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

The patient is a 61-year-old obese female who underwent bilateral mastectomies in 2004 for breast cancer. She was further treated with chemotherapy. She is now seeking bilateral breast reconstruction. She has been seen by a board certified plastic surgeon in the past prior to her mastectomy and in follow-up in December 2004. At that time it was proposed that the patient be seen in July or August 2005 to plan the reconstructive procedures. It was appropriately suggested that the patient lose 60 pounds if she were to be considered a candidate for a TRAM flap. There is no record of the patient being seen by the plastic surgeon since December 2004. In the interim, the patient transitioned to a new medical group in January 2005. Her reconstructive surgeon is not affiliated with the patients new medical group. She has requested authorization and coverage to continue care with her reconstructive surgeon.Review of the submitted information reveals no medical necessity for the requested services. Recent medical records have not been provided and there is no evidence indicating whether the patient is/is not a candidate for breast reconstruction. The Health Plan has appropriately offered the patient the option of seeing an in-network plastic surgeon for a breast reconstruction evaluation. Based upon the information provided, there is no evidence the patient requires the services of her reconstructive surgeon. Therefore, I have determined that the requested services are not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a 6-year-old male enrollee has requested occupational therapy (OT) for treatment of the enrollees autism spectrum disorder and developmental delays.  Findings:  The physician reviewer found that the submitted documentation and relevant literature demonstrates the medical necessity of the requested occupational therapy (OT). OT is the standard of care for treating autistic children and it is supported in the peer-reviewed literature. Case-Smith and Arbesman compiled a meta-analysis of the research literature, documenting the value of OT in the autistic childhood population. Moreover, Myers and Johnson also noted that OT is of significant value when the child transitions into a school setting, such as this patient. In this case, the patient is a 6-year-old male with autism and motor and sensory deficiencies. Occupational therapy was initiated at the age of 3 years and serial progress reports indicate progressive improvement. Given the patients previous response to OT, continued treatment with this modality is medically appropriate and indicated to address his ongoing deficits in motor abilities and sensory processing. Therefore, based on the medical literature cited above and the documentation submitted for review, the requested occupational therapy is medically necessary for treatment of the patients medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld

A 68-year-old female enrollee has requested the Walk-Aide functional electrical stimulation device for treatment of her multiple sclerosis.  Findings:  Three physician reviewers found that the device at issue (WalkAide) is primarily a compensatory orthosis that triggers ankle dorsiflexion using peripheral neural pathways during the swing phase of gait. The same result, however, is accomplished using a conventional (passive) ankle foot orthosis (AFO) such as a molded thermoplastic AFO. There are a few studies in the literature on functional electrical stimulator (FES) devices such as the WalkAide, but they have not generally compared FES devices against conventional AFO equipment. Sheffler and colleagues reported on a recent small clinical trial and found no significant functional improvement with use of a transcutaneous peroneal nerve stimulation device over a conventional ankle foot orthosis. Overall, FES devices for treatment of foot drop are experimental, investigational and unproven with respect to effectiveness and outcomes in comparison to conventional orthotic options for foot drop related to MS or other neurological conditions. In the present case, the patient is documented to have only mild weakness at the right ankle dorsiflexor. Further, it is not evident that she has been trialed with an optimally fitted conventional AFO. Since it has not been established that a custom molded AFO is inadequate to assist this patient in her foot drop secondary to MS, the use of the WalkAide was appropriately classified as investigational in this instance. Accordingly, I have determined the device at issue was not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.
Appeal type: Experimental/Investigational
Decision: Overturned

A 33-year-old female enrollee has requested Provigil for the treatment of her multiple sclerosis. Findings:  Three physician reviewers found that fatigue is a very common complaint associated with multiple sclerosis. Apart from life changes, rest, and aerobic therapy, there are very few pharmacological interventions that have shown benefit. Amantadine has been used with statistically significant but rather mild success. Two studies have been published in the medical literature suggesting the beneficial effects of Provigil in treating MS-induced fatigue. Provigil is a unique wake-promoting agent that is chemically distinct from traditional stimulants. Zifko and colleagues presented an open-label study showing that Provigil significantly improves fatigue and sleepiness and is well-tolerated by patients with MS. Rammohan and colleagues concluded in a two-center phase II study that 200 mg/day of Provigil significantly improves fatigues and is well-tolerated in patients with MS.
Appeal type: Urgent Care
Decision: Overturned

