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

A 60-year-old female enrollee has requested Lap band removal for treatment of her status post Lap band placement. Findings:  The physician reviewer found that the submitted documentation supports the medical necessity of the requested services.  A Lap band can induce pseudoachalasia, and this may be reversible in some patients following removal of the band.  This does not appear to be due to any constrictive effect of the band, but instead alterations of lower esophageal sphincter function and esophageal peristalsis.  For patients with achalasia, the band needs to be removed to be able to technically conduct a Heller myotomy and carry the myotomy satisfactorily onto the stomach.  Therefore, it is medically necessary to remove the Lap band to determine if the patient has pseudoachalasia, and if no resolution of symptoms, then perform a Heller myotomy.  All told, the requested Lap band removal is medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the positron emission tomography (PET) scan for evaluation of the enrollees Crohns disease. Findings: The physician reviewer found that Elevated C-reactive protein correlates well with disease activity in patients with inflammatory bowel disease. In this case, the patient had ongoing elevation of C-reactive protein, and disease activity seen in the jejunum during surgery in the past, but the location of current disease activity was not clearly elucidated by other testing. In patients with Crohns disease, treatment decisions depend on the extent and severity of disease activity, as certain therapies are more effective in certain portions of the gastrointestinal tract, and more extensive disease may require medications which have more severe side effects. FDG PET in Crohns disease shows good correlation with the clinical, endoscopic and biological activity of the disease. FDG PET allows reliable detection of moderate to severe inflammation in bowel segments involved by Crohns disease. Another study support PET as an excellent method for the noninvasive quantification of bowel inflammation in patients with IBD. Given that the patient had failed multiple medications, was on a high dose of Entyvio with the addition of Entocort, had ongoing clinical disease symptoms, and had negative testing with magnetic resonance enterography and capsule endoscopy, the FDG PET scan had the potential to provide useful diagnostic information to manage the patients Crohns disease. Final Result: The reviewer determined that the diagnostic procedure at issue was medically necessary for evaluation 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

The parent of a four-year-old male enrollee requested a circumcision for medical treatment of the enrollees medical condition.  Findings:  The physician reviewer found that the requested circumcision is not medically necessary for treatment of this patients medical condition. Based on the available medical literature, the health benefits of circumcision can be achieved by good hygiene. In addition, a risk benefit analysis does not support the circumcision role in health to a level that would warrant advising circumcision for all males. There is no health mandate in the United States at this time that would support this patients circumcision as medically necessary without medical issues that support the procedure.
Appeal type: Medical Necessity
Decision: Overturned

The patient is a 33-year-old female who is 66 inches tall, weighing 326 pounds with a body mass index (BMI) of 52. She is requesting authorization for gastric bypass surgery. The patients comorbid conditions include hypertension, degenerative joint disease, depression, gastroesophageal reflux disease, and obstructive sleep apnea. She has completed a psychological evaluation and was found to be an appropriate candidate for weight loss surgery. At issue is whether gastric bypass surgery is medically necessary for treatment of her medical condition.With a BMI of 52 and comorbid conditions, the patient meets nationally accepted medical necessity criteria for consideration of weight loss surgery. It is highly likely that gastric bypass surgery will be beneficial for this patient. Furthermore, the patient does not require further dietary workup prior to undergoing weight loss surgery. There is no scientific evidence demonstrating that structured diet or exercise plans have been successful in the treatment of the obese. In fact, the Swedish obesity study identifies that even though there may be reduction or resolution of some symptoms with diet and exercise, surgery has the longest and best long-term outcome for the obese. Based upon the information set forth above, I have determined the requested procedure is medically necessary for treatment of the patients medical condition. The Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Upheld

