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

Nature of Statutory Criteria/Case Summary: The patient is a 64-year-old male who presented to the podiatrist with a six-month history of right heel pain. Findings:  The physician reviewer found that after attempts with over-the-counter orthotics, it is standard of care to biomechanically correct the over-pronated gait with custom functional firm orthotics. The biomechanics of custom orthotics is very sound. They reduce over-pronation by keeping the foot in a neutral position. This alleviates pressure on the plantar fascia and plantar heel, resolving patients pain (Fong). It is well documented that this patient suffers from right heel pain. Diagnosis of plantar fasciitis and over pronated gait have been made. The patient has attempted OTC orthotics without resolution of pain. After careful review of the enclosed information, the requested custom orthotics are medically necessary to treat this patients plantar fasciitis. Therefore, the requested custom orthotics are medically necessary and the Health Plans decision should be overturned.Final Result: The reviewer determined that the requested devices 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 podiatry 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

A 32-year-old female enrollee has requested baseline Plaquenil eye exam (optical coherence tomography) for evaluation of her high risk medications.  Findings:  Three physician reviewers found that the services at issue were and are likely to be more effective for this patient than other available options. The medical literature supports the services in dispute in this clinical setting. A baseline examination is advised for patients starting Plaquenil to serve as a reference point and to rule out maculopathy, which may be a contraindication to their use. In addition, annual or even every six month exams for Plaquenil toxicity is the standard of care. In sum, the baseline Plaquenil eye exam, OCT performed and annual eye exams for evaluation of Plaquenil toxicity, is the standard of care and likely to be more beneficial than any standard treatments.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for fertility preservation services. Per the American Society for Reproductive Medicine (ASRM), patients preparing to undergo gonadotoxic medical therapy, radiation therapy, or gonadectomy should be provided with prompt counseling regarding available options for fertility preservation for iatrogenic infertility. Currently, embryo, oocyte, and ejaculated or testicular sperm cryopreservation remain the principal established modalities for fertility preservation. The ASRM specifically mentions that in the setting of emergent fertility preservation, initiation of the stimulation should start as soon as possible regardless of phase of menstrual cycle (so-called immediate or random-start COS). This patients records document that this was the approach followed by the treating provider. There was a high probability that the planned cancer treatment would adversely affect the patients fertility potential. Thus, it was the best option for maximizing the patients chances of achieving an ongoing pregnancy. All told, the fertility preservation services provided were medically necessary for treatment of this patient.Final Result: The reviewer determined that the services at issue were 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 obstetrics and gynecology with subspecialty certification in reproductive 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: Experimental/Investigational
Decision: Overturned

A 30-year-old female enrollee has requested authorization and coverage for use of Alloderm in the nasal septal repair surgery. The Health Plan has denied this request indicating that the requested service is considered investigational for treatment of the enrollees nasal septal perforation.  Findings:  Two physician reviewers found that the patient has a documented symptomatic nasal septal perforation. She has attempted non-surgical and symptomatic treatment without success. Physical examination and a computed tomography (CT) report confirm the diagnosis of a nasal septal perforation that measures approximately 1 cm. The providers recommendation is for surgical repair of the septal perforation with use of Alloderm. The use of Alloderm was denied by the Health Plan stating that the requested service is considered investigational and experimental. The patient is documented to have a symptomatic nasal septal perforation. Septal perforation repair is recommended and is justified. As discussed by Romo and colleagues, septal repair is complicated due to various factors including the lack of available tissue for closure. The approach described in this reference provides different algorithms for different-sized defects. The technique described for a 1 cm perforation is similar to what is requested by the treating surgeon in this patients case. A material is interposed between the mucosal flaps that are used to close the perforation and the provider has selected Alloderm. This use of Alloderm is consistent with the findings from Kridel and colleagues who concluded that, The need for a connective tissue interpositional graft is generally accepted by all authors who use intranasal mucosal flap advancements. The interposed graft maintains a barrier between the corresponding repaired flaps during healing and, therefore, decreases the risk of incisional breakdown and reperforation. The authors noted that while other materials may be used in lieu of Alloderm for this interposition, however other materials would require additional incisions creating possible donor site morbidity or other complications. From experiences in breast reconstruction and other applications, Alloderm is noted to provide a scaffold for the ingrowth of tissue, and is therefore a reasonable clinical option to aid in the closure of a septal perforation. Thus, based on this information, the recommended procedure of septal repair with Alloderm is likely to be more beneficial than standard alternatives in the surgical repair of this patients septal perforation.
Appeal type: Medical Necessity
Decision: Upheld

A 23-year-old male enrollee requested intensive outpatient program (IOP) services for medical treatment of his alcohol abuse.  Findings:  The physician reviewer found that the records indicate that this patient had completed initial IOP, with sobriety. He had shown improvement. He was not being treated for psychiatric conditions at that time other than attention deficit disorder and he had no medical comorbidities. He was an active and engaged participant in his treatment. Thus, at this point he had achieved successful and maximum benefit from IOP treatment and could have been stepped down to outpatient care, with the adjunctive sober support of AA or other 12-step groups. For these reasons, the requested continuation of IOP services was not  medically necessary for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned

