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

A 37-year-old female enrollee has requested bariatric revision surgery (duodenal switch) for treatment of her obesity. Findings:  The physician reviewer found that the medical literature supports the opinion that the performance of a revisional procedure similar to the initial operation will fail in many instances, because the basic problem is metabolic and not mechanical.  Rapid gastric emptying, as seen in this patients case, leads to an enhanced insulin response resulting in either hypoglycemia or hyperglycemic episodes, and the most dramatic rises and falls have been associated with small pouches and wide anastomoses.  Duodenal switch is a medically appropriate solution to the problem.  If this procedure is not performed, the patients comorbidities will likely worsen.  Thus, bariatric revision surgery (duodenal switch) is medically indicated for this patient.
Appeal type: Medical Necessity
Decision: Upheld

A 59-year-old male enrollee has requested intensity modulated radiation therapy for treatment of his recurrent prostate cancer. Findings:  The physician reviewer found that the medical literature does not support the clinical benefit of the administration of radiation to grossly positive lymph node metastatic disease after treatment with chemotherapy and hormone ablation. Radiation, specifically IMRT, for the treatment of metastatic adenocarcinoma in retroperitoneal lymph nodes is of unproven efficacy and not medically necessary in this setting. The standard of care remains chemotherapy or hormone ablation. For this patient, with metastatic disease, the requested local treatment is not likely to provide positive results and remains unproven in the medical literature.
Appeal type: Experimental/Investigational
Decision: Upheld

A 50-year-old male enrollee requested a dynamic knee ankle foot orthosis (Otto Bock C-Brace for treatment of his Charcot Marie Tooth disease. Findings:  Three physician reviewers found that the patient is able to ambulate with bilateral AFOs and a cane. Studies of the Otto Bock C-Brace are currently limited. Further, comparative studies have not demonstrated the C-Brace to be superior beyond the standard care option of an AFO (de Wit, et al; Geboers, et al). Given the lack of scientific data showing improved health outcomes and improved ambulation with the C-Brace in this clinical setting, the requested equipment is not likely to be more beneficial for treatment of this patients medical condition than any available standard therapy.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested authorization and coverage for 25-30 vision therapy sessions, one hour each week for treatment of the enrollees vision processing disorder, auditory processing disorder, and learning disability. Findings:  Two physician reviewers found that the report by the American Academy of Ophthalmology (AAO) and the American Association for Pediatric Ophthalmology and Strabismus (AAPOS) reports that vision therapy is not effective for treating learning disabilities and dyslexia. Numerous double blind studies have concluded that vision therapy with special glasses, colored lenses or vision exercises do not help with learning, reading or visual accommodation skills. One study found that eye exercises are not effective given the lack of scientific evidence on its efficacy. Another study conducted a research study on treatment approaches for children with reading disabilities and recommended phonics as the most effective approach over vision therapy. All told, the requested 25-30 vision therapy sessions, one hour each week, are 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: All three physician reviewers are board certified in pediatrics with sub-specialty certification in developmental and behavioral pediatrics 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: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested a specific number and dosage of Toradol tablets for treatment of her endometriosis.   The physician reviewer found that upon review of the clinical notes, the documentation fails to demonstrate the medical necessity for the requested quantity of Toradol tablets when, instead, a lesser quantity of Toradol tablets is medically necessary. Chronic pain, as evidenced by this patient, is typically multifactorial and can be very difficult to manage. Medical studies and prescribing data, as it relates to the use of Toradol beyond recommended dosage, indicate strong concerns about its effects on the gastrointestinal and nephrotic systems as well as potential for cardiac effects. There is very limited information about the safe interval between dosing schedules.  This patient desires to use Toradol daily. This is beyond the scope of the approved use of Toradol or most other non-steroidal anti-inflammatory drugs (NSAIDs). Secondly, the use of NSAIDs for chronic pelvic pain have limited benefit in long term use. Toradol, to be used on a regular basis, is not part of the long term management algorithm for endometroic pain. Additionally, this patient is also chronically on another NSAID.  All told, the Health Plans approval of Toradol at a reduced quantity is medically reasonable and appropriate in this setting. In sum, the requested quantity of the medication Toradol is not medically necessary for treatment of this patients endometriosis.  Final Result: The reviewer determined that the requested quantity of 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 obstetrics and gynecology 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 51-year-old female enrollee has requested for a carotid duplex study for evaluation of the of her carotid arteries. Findings:  The physician reviewer found that there is a tradition of searching for carotid lesions with carotid ultrasound after Hollenhorst plaques are found. This is particularly important in patients with new visual symptoms. Atheromatous plaques in the carotid system may send platelet-fibrin-cholesterol emboli up into the retinal arterioles. As they briefly interrupt retinal blood flow, these `Hollenhorst plaques` often cause transient monocular loss of vision lasting from seconds to minutes. In middle-aged and elderly adults, abrupt transient monocular visual loss is presumptively caused by carotid-source emboli, although there can be other reasons, such as complex migraines.  Older studies linking Hollenhorst plaques to carotid artery disease generally involved symptomatic subjects. However, in this case no abrupt visual symptoms are described. The patient has asymptomatic Hollenhorst plaques without a carotid bruit on examination. Current data indicates the prevalence of significant carotid stenosis in patients with asymptomatic Hollenhorst plaques is 6% to 9%. With acknowledgement of this rate of carotid stenosis with asymptomatic Hollenhorst plaques, Guidelines from the American Society of Neuroimaging and the Society of Vascular and Interventional Neurology advise that, Screening for carotid stenosis among patients with asymptomatic Hollenhorst plaques is not recommended.
Appeal type: Experimental/Investigational
Decision: Upheld