The patient is a 50-year-old female with worsening fibromyalgia.  She has been taking Suboxone to relieve symptoms of pain and fatigue and has found it effective. She recently changed Health Plans, and her request for continued authorization and coverage of the medication has been denied based upon a determination that it is not medically necessary for treatment of her fibromyalgia.Suboxone was approved by the FDA specifically to assist opioid dependent patients wean off of narcotic medications. Suboxone has not been approved for the treatment of fibromyalgia and this patients usage is not consistent with the intended purpose of the medicaton.  Therefore, I have determined the requested medication is not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld

A 41-year-old male enrollee has requested acute inpatient psychiatric treatment for the treatment of his polysubstance dependence. Findings:  The physician reviewer found that the patients affect was stable and appropriate. He was not suicidal, homicidal or psychotic. His judgment was poor with fair insight. The patient was admitted to complete his withdrawal of various substances. He received pharmacologic treatment for his bipolar disorder as well as various therapies. The patient was not suicidal, homicidal or overly aggressive at the time of admission. He was not decompensated in any way, nor was his withdrawal a medical issue requiring inpatient care. The patient did not need 24/7 professional observation in a psychiatric hospital. His treatment needs could have safely and effectively been rendered at a lesser level of care. Inpatient psychiatric care at an acute psychiatric hospital facility was not medically indicated.
Appeal type: Medical Necessity
Decision: Upheld

A 50-year-old female enrollee has requested gender reassignment surgery for treatment of her gender identity disorder. Findings:  The physician reviewer found that upon review of the submitted documentation, the requested surgery is not medically appropriate at this time. The requested surgery is complex in nature and can be a lengthy procedure, approximately 4-6 hours. The relative surgical risks in a patient with a body mass index (BMI) of 39 are increased and it is appropriate to have the patient lose weight prior to surgery not only to reduce the surgical risks, but also to aid with postoperative therapy. The risks of deep vein thrombosis (DVT) are increased in obese patients, patients on estrogen and lengthy surgeries. These risks can be minimized by discontinuing estrogen prior to surgery and requiring presurgical reduction of the patients BMI. Postoperatively, patients are often on strict bed rest for 5-7 days, further increasing the risks of DVT. In addition, daily intravaginal dilation is necessary for six months postoperatively to prevent vaginal stenosis. The large abdominal pannus that is likely present in an individual with a BMI of 39 may also restrict this essential postoperative care. Based on the reasons provided above, the requested procedure is not medically appropriate at this time and therefore is not currently medically necessary.
Appeal type: Experimental/Investigational
Decision: Upheld

A 25-year-old female enrollee has requested an MRI scan of the left breast for evaluation of her left breast mass.  Findings:  Three physician reviewers found that in this patients case, the requested MRI scan of the left breast is not likely to be of greater benefit than other available modalities.  This patient has a palpable left breast mass.  She was evaluated with a left breast ultrasound and mammogram, and both studies were negative.  In this clinical setting, clinical follow-up and/or biopsy are appropriate.  Per the current medical evidence, MRI should not be used in lieu of biopsy for suspicious findings.  Therefore, the requested MRI scan of the left breast is not likely to be more effective than other methods of evaluation.
Appeal type: Medical Necessity
Decision: Overturned

