nipples, areolae, and breasts cannot be achieved. Furthermore, the two sides of the human body are not the same and can never be made the same. A patient with preoperative asymmetry prior to surgery will most likely have asymmetry after surgery, even though the surgeon strives to decrease the degree of asymmetry at surgery. No surgeon can guarantee or predict final breast size after breast reduction surgery any more than they can after breast augmentation. The error in the preoperative estimate versus final result can be as high as between 1 and 2 cup sizes. In this patients case, the end result, though not perfect, was within the realm of acceptability for this surgery. Reconstructive surgery is defined as a procedure performed to correct or repair abnormal structures due to congenital defects, developmental anomalies, trauma, infection, tumors or disease to improve function and/or create a more normal appearance. The patients breast asymmetry would not be considered abnormal and this degree of asymmetry is present in a significant portion of the non-operated public. The patients current condition is normal in that the dog ear and asymmetry are not visibly affected by disease or infection, and the asymmetry is not so great so as to be considered abnormal. Thus, the proposed procedure does not meet the definition of reconstructive surgery as defined by California law. With regard to the medical necessity of the proposed procedure, the initial surgery was performed to treat a functional problem, namely neck and back pain. Those problems apparently have resolved. No current functional problems relating to the patients breast asymmetry have been documented. Thus, the proposed surgery is not medically necessary for treatment of this patients condition.
Appeal type: Experimental/Investigational
Decision: Overturned

A 56-year-old female enrollee has requested a magnetic resonance imaging (MRI) scan of the chest/breasts and a positron emission tomography (PET) scan for evaluation of her status post ductal carcinoma in situ (DCIS) surgery.  Findings:  Two physician reviewers found that a follow-up MRI showed an additional mass in the upper inner quadrant 1.5 cm in diameter which also proved to be malignant. A PET scan performed on the date in question showed no evidence of metastatic disease. A repeat MRI of the breasts/chest and a PET scan were requested for follow-up. Additional information has been submitted which indicates that when the patient presented to her provider on the date in question, there were concerns regarding a hardened area under her scar, subsequent to radiation treatment. The provider noted that it was difficult to determine if there is a recurrence or whether the hardened area is fat necrosis. In addition, it has been noted that the patient is status post mantel radiation for Hodgkins lymphoma. The provider recommended authorization and coverage for an MRI and PET scan of the breasts. As previously indicated, the requested MRI is medically reasonable and appropriate in this patient who has biopsy proven multicentric disease. MRI is the most sensitive test for multicentric disease and would be of greater benefit than conventional mammographic imaging in this clinical setting. The requested PET scan is also medically reasonable. PET is the most sensitive means with which to evaluate the entire body for metastatic disease, particularly the axilla. The absence of hypermetabolic uptake on a prior PET scan should not preclude the future use of PET in this situation. All told, the requested diagnostic scans are likely to be more beneficial for evaluation of this particular patient than any other available standard therapy.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested three-dimensional breast tomosynthesis for evaluation of her medical condition. Findings:  Three physician reviewers found that there is sufficient support for the services at issue in this clinical setting.  Due to the tomographic qualities of this technique, radiologists are often able to subtract out underlying dense glandular tissue from architectural distortion thereby decreasing callbacks and increasing detection of small cancers.  This advantage is particularly seen in patients with heterogeneously or very dense breast tissue.  The addition of the technique has gained worldwide favor among radiologists for the advantages described above.  Thus, the addition of three-dimensional breast tomosynthesis to the usual two-dimensional screening mammographic images is likely of more benefit to the patient than two-dimensional mammography alone. Final Result: Three reviewers determined that the services at issue were likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned.  Credentials/Qualifications: All three reviewers are board certified in diagnostic radiology 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

Nature of Statutory Criteria/Case Summary:  An enrollee has requested Zohydro ER for treatment of his medical condition.  Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested medication.  This patient has non-malignant chronic pain, which will often worsen or recur as a result of opioid rebound.  The current standard of care for chronic pain is treatment in a multidisciplinary practice to include physical therapy, massage therapy, cognitive behavioral therapy, and injections to help reduce pain.  Researchers reported that high-dose opiates might contribute to pain sensitization via opioid-induced hyperalgesia, decreasing patient pain threshold and potentially masking resolution of a preexisting pain condition.  In this retrospective study, the majority of patients undergoing detoxification of high-dose opiates for chronic pain reported a significant decrease in pain at the end of the study, further supporting the theory of opioid-induced hyperalgesia.  High-dose opiates may also cause adverse outcomes.  Researchers also reported that prolonged use of high dose opiates might induce tolerance, abnormal pain sensitivity, and hormonal effects.  The aim of current guidelines is to protect patients from the adverse effects of opioid therapy.  All told, the requested Zohydro ER is not medically indicated for the treatment of this patient.  Final Result: The reviewer determined that the requested medication is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.  Credentials/Qualifications: The reviewer is board certified in 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: Medical Necessity
Decision: Overturned