A forty-nine year-old female with nipple retraction is requesting authorization for an MRI of the breast. A mammogram was negative with heterogeneous breast tissue. An ultrasound of the breast performed three months after the mammogram was also negative. The patient has been seen several times by her clinician since that time and no breast masses were palpated.  Reviewers Findings:The reviewing physician found that the physical finding of new nipple retraction can indicate an underlying malignancy. In light of the results of the physical exam, the negative ultrasound, and the heterogeneous dense breast tissue on mammogram, an MRI is warranted in this setting for purposes of problem solving.  Therefore, the reviewing physician found that the Health Plan denial should be overturned.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for breast reconstruction surgery. The Health Plan has denied this request indicating that the requested procedure is not medically necessary for treatment of the enrollees condition. The submitted documentation supports the medical necessity of the procedure at issue.The patient with evidence of bilateral breast deformity, mild to moderate in severity as the result of previous mastectomy and breast reconstruction for a diagnosis of bilateral breast cancer. She has undergone previous revision with fat injection. She is noted to have an animation deformity, as well as breast deformity and asymmetry as seen on photographic review. Based on the entirety of the documentation provided, the patient does not have a normal appearance of the breasts. There is no functional impairment, but breast reconstruction is aimed at restoring a relatively normal appearance, which the patient does not exhibit. As the patient has described, there is evidence of moderate excess soft tissue of the bilateral inferior poles that creates a moderately abnormal appearance. The patient has evidence of common complications associated with reconstructive breast surgery, namely abnormal appearance. Cosmetic surgery is aimed at improving on relatively normal structures. The patient has evidence of abnormal bilateral breasts because of a previously, severely deforming mastectomy and attempted breast reconstruction that is currently complicated by deformity. This is reconstructive surgery. The American Society of Plastic Surgeons notes that cosmetic surgery is performed to reshape normal structures of the body in order to improve the patients appearance and self-esteem. 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. Breast reconstruction is done to approximate a normal appearance and this should include complications related to breast reconstruction. By correcting the specific complaint concerning her inferior pole deformity, this would likely provide more than a minimal improvement for this patient. Therefore, the breast reconstruction surgery is medically necessary for treatment of this patients condition.Final Result: The reviewer determined that the requested procedure 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 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

A 42-year-old male enrollee has requested for a SPECT scan and associated services for evaluation of his memory loss and depression. Findings:  Three physician reviewers found that there are no accepted standards of SPECT findings which can be construed as specific evidence of neuropsychiatric abnormalities. SPECT scanning for psychiatric symptoms is considered experimental with descriptive studies performed without adequate case-control proof of data. There is no evidence that the use of SPECT scanning in this patient would lead to a more definitive diagnosis or specific treatment planning.
Appeal type: Medical Necessity
Decision: Upheld