The spouse of a 59-year-old male enrollee has requested transfer to a facility with a higher level of care for the  treatment of the enrollees multiple medical conditions including Guillain-Barre Syndrome. Findings:  The physician reviewer found that this patient has had a severe paralytic illness, consistent with Guillain Barre Syndrome (GBS). The prolonged nature of his symptoms, along with observed atrophy, suggests axonal involvement as is seen in the acute axonal variant of GBS. CIDP is a chronic form of demyelinative neuropathy, reaching a nadir in more than eight weeks. IVIG can be beneficial for GBS, but does not always result in improvement. Plasmapheresis has been shown beneficial for GBS when given early in the illness. As with other inflammatory neuropathies, CIDP is treated with immunosuppressants with variable levels of evidence for the efficacy of each. The first line treatment for CIDP is accepted as steroids, IVIG or plasmapheresis. Electrodiagnosis may help differentiate CIDP and may show axonal loss. This could help clarify relevance of other immunosuppressive therapy. Although further evaluation regarding the possibility of CIDP may not yield different treatment options, the potential for improvement is greater at a higher level of care, where the diagnosis can be clarified, and treatment options fully assessed. In addition, wound care for a stage IV decubitus ulcer may require skin grafting, which is best done in an acute setting, rather than a rehabilitation hospital. Thus, transfer to a higher level of care at UCLAs acute-care hospital (which has expertise in GBS) is medically necessary.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for breast reduction.Cabral and colleagues state, Women with increased breast size experience symptoms such as pain in the neck, shoulders and lumbar spine, headache, intertrigo in the inframammary fold, difficulty in performing daily activities, paresthesia in the hands (due to weight on the anterior chest wall and compression of the brachial plexus), difficulty in exercising, low self-esteem, and body dissatisfaction.According to the American Society of Plastic Surgeons (ASPS), reduction mammaplasty is recommended when documentation shows severe symptoms of macromastia with at least two of the following signs or symptoms impacting health-related quality of life: chronic breast pain due to weight of the breasts; intertrigo unresponsive to medical management; upper back, neck, and shoulder pain; backache; thoracic kyphosis; shoulder grooving from bra straps; upper extremity paresthesia due to brachial plexus compression syndrome secondary to the weight of the breasts being transferred to the shoulder strap area; headache; or congenital breast deformity. The decision to perform reduction mammaplasty should be based on patient symptoms and a surgeons assessment of the likelihood of benefit as opposed to the amount (weight) of breast tissue to be removed.In this case, the records reflect that the patient reported neck and back pain, with shoulder grooving documented on physical examination and in photographs. She had significant intertrigo, although the records did not reflect if it was unresponsive to medical management. Given that the documentation reflects at least two symptoms impacting quality of life, the requested breast reduction is medically necessary for the treatment of this patient.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; or (2) to create a normal appearance, to the extent possible. In this case, bilateral breast hypertrophy is an abnormal structure of the body caused by a developmental abnormality. The requested service will improve function. Accordingly, the requested breast reduction is reconstructive in nature for treatment of this patient. Final Result: The reviewer determined that the requested services 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: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Botox. Findings:  Three physician reviewers found there is sufficient support for the requested services in this patients case. Botox has been shown to be effective for the management of chronic migraine. Botox has been approved by the U.S. Food and Drug Administration (FDA) for use in prophylactic management in chronic migraine. This patient fits the criteria for chronic migraine. The enrollee has failed accepted preventative therapies, including medications within the antihypertensive and antidepressant classes. Therefore, Botox is likely to be superior over other available treatment options in this clinical setting.Final Result: The reviewers determined that the requested services are 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 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.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/ Case Summary:  The enrollee requested reimbursement for laboratory testing. The enrollee has osteoarthritis, hypothyroidism, mixed hyperlipidemia, nocturia, and erectile dysfunction (ED).  An internal medicine note indicated enrollee complaints of ongoing pain in the right knee and bilateral shoulders. Examination demonstrated unremarkable vital signs but a body mass index (BMI) of 32.  Due to his age and gender, the physician believed he needed a more complete cardiovascular evaluation. His diagnoses of ED, presence of abdominal/visceral fat, and hypothyroidism raised his risk for cardiovascular disease.  The enrollee is currently on Crestor, but did not have complete knowledge of his cardiovascular risk. Laboratory testing was performed through a specialty lab and The Treatment Consideration Summary included lifestyle and dietary modification, statins, ezetimibe, niacin, fibrates, omega-3 fatty acids, and soluble fiber supplements. The use of advanced lipid testing, including particle analysis and genetic testing for predisposition for statin myalgias, is neither standard-of-care nor justified based on well-designed clinical research outcome studies.  Conventional lipid testing is recommended by professional societies for cardiovascular risk assessment. This approach would have represented current and contemporary standard of care for this enrollee with hyperlipidemia.  Novel lipid testing strategies have not been proven to offer actionable clinical benefit with definitive improved outcomes when compared to conventional lipid analysis. The clinical documentation does not reveal assessment findings to support the testing panel performed on this enrollee.  Final Result: Three of the three reviewers determined that the requested services were not likely to be more beneficial than any available standard therapy for treatment of the enrollees medical condition. Credentials/Qualifications: Three reviewers are board certified in cardiovascular 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: Overturned