A 64-year-old female enrollee has requested the medication Xifaxan 400 mg for the treatment of the enrollees small intestinal bowel overgrowth. Findings:  The physician reviewer found that Rifaximin (Xifaxan) is an approved drug for the treatment of small intestinal bacterial overgrowth (SIBO). The medical literature does not support use of one of the formulary alternatives over the use of Xifaxan. Instead, the literature shows lower recurrence of SIBO with Xifaxan. Additionally, other antibiotics indicated for SIBO carry a higher risk for Clostriudium difficile. The use of Xifaxan is medically indicated for treatment of this patients condition. The proposed dose of Xifaxan 400 mg to be taken orally 3 times a day for 10 days is medically appropriate and does not pose any significant risk.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested acute inpatient mental health treatment for treatment of her behavioral health condition. Findings:  The physician reviewer found that inpatient psychiatric care is aimed at decompressing the acute exacerbations of episodic serious mental illness. In this case, the patient presents with medical issues and psychosis cast upon an autistic baseline. The American Psychiatric Association articulates this process stating The psychiatrist should determine the least restrictive setting for treatment that will be most likely not only to address the patients safety, but also to promote improvement in the patient's condition. The determination of an appropriate setting for treatment should include consideration of the patient's symptom severity, co-occurring psychiatric or general medical conditions, available support system, and level of functioning. In this particular case, psychiatric hospitalization was initially indicated and discharge during this time would have been premature. Based on the illness severity, treatment at this time could not have been reasonably conducted in a less restrictive setting. The inpatient team was relying on a medication protocol in a specialty setting yet the illness burden that prompted the admission had not yet been adequately controlled. This type of protracted response is not uncommon as treatment with a medication like she was prescribed often results in initial positivism due to its sedating effects but the more enduring antipsychotic effects can take significantly longer to achieve. As active treatment continued, including family involvement and the administration of prescribed medications, the patient began to improve. She had a family meeting scheduled which would have been a reasonable opportunity to progress with transition to a less restrictive treatment setting. Although the patient will require long-term specialty services provided by behavioral health care professionals, the acute psychiatric syndrome that prompted the admission had resolved. Thus, based on the documentation provided, the initial services at issue were medically necessary but not thereafter. Final Result: The reviewer determined that a portion of the services at issue were medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be partially 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: Overturned

The parent of a two-year-old male enrollee has requested speech therapy for treatment of the enrollees severe expressive language impairment.  Findings:  The physician reviewer found that speech and language therapy is medically necessary for this patient with severe expressive language delay.  As noted by Nelson and colleagues, speech and language development is considered by experts to be a useful indicator of a childs overall development and cognitive ability and is related to school success.  Per Nelson and colleagues, identification of children at risk for developmental delay or related problems may lead to intervention services and family assistance at a young age when chances for improvement are best.  The current medical evidence indicates that speech and language delay must be taken very seriously in young children, because the long-term consequences may be substantial. According to Law and colleagues, there is an overall positive effect of speech and language therapy interventions for children with expressive phonological and expressive vocabulary difficulties. These authors noted that children with speech and language difficulties that persist into primary school may have long-term problems regarding socialization, behavior, literacy and school attainment.  This patient has severe expressive language delay that is negatively impacting his ability to communicate in an age-appropriate manner.  The current medical literature has shown that speech and language therapy can result in significant improvement in this clinical scenario.  Therefore, the requested speech therapy is medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld

A male enrollee requested Subsys for medical treatment of his medical condition.  Findings:  The physician reviewer found that the current standard of care for chronic pain is treatment in a multidisciplinary practice to include physical therapy, massage therapy, behavioral therapy, and injections to help reduce pain.  Subsys is a potent short acting opioid with highly addictive properties.  The medical evidence does not support Subsys in this clinical setting.  Baron and McDonald reported that high-dose and short acting opiates might contribute to pain sensitization via opioid-induced hyperalgesia, decreasing patient pain threshold and potentially masking resolution of a preexisting pain condition.  All told, the requested medication Subsys is not medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for laparoscopic sleeve gastrectomy bariatric surgery. Findings:  The physician reviewer found that  the submitted documentation fails to demonstrate the medical necessity of the requested services.  Bariatric surgery is currently indicated for treatment of morbid obesity defined as a body mass index of 40 or 35 with serious obesity comorbid conditions.  In this patients case, the records do not document diabetes, sleep apnea, cardiovascular disease or hypertension at this time.  The medical evidence does not support the requested services in this clinical setting.  All told, the requested laparoscopic sleeve gastrectomy bariatric surgery is not medically indicated for the treatment of this patient. Final Result: The reviewers 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: Physician reviewer is board certified in surgery and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested mastectomy revision procedures for treatment of the patients gender dysphoria. Based on the patients gender dysphoria and identification as a male, the aim is for a normal appearance of the breasts for a male. Fat grafting on the right inferior breast and nipple/breast revision on the left is consistent with this goal. Reconstructive surgery is performed on abnormal structures of the body, caused by congenital defects, developmental abnormalities, trauma, infection, tumors or disease. It is generally performed to improve function, but may also be done to approximate a normal appearance. Based on the documentation provided for review, the patient has significant abnormality of the right inferior lateral breast and significantly asymmetric nipple areolar complexes. The patient previously had the appearance of female breasts and underwent bilateral mastectomies and free nipple grafting to achieve a male contour of the chest. His current appearance is considered abnormal. The patients abnormal structure of the body is based on his diagnosis of gender dysphoria, a disease or developmental abnormality. The proposed surgery is being performed to create a normal appearance to the extent possible, as the patient has a significantly abnormal appearing chest contour based on the right lateral inferior breast and asymmetric nipple areolar complexes. In addition, the requested fat grafting and resizing of the left nipple areolar complex would be expected to provide more than a minimal improvement in the appearance of the patient. However, the request for excision of axillary fullness has not been established as medically necessary or reconstructive in nature for treatment of the patients medical condition. Based on the documentation provided, the axillary fullness and bilateral dog ears are considered part of the normal male contour. Therefore, a portion of the requested surgeries are medically necessary and reconstructive in nature for treatment of the patients medical condition.Final Result: The reviewer determined that a portion of the requested surgeries are medically necessary and reconstructive in nature for treatment of the patients medical condition. Therefore, the Health Plans denial should be partially overturnedCredentials/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: Medical Necessity
Decision: Overturned