A female enrollee requested total disc arthroplasty with discectomy (CPT code 22856) for medical treatment of her medical condition.  Findings:  Three physician reviewers found that the patients physical examination revealed 5/5 motor strength, intact sensation, a steady gait, and normal deep tendon reflexes.  There was no documentation of a significant musculoskeletal or neurological deficit upon examination.  There was no mention of an attempt at any recent conservative management to include active rehabilitation.  There is a lack of support for the requested services in this clinical setting.  Therefore, the requested total disc arthroplasty with discectomy is not likely to be of greater benefit than other treatment options.
Appeal type: Medical Necessity
Decision: Overturned

A 47-year-old female enrollee has requested peripheral nerve stimulation via neurostimulator facial implants for the treatment of her atypical trigeminal neuralgia. Findings:  The physician reviewer found that the medical literature yielded limited information regarding the use of peripheral nerve stimulation. However, there is evidence of a paper published by Slavin and colleagues in their 2006 publication which presents an algorithm for surgical management of face pain. The authors suggested, If the patient is diagnosed with trigeminal neuropathic (not neuralgia), and maintains some degree of sensation in the area of the pain, and the pain is localized to distribution of the supraorbital or infraorbital nerves, the treatment of choice is trigeminal branch stimulation with peripheral nerve stimulation technique. This patient appears to meet the aforementioned criteria for peripheral nerve stimulation. As such, she is an appropriate candidate for the proposed procedure. Given the severity of her condition and the lack of effective treatment modalities, peripheral nerve stimulation via neurostimulator facial implants is medically appropriate and indicated.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary:   An enrollee has requested advanced lipoprotein testing for evaluation of her medical condition.  Findings:  Three physician reviewers found that there is a lack of support for the services at issue in this patients case.  In this circumstance, guidelines for the evaluation and management of dyslipidemia and cardiac risk are available and do not recommend routine screening with specialized testing, including the testing requested.   Treatment change based on the results of these specialized tests has not been shown to improve cardiac outcomes incremental to that achievable using standard clinical risk profiles combined with basic lipid analysis.  Moreover, this patient is already on maximal tolerated therapy with inability to take statin medication, so her treatment would likely not change regardless of test results.  Thus, advanced lipoprotein testing was not likely to have been more effective than other methods of evaluating this patient.  Final Result: Three reviewers determined that the services at issue were not likely to be more beneficial for evaluation 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 cardiovascular disease and is actively practicing.  All three reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a female enrollee requested authorization and coverage for orthognathic surgery for the treatment of irregular facial structure.  The health plan denied the enrollees request indicating that the requested surgery is not medically necessary.One oral surgical physician reviewer performed a medical necessity Independent Medical Review.  The oral surgical reviewer overturned the health plans denial on the basis that the requested surgery is medically necessary.
Appeal type: Medical Necessity
Decision: Upheld