A 58-year-old female enrollee has requested emergency services for the treatment of her medical condition. Findings:  The physician reviewer found that an emergency involves acute symptoms of such severity that a prudent layperson would believe that her health would be at risk without immediate medical attention. This patient presented with swelling and redness of her right knee. Her symptoms had been worsening over the course of one week. Her physician was concerned that the patient may have developed a recurrent deep vein thrombosis. It was appropriate for this patient to have been emergently evaluated, including an INR check and venous Doppler exam. A prudent layperson in this situation would have reasonably believed her health was in serious jeopardy without immediate medical attention. With regard to the acute hospital care provided on some of the dates of service in question, the submitted documentation does not demonstrate that these services were medically necessary. The venous Dopplers were negative for deep vein thrombosis, and the patients white blood cell count was normal. The elevated INR in and of itself did not require inpatient treatment for adjustment of the patients Coumadin dose, as the patient was not exhibiting signs of active bleeding. There is no documentation that the cellulitis was circumferential or involved more than 50% of the involved extremity. The patient had not failed a trial of outpatient antibiotics. Her vital signs were stable during the entire course of her stay. All told, the patient was appropriate for outpatient treatment with oral antibiotics during the dates of service at issue. Thus, the patients symptoms on the initial date of service met prudent layperson criteria for emergency care. A prudent layperson with an average knowledge of medicine would reasonably expect the absence of emergency care to jeopardize her health. However, acute hospital care services provided on the additional dates of service were not medically necessary.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary:  An enrollee has requested authorization and coverage for scar revision surgery (CPT 13120  repair, complex, scalp, arms, and/or legs).Oosterwijk and colleagues state, Scar contractures are the pathological outcome of excessive scarring and ongoing contraction...When contracting scar tissue is across or adjacent to a joint, this may result in loss of range of motion (ROM) in one or more movement directions of that joint. This can subsequently cause problems in the performance of activities concerning daily living (ADL), school, work, sports, and leisure time and, therefore, poses a threat to quality of life in the long term. Additionally, Eilers and colleagues state, Surgical scars are best treated with a combination approach to address various features of the scarFirst, the clinician should assess if there is significant tension or webbing associated with the surgical scar. In this case, surgical revision of the scar is often warranted. In this case, the patient underwent excision of an intramuscular lipoma of her deltoid muscle. Photograph shows that the scar is flat, moderately widened, and well-healed. There is no evidence of tension, webbing, or scar hypertrophy. Skin healing is asymptomatic, with no pain, wound healing, or functional issues noted. Therefore, scar revision surgery is not medically necessary to treat the patients medical condition.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; (2) to create a normal appearance, to the extent possible. In this case, the patients scar shows normal healing. A scar showing normal healing is not an abnormal structure of the body. There are no functional issues. The appearance is consistent with normal healing following a surgical procedure. The California reconstructive surgery statute does not apply to this patient. Therefore, the requested scar revision surgery is not reconstructive in nature.Final Result: The reviewer determined that the requested service is not medically necessary for treatment of the patients medical condition and not reconstructive in nature. 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: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested Harvoni for treatment of the enrollees chronic hepatitis C virus genotype 6.  Findings: The reviewer found that according to 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, regardless of fibrosis, should be treated except those with limited life expectancy due to non-liver-related conditions. For treatment-naive patients with genotype 6 hepatitis C, the guidelines recommend Harvoni for 12 weeks. This is based on both in vitro data and clinical trial results showing 96% sustained virologic response after 12 weeks of therapy (Wong, et al; Kohler, et al). The AASLD guidelines cite data showing reduced survival with delayed treatment (Jezequel, et al). For these reasons, the requested treatment with Harvoni for 12 weeks is supported as medically necessary for the treatment of this patients hepatitis C infection.Final Result: The reviewer determined that the 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: Upheld