The patient has requested authorization and coverage for occlusal orthotic device. This patients symptoms support a diagnosis of TMJ disorder and myofascial pain disorder. Occlusive splint devices have been shown to be beneficial in patients with TMJ disorder and myofascial pain, with improvement in up to 90% of patients. There are various types of splints available to treat myofascial pain. Overall, the medical literature supports the safety and utility of a single maxillary or mandibular splint as a well-accepted treatment method in this clinical setting. Given these findings, the requested occlusal orthotic device is medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested device 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 oral and maxillofacial surgery and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned

The parent of a five-year-old female enrollee has requested occupational therapy utilizing sensory integration techniques for treatment of the enrollees flaccid hemiplegia. Findings:  Two physician reviewers found that in the available medical literature it becomes clear that the requested occupational therapy with sensory integration is medically indicated for this patients flaccid hemiplegia. Specifically, this conclusion is based on the articles by Yu and colleagues, and Bumin and Kavak. Cerebral palsy is a chronic condition and this patients history clearly demonstrates acute impairment of her ability to learn different motor strategies for maximizing function of her limbs affected by her flaccid hemiplegia. At issue is the notion that plasticity in the developing brain, albeit a brain with underlying neurologic disease such as the pathogenetic process that gave rise to this patients cerebral palsy and speech and language delays, still exists, and can be utilized to improve overall neurologic health. Thus specific treatment, including occupational therapy can be used to help induce brain plasticity, with the ultimate goal of retraining neural circuitry not compromised by the underlying pathogenetic process. Taken together, sensory integration-based occupational therapy for this patient is necessary to reduce the physical and mental effects of the underlying neurologic condition and to achieve maximum function in maintaining daily activities affected by this patients flaccid hemiplegia. Thus, in this instance, the requested occupational therapy utilizing sensory integration techniques should not be considered investigational.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for sensory integration therapy. There is insufficient evidence in current medical literature to support the use of sensory integration therapy in this clinical setting over any standard available therapy. In a systematic review and meta-analysis of intensive multidisciplinary intervention for pediatric feeding disorders, Sharp and colleagues conclude, Intensive, multidisciplinary treatment holds benefits for children with severe feeding difficulties. Marshall and colleagues note that multidisciplinary intervention for childhood feeding difficulties may involve operant conditioning or systematic desensitization intervention, which help children improve in dietary variety/intake, and more reductions in difficult mealtime behaviors in children with autism spectrum disorder. The American Academy of Pediatrics notes that, while sensory-based therapies are increasingly used by occupational therapists and sometimes by other types of therapists in the treatment of children with developmental and behavioral disorders, Parents should be informed that the amount of research regarding the effectiveness of sensory integration therapy is limited and inconclusive. In a review of sensory integration therapy for people with autism spectrum disorder, Watling and Hauer found moderate evidence to support the use of Ayres Sensory Integration within the scope of occupational therapy to improve performance, that the results for sensory-based methods were mixed and recommended further research with higher level studies and larger samples. Leong and colleagues describe sensory integration therapy as a controversial treatment method that is widely used for people with disabilities without convincing evidence regarding its effectiveness. In this clinical setting, there is insufficient evidence in current medical literature supporting the use of sensory integration therapy. Therefore, sensory integration therapy is not likely to be more beneficial for treatment of the patients condition than any available standard therapy.Findings:  Two of the three physician reviewers found the requested (sensory integration therapy is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the requested 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 neurology with special qualification in child neurology 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.