The parent of an 11-year-old male enrollee has requested Nutropin for the treatment of the enrollees short stature. Findings:  The physician reviewer found that the patient has constitutionally delayed adolescence with a normal predicted adult height. The patients predicted adult height based upon a delayed bone age (estimated at a 4 year delay at 10 years) appears to lie near the mid parental estimate assuming that he still had a retarded bone age of 3 years (based on the Greulich and Pyle Hand Atlas). As such, the medical necessity of growth hormone for this patient has not been established.
Appeal type: Medical Necessity
Decision: Overturned

A 90-year-old female enrollee requested authorization and coverage of skilled nursing care due to gastrostomy tube feedings and decubitus care. The Health Plan denied the enrollees request indicating that the requested treatment is not medically necessary.One physician reviewer performed a medical necessity Independent Medical Review.  The physician reviewer overturned the health plans denial on the basis that the requested services are medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned

A 40-year-old female enrollee requested authorization and coverage of serial micro follicular transplantation. The Health Plan denied the request indicating that the requested procedure is not medically necessary for the treatment of the enrollees B-neoplasm of the scalp.One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer overturned the Health Plans denial on the basis that the requested procedure is medically necessary.
Appeal type: Medical Necessity
Decision: Overturned

A 62-year-old female enrollee has requested an MRI of the right breast for evaluation of her breast cancer. Findings:  The physician reviewer found that there are several indications for MRI of the breast including pre-operative evaluation of extent of cancer, post-operative evaluation of residual cancer, evaluation of extent of lobular cancer, identification of an occult primary cancer with positive axillary lymph nodes, screening of high-risk patients, and problem solving. An indication for non-malignant disease is evaluation of breast implants. High-risk patients are those with a personal or family history of breast cancer or a genetic predisposition for breast cancer such as a BRCA 1 or 2 gene.  High-risk patients also include those with biopsy proven atypia, lobular carcinoma in situ, radial scar and prior mantle radiation. Based on the clinical evidence provided, the patient falls within the high-risk category given her history of breast cancer.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Gammagard Liquid 30 gm IV every four weeks. Researchers note that measurement of IgG subclass concentrations is a standard laboratory test run as part of a panel to investigate the suspicion of antibody deficiency that may also help determine a revaccination strategy for patients and support patient management. Researchers indicated that IgG subclass 2 deficiency is a condition in which the patient is unable to mount an adequate antibody response to polysaccharide antigens. These antigens are commonly found on gram-positive organisms, such as pneumococcus, staphylococcus and streptococcus bacteria. This failure to respond to polysaccharide antigens also results in minimal or no response to vaccines that use polysaccharide components, such as the pneumococcal vaccine. Thus, the diagnostic presentation is one where the patient has laboratory confirmation of low IgG levels, clinical history of recurrent infections with polysaccharide containing bacteria, such as sinusitis, otitis, and pneumonia, and a failure to respond to a vaccine challenge, such as pneumococcal vaccine. In this case, the provider has documented that the patient had low IgG2 levels and that she had allergic reactions to vaccines in the past. It is also noted that the patient has had upper respiratory infections in the past. However, there is no documentation of a vaccine challenge. Therefore, on this basis, the patient does not meet the guideline recommended evaluation for IgG subclass 2 deficiency. In this clinical setting, the requested medication is not medically indicated. Therefore, Gammagard Liquid 30 gm IV every four weeks is not medically necessary 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 allergy and immunology 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 55-year-old female enrollee has requested Avastin for treatment of her ovarian cancer.  Findings:  Two physician reviewers found that Avastin in combination with Taxol has demonstrated safety and efficacy. Clinical trials in the treatment of breast and lung cancer have yielded positive results in terms of progression-free and overall survival when Avastin is added to Taxol chemotherapy. Both Avastin and Taxol have activity in refractory ovarian cancer.