The enrollee has osteoarthritis of the left knee. She has complaints of dull, constant pain that is exacerbated by walking and exercise. The enrollee stated her symptoms began approximately five years prior.  She has tried anti-inflammatory medications, a steroid injection and viscosupplementation (Synvisc One).  The physician indicated the enrollee had joint space narrowing in the medial compartment; according to imaging. The physician indicated viscosupplementation (Synvisc One) has provided relief in the past; therefore, the physician recommended an additional injection. A professional society reports the use of intra-articular hyaluronic acid injections is indicated for the treatment of osteoarthritis in the knee in adults who are not good candidates or who do not respond to other treatment options. The use of viscosupplementation (Synvisc One) injections are indicated for those who have ongoing history of knee pain with joint space narrowing. Therefore, the enrollee is an appropriate candidate to undergo the requested injection as it has previously provided good relief.Final Result: The reviewer determined that the requested service is medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The physician reviewer is board certified in orthopedic surgery and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or similar medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld

A 61-year-old female enrollee has requested for a PET scan for evaluation of her weight loss, malnutrition and chronic pain. Findings:  Two physician reviewers found that several articles have shown that PET scans can be useful in the evaluation of paraneoplastic neurological syndrome. Talbot and colleagues found success in the use of PET scans for neurological paraneoplastic syndrome but state that the clinical utility of PET scans in other paraneoplastic syndromes has not yet been sufficiently studied. A review of the peer-reviewed literature did not show sufficient support for PET studies in patients with non-neurological paraneoplastic syndrome.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The parent of a patient is requesting authorization and coverage of residential treatment center services. The Health Plan had denied the services as not medically necessary to treat the enrollees behavioral health condition. At issue in this case is whether the requested RTC services were medically necessary for the treatment of the patients behavioral health condition.Findings:  The physician reviewer found that the American Academy of Child and Adolescent Psychiatry and the American Association of Community Psychiatrists Child and Adolescent Level of Care Utilization System (CALOCUS) provides a reliable framework for determining the appropriate level of care for adolescents needing mental health treatment. Using CALOCUS, treaters score patients on a scale of 1-5 using a six-pronged Dimensional Rating System. The six dimensions include: (1) risk of harm; (2) functional status; (3) medical, addictive and psychiatric comorbidity; (4) recovery environment (a. stressors and b. supports); (5) treatment and recovery history; and (6) engagement. The composite score is then used to determine the level of care needed. The patient presented with a composite score of 17. For a CALOCUS composite score of 17, the recommended level of care is high-intensity outpatient therapy. Therefore, the RTC services were not medically necessary for this patient.Final Result: The reviewer determined that the services at issue were not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is board certified in psychiatry with subspecialty 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.
Appeal type: Medical Necessity
Decision: Upheld

The parent of a 16-year-old male enrollee has requested for surgical repair of pectus carinatum for treatment of the enrollees pectus carinatum. Findings:  The physician reviewer found that the photographs show pectus carinatum, this condition was not so severe as to be considered an abnormal structure of the body. In this patients case, the requested surgery is not being performed to improve function or create a normal appearance from an abnormal appearance. There are no functional complaints. The proposed surgery offers only a minimal improvement in the appearance of the patient. All told, the submitted documentation does not demonstrate the medical necessity of the requested repair of pectus carinatum.
Appeal type: Medical Necessity
Decision: Overturned

A 25-year-old female enrollee requested authorization and coverage of surgery to remove a lump at the back of her hips. The Health Plan denied the request indicating that the requested procedure is not medically necessary for treatment of the enrollees right gluteal mass.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.