A 24-year-old female enrollee has requested coverage for inpatient detoxification and comprehensive residential treatment program services for treatment of her opioid dependence.  Findings:  The physician reviewer found that the American Society of Addiction Medicine (ASAM) placement criteria, the patient was not showing severe withdrawal risk which would require management in the acute inpatient detoxification. In addition, she did not require medical monitoring, and there is no documentation of any emotional or behavioral component complications which require the 24-hour structured setting.
Appeal type: Medical Necessity
Decision: Upheld

The patient is a 44-year-old female with premature natural menopause beginning at an unknown date and treated with oral estradiol for an unknown duration. In addition, the patient has had two insertions of estrogen and testosterone pellets and is seeking reimbursement for this therapy. The information submitted does not demonstrate the patients response to either the oral estradiol therapy or the pellet therapy. The patients blood tests indicate an estradiol level in the premenopausal range with testosterone in the low male range initially and twice the normal female range subsequently. The Health Plan has denied reimbursement for the pellet therapy.Evidence regarding the safety and efficacy of hormone pellets is lacking. There were other safe and effective therapies available for the patient including estrogen patches with or without progesterone. Dose control of blood levels of hormones with pellets is difficult and has associated risks. This is especially a concern in this patient whose testosterone levels were too high and therefore, having a significant concern relative to cardiovascular disease. Furthermore, the evidence of testosterone therapy in a patient such as this is at best equivocal. Based upon the information set forth above, I have determined the therapy at issue was not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.
Appeal type: Experimental/Investigational
Decision: Overturned

A 55-year-old male enrollee has requested a balloon sinus ostial dilation for treatment of his chronic sinusitis. Findings:  Two physician reviewers found the submitted documentation and relevant literature supports the use of sinus balloon ostial dilation in this clinical setting. This patient has indications for surgery at this time. This patient has chronic sinus pain and a CT scan of the paranasal sinuses revealed mucosal inflammation, which has not responded to treatment. Balloon sinus ostial dilation is an accepted procedure for the treatment of refractory sinusitis and is well supported in the scientific literature. Based upon the documentation provided, the patient is an appropriate candidate for the proposed surgery. All told, the requested procedure is likely to be more beneficial than any available standard therapy for treatment of the enrollee's medical condition.
Appeal type: Medical Necessity
Decision: Upheld

A female enrollee requested an ultrasound for medical evaluation of her medical condition.  Findings:  The physician reviewer found that in this patients case, due to the advantages of mammographic screening versus ultrasound, it would be reasonable to make an attempt at mammography.  At the completion of the mammogram, the interpreting radiologist would be in a position to decide if ultrasound or attempts at additional mammographic images are appropriate.  Mammography offers distinct advantages such as search for architectural distortion or calcifications which may be associated with malignancy.  All told, the requested ultrasound is not medically indicated for the evaluation of this patient.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary:  An enrollee has requested authorization and coverage for a new power wheelchair with power seating (seat adjuster).Compliance is the key to pressure injury prevention when the physical capacity to perform the appropriate maneuvers is intact. According to medical literature, lack of compliance can result in pressure ulcer development with or without tools such as power tilt-in-space. A person who has been prescribed bilateral lower limb prostheses, moreover, is someone who has been, or should have been screened and established to have the physical capacity in the upper body to manage this highly demanding task (i.e., ambulation with bilateral lower limb prostheses), which requires upper body strength and conditioning to compensate for the lower limb amputations. This level of physical capacity in the upper body should be more than sufficient to manage using a power wheelchair without power seating features such as power tilt-in-space. In this case, the patient has bilateral lower limb amputations that have healed. She has been prescribed bilateral lower limb prostheses, for which she is undergoing physical therapy and making slow progress with respect to ambulation. In the interim, she has been using a power wheelchair for her functional mobility. There are no indications that the patient requires any other requested features that are not available on her current power mobility device. She does not require power seat elevation for any medical purpose, as she is already independent with her transfers without this feature. She does not require power recline, as she is independent with transfers and she can rest or perform hip flexor stretches outside of her wheelchair. Additionally, there are no objective indications that her current wheelchair does not meet her functional needs. She does not have impairments that would preclude independent pressure relief without power tilt-in-space. Therefore, a new power wheelchair with power seating (seat adjuster) is not medically necessary for the treatment of the patients medical condition.Final Result: The reviewer determined that the requested durable medical equipment 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 physical medicine and rehabilitation 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