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient is a transgender female who was diagnosed with gender dysphoria. Findings:  The physician reviewer found that the patients provider noted the patient has severe gender dysphoria related to her appearance and voice.  In a letter, the provider noted that the patient had been living as a female for more than one year and was being treated with hormone therapy. The patient has requested coverage for any or all facial feminization surgeries (forehead lift, hairline lowering, orbital bony contouring, rhinoplasty closed with Weirs and cartilage grafts, cheek implants-small combined, subnasal lip lift with fat augmentation, thyroid cartilage shave, and voice feminization-local). The Health Plan denied the request and reported the requested services are not medically necessary for the treatment of this patient. At issue in this case is whether any or all facial feminization surgeries (forehead lift, hairline lowering, orbital bony contouring, rhinoplasty closed with Weirs and cartilage grafts, cheek implants-small combined, subnasal lip lift with fat augmentation, thyroid cartilage shave, and voice feminization-local) are medically necessary for the treatment of the patients medical condition. The World Professional Association for Transgender Health (WPATH) states that facial plastic reconstruction, voice therapy and/or surgery are medically necessary gender affirming procedures. These procedures are medically indicated treatments for gender dysphoria.  In this patients case, the records document gender dysphoria related to her appearance and voice. Facial feminization surgery is associated with improved mental health quality of life in transgender patients. Medical evidence supports the requested services in this clinical setting. Therefore, facial feminization surgeries (forehead lift, hairline lowering, orbital bony contouring, rhinoplasty closed with Weirs and cartilage grafts, cheek implants-small combined, subnasal lip lift with fat augmentation, thyroid cartilage shave, and voice feminization-local) 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 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: Urgent Care
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested reimbursement for psychiatric services provided. Findings:  The physician reviewer found at issue in this case is whether the enrollee received psychiatric emergency medical services on the dates of service in question. California law defines emergency services and care as an additional screening, examination, and evaluation by a physician, or other personnel to the extent permitted by applicable law and within the scope of their licensure and clinical privileges, to determine if a psychiatric emergency medical condition exists, and the care and treatment necessary to relieve or eliminate the psychiatric emergency medical condition, within the capability of the facility. The services at issue were not necessary for treatment of a psychiatric emergency medical condition. A psychiatric emergency consists of a patient who is an imminent danger to himself or to others. This can be due to a variety of things including, mania, psychosis, suicidal ideation, homicidal ideation, delusions, and delirium. Per the documentation submitted for review, the patient had none of these symptoms. The patient has a history of intermittent suicidal ideation. However, his last episode of suicidal ideation was two weeks prior to admission. The patient had an episode of self-cutting one week prior to admission. However, upon admission to the IOP, the patient denied any suicidal or homicidal ideation. Moreover, there was no psychiatric evaluation performed on admission. The documentation included a risk assessment, but this is not a psychiatric evaluation. There was no psychiatric assessment or diagnosis given. A medical and psychiatric history was also not obtained. Moreover, the documentation submitted for review does not demonstrate that the patient was a danger to himself or others. For the reasons provided, the patient did not receive psychiatric emergency medical services on the dates of service at issue.Final Result: The reviewer determined that the patient did not receive psychiatric emergency medical services on the dates of service at issue. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is board certified in psychiatry with sub-specialty certification in child and adolescent 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.