A 49-year-old female enrollee has requested for a panniculectomy for treatment of her low back pain.  Findings:  The physician reviewer found that the proposed panniculectomy does not meet the requirements of reconstructive surgery as defined by California law. The submitted documentation does not demonstrate the patients abdominal pannus is an abnormal structure of the body caused by infection, trauma, tumor or disease.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for polycarbonate lenses (code V2784), progressive lenses (code V2781), and anti-glare lenses (code V2745). Findings:  The physician reviewer found that Presbyopia is the age-related loss of accommodation and near vision. In this patients case, the presbyopia is significant enough that it requires corrective lenses to have functional vision. Although the degree of myopia and astigmatism is minimal, it is not unreasonable to correct it. Polycarbonate lenses are standard lenses that offer additional protection from accidental trauma. In this case, the patient has a history of LASIK, which weakens the structure of the cornea. Therefore, polycarbonate lenses (code V2784) are medically necessary for the treatment of the patients medical condition. The use of progressive lenses is not considered a medical necessity and is considered more a patient preference. Likewise, there is no medical necessity for anti-glare coating. Although the patient reports glare and halos at night, this is more likely to be related to the history of LASIK (which affects the asphericity of the cornea) and also due to the fact that her current glasses have the wrong prescription. Thus, progressive lenses (code V2781) and anti-glare lenses (code V2745) are not medically necessary for the treatment of the patients medical condition.Final Result: The reviewer determined that some of the requested equipment is 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 ophthalmology 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 43-year-old female enrollee has requested for detoxification and drug rehabilitation services for treatment of her opiate and benzodiazepine dependence. Findings:  The physician reviewer found that the patient did get lab work up, physical examination and typical residential type treatments, as per the progress notes. There is mention of a recovery program. The patient is noted as being anxious and depressed. The patient has chronic pain, which is a risk factor for relapse. She noted feeling nervous, dysphoric and reported fleeting suicidal thoughts. Additionally, although the patient showed motivation for recovery, it was early in the recovery process.  She was at high-risk for relapse without the structure of the treatment provided.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for soft tissue mobilization, phonophoresis with dexamethasone cream, ultrasound, iontophoresis, electric stimulation, traction and therapeutic massage. The Health Plan has denied this request indicating that the requested services are not medically necessary for treatment of the enrollees hip impingement and mild scoliosis.Findings: The submitted documentation fails to demonstrate the medical necessity of the requested services in this clinical setting. The proposed interventions do not address the patients underlying condition. Femoroacetabular impingement is a poorly understood condition, overall, with limited high grade evidence in the extant literature to inform optimal management outside of surgery to address pathological anatomy. (Amanatullah et al; Freke et al; and Mansell et al). Accordingly, soft tissue mobilization, phonophoresis with dexamethasone cream, ultrasound, iontophoresis, electric stimulation, traction and therapeutic massage are not expected to positively affect the patients clinical course or functional outcomes in a significant manner for her hip dysplasia/femoroacetabular impingement or other conditions. There is a lack of support in the medical literature to indicate that these services would provide a marginally significant improvement in terms of symptom management over an independent exercise program and independently applied palliative measures. As such, sustained or objective benefit of the proposed measures would not be reasonably be expected in this clinical setting. Therefore, soft tissue mobilization, phonophoresis with dexamethasone cream, ultrasound, iontophoresis, electric stimulation, traction and therapeutic massage are not medically necessary for the 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 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 authorization and coverage for Xeljanz 5 mg tablet two (2) times daily. Findings:  The physician reviewer found that  There is substantial clinical evidence to support the use of oral Janus kinase (JAK) inhibitors, such as tofacitinib, for treatment of alopecia areata. Jabbari and colleagues performed an open-label pilot study to evaluate the efficacy of tofacitinib. The authors noted that eight out of twelve patients demonstrated at least 50% hair regrowth, as measured by Severity in Alopecia Tool (SALT) scoring. Liu and colleagues performed a study of 90 patients with at least 40% scalp hair loss. The authors found that 77% of patients treated with tofacitinib achieved a clinical response, with 58% of patients achieving greater than a 50% change in SALT score. They also found that tofacitinib was well tolerated, and without serious adverse effects. While contact immunotherapy and systemic steroids may be used to treat severe alopecia areata, these standard therapies may have less satisfactory results and are associated with side effects. Therefore, Xeljanz 5 mg tablet two (2) times daily is likely to be more beneficial for the treatment of the patients condition than any available standard therapy.Findings:  Two of the three physician reviewers found the requested Xeljanz 5 mg tablet two (2) times daily is 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 Xeljanz 5 mg tablet two (2) times daily is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: Physician reviewers 1, 2, and 3 are board certified in dermatology 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.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary:  An enrollee has requested bronchial thermoplasty for treatment of her chronic asthma.  Two physician reviewers found that bronchial thermoplasty is not generally accepted as the standard of care for the treatment of asthma. Thomson and colleagues studied the safety of bronchial thermoplasty and found that there was no difference in forced expiratory volume in 1 second (FEV1), emergency room (ER) visits or admissions between the bronchial thermoplasty group and the control group. Also, the clinical trial by Castro and colleagues evaluated the effectiveness and safety of bronchial thermoplasty versus a sham procedure in subjects with severe asthma who remain symptomatic despite treatment with high-dose inhaled corticosteroids and long-acting beta-agonists. In this trial there were 190 patients in the bronchial thermoplasty group and 98 patients in the sham group. The therapeutic effect of sham group was similar to bronchial thermoplasty. Actually, if you include adjustment for the patients who dropped out of the study before one year, the sham placebo group did better than the bronchial thermoplasty group. There was no adjustment for the greater number of the bronchial thermoplasty treated patients dropping out before one year compared to the sham group. In sum, there is a lack of support in the medical literature that the use bronchial thermoplasty would improve the long term functional outcome of the patients condition. All told, the requested services are not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Final Result: Two reviewers determined that the requested services are not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld.  Credentials/Qualifications: All three reviewers are board certified in internal medicine with sub-specialty certification in pulmonary disease 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

A 45-year-old female enrollee requested authorization and coverage of an MRI of the right breast. The Health Plan  denied the request indicating that the requested MRI is not medically necessary for evaluation of the cysts in the enrollees right breast.One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer upheld the Health Plans denial on the basis that the requested MRI is not medically necessary.
Appeal type: Medical Necessity
Decision: Overturned

A 51-year-old female enrollee has requested Synvisc injections for the treatment of her osteoarthritis. Findings:  The physician reviewer found that the patient has severe joint disease in her right shoulder. Conservative treatment has not been effective and Synvisc injections were offered as a non-surgical treatment alternative. Although most commonly used to treat the knee, Synvisc has been utilized in other joints with positive results. This series of injections can reasonably be expected to decrease the patients pain and postpone the need for surgical intervention.