Nature of Statutory Criteria/Case Summary: An enrollee has requested an Afirma Thyroid FNA Analysis test for evaluation of her medical condition.  Findings: Two physician reviewers found that while a fine needle aspiration biopsy of a suspicious thyroid nodule is typically an accurate means of assessing whether the nodule is benign or malignant, approximately 15% of fine needle aspiration biopsy results are considered to be indeterminate.  Until recently, the only way to establish whether the nodule was thyroid cancer was via surgical excision, even though the majority of the cases turn out to be benign.  A relatively new test, Afirma Thyroid FNA Analysis, utilizes a gene expression classifier in order to help determine the likelihood of malignancy of nodules with indeterminate cytology on fine needle aspiration biopsy, thereby decreasing the need for unnecessary surgeries.  Because it is very sensitive and has a high negative predictive value, a negative Afirma result is rather suggestive of a benign nodule and can therefore preclude such surgical procedures.  All told, Afirma Thyroid FNA Analysis test was likely to have been superior over other methods of evaluating this patient.  Final Result: Two 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:  One reviewer is board certified in internal medicine and is actively practicing. Two reviewers are  board certified in internal medicine with sub-specialty certification in endocrinology 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: Overturned

A 20-year-old female enrollee has requested partial hospitalization for treatment of her eating disorder. Findings:  The physician reviewer found that this eating disordered young woman has experienced a slowly progressive course of intensive treatment for her disorder. The records indicate that she has relapsed multiple times without such treatment intervention in the past and then required an inpatient treatment episode. She was transitioned to PHP after 104 days of residential treatment, but actually appeared to reside on the residential unit. The progressive aspect of that transition was that she was granted and able to go on passes successfully. She attained 90% of her ideal body weight (IBW) and maintained it for 2 weeks at the time of the last notation. At that time, she was more open to being off of a high restriction status. Thus, by that date of service, she could have been safely transitioned to an intensive outpatient program (IOP) level of care for adequate management of her condition.
Appeal type: Medical Necessity
Decision: Overturned

A 56-year-old male enrollee has requested a wheelchair (Quantum power wheelchair (HCPCS codes K0861) group 3 standard, multiple power option, sling/solid seat/back and E1007 wheelchair accessory, power seating system, combination tilt and recline, with mechanical shear reduction)for treatment of her cardiomyopathy.   Findings:  The physician reviewer found that the submitted documentation establishes the medical necessity of the requested wheelchair. According to therapy notes the patient has not ambulated in over three years and uses axillary crutches for transfers. This patient would benefit from the use of the requested power wheelchair as it allows the patient to function within the house and within the community. Additionally, as a result of the patients angle of his hips post-fusion he requires a reclining chair and is vulnerable to skin breakdown, needing frequent shifting and pressure relief that a tilting chair provides. Therefore, due to the patients low functional level, hip fusion, chronic pain, cardiomyopathy, and skin breakdown the power wheelchair prescribed is medically necessary. All told, the medical necessity of the requested equipment has been established.
Appeal type: Experimental/Investigational
Decision: Upheld

A 59-year-old female enrollee has requested a Dynesys surgical procedure for the treatment of her lumbar stenosis and grade 1 spondylolisthesis. Findings:  Three physician reviewers found that the literature does not support the use of the Dynesys device for grade I spondylolisthesis. At this time, there is no long-term outcome data that exists to support its safety and efficacy. Further studies are needed to establish that the Dynesys device is appropriate and efficacious for this indication.