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

Nature of Statutory Criteria/Case Summary: An enrollee has requested reconstructive surgery for removal of excess skin on breast, abdomen, and arms for treatment of the enrollees excess skin.   Findings: The physician reviewer found that the submitted documentation supports the medical necessity of a portion of the requested services.  The medical records document massive weight loss.  She has evidence of functional deficits related to her resulting in excess soft tissue of the breasts and abdomen.  Photographs support that this is a severely abnormal condition of the abdomen and breasts, but not for the arms.  With regards to the patients case, the photographs only support a moderate condition and a functional deficit has not been adequately described.  However, this determination is also dependent on the timing of the reconstruction.  Per the medical evidence, there is a strong correlation with increased complications in body contouring patients who have surgery with a body mass index greater than 30.  Therefore, it is reasonable to have evidence of a stable weight prior to body contouring procedures.  However, this patient has had evidence of a stable weight for at least one year.  Her continued weight loss was based on recommendations to satisfy a cut-off body mass index of 30.  Given her overall clinical scenario, waiting an additional six months does not appear to be indicated for this patient.  In sum, removal of excess skin on breast and abdomen before a six-month waiting period is medically necessary.  However, the records do not indicate that the brachioplasty is medically indicated for the treatment of this patient.Final Result: The physician reviewer determined that a portion of the requested services 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 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

Nature of Statutory Criteria/Case Summary: An enrollee has requested  reimbursement for advanced lipoprotein testing for evaluation of the enrollee who presented to her provider for examination.Findings:  The physician reviewer found that the patient had advanced lipoprotein analysis as part of a medical evaluation for lifestyle alterations. The values obtained showed increased cholesterol as well as abnormal values on the sub-fractions such as low density lipoprotein particle count. The patient has requested reimbursement for advanced lipoprotein testing. The Health Plan denied this request for reimbursement and reported that the services at issue were investigational for the evaluation of this patients medical condition. There is insufficient data to support the use of advanced lipoprotein testing in this clinical setting. While some researchers have advocated use of advanced lipoprotein testing for evaluation of cardiovascular risk to help make treatment decisions for patients with hyperlipidemia, the American College of Cardiology (ACC) guidelines do not support the use of advanced lipoprotein testing. Rather, their guidelines recommend use of standard risk factors and standard lipid profile to make decisions about lipid management. In addition, the guidelines have moved away from specific target values and emphasize use of the pooled risk score analysis for decisions regarding statin therapy. Therefore, the advanced lipoprotein testing was not likely to have been more beneficial than the standard testing options for the evaluation of this patient.Final Result: All 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: Physician reviewer number one is board certified in internal medicine with sub-specialty certification in cardiovascular 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.Physician reviewer number two is board certified in internal medicine with sub-specialty certification in cardiovascular 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.Physician reviewer number three is board certified in internal medicine with sub-specialty certification in cardiovascular 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 laser hair removal for treatment of his medical condition.  Findings: The physician reviewer found that Pilonidal disease describes a spectrum of clinical presentations, ranging from asymptomatic hair-containing cysts and sinuses to large symptomatic abscesses of the sacrococcygeal region that have some tendency to recur.  Part of the pathophysiology of the disease is attributed to the hair follicles and hair in the region.  It been established to be safe and effective to treat the spectrum of pilonidal disease with laser hair removal to remove one of the causative factors.  It is accepted medical care to treat the excess and pathologic hair growth in the region with laser to decrease the recurrence of the pilonidal disease.  This is a chronic problem and while surgery is part of the treatment, removal of hair in the area is also part of the treatment.  In sum, the requested laser hair removal is medically indicated 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 dermatology 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 59-year-old female has requested Lyrica for treatment of fibromyalgia and neuropathic pain.  Findings:  The physician reviewer found that the patient has had better control of pain with Lyrica.  In an Arthritis & Rheumatism 2005 article on the use of Lyrica for the treatment of fibromyalgia, there was a significant reduction in pain compared to placebo and improvements in fatigue. Lyrica has recently been FDA approved for the treatment of fibromyalgia. It is within standards of good medical practice to use Lyrica for chronic pain management. A dose of 75mg three times a day would be medically appropriate.
Appeal type: Medical Necessity
Decision: Overturned

A 64-year-old female enrollee has requested for pre-surgical workup for evaluation of her pancreatic cancer. Findings:  The physician reviewer found that the current radiologic evaluation does not clearly demonstrate advanced disease, and the ascites fluid was not found to harbor malignant cells. Thus, it is not clear that the patient does in fact have unresectable disease. Since surgery is the only treatment that may offer long-term survival, it should not be ruled out based on ambiguous radiologic findings. The proposed MRI should be performed; if no additional information is obtained, the proposed diagnostic laparoscopy and liver biopsy should be performed to resolve the issue of advanced disease versus resectable disease.
Appeal type: Experimental/Investigational
Decision: Upheld

A 52-year-old female has requested bilateral MRI of the breast for evaluation purposes.  Findings:  Three physician reviewers found that the patient has a family history of breast cancer.  Per the submitted documentation, her sister had breast cancer.  The patient presented last year with a palpable lump in the left breast.  Left breast ultrasound showed two areas of concern in the left breast at the 12 oclock and 1 oclock positions.  A left breast ultrasound performed six months later was benign.  The following year, a screening mammogram was negative.  The patients provider has recommended a bilateral breast MRI due to the patients family history and dense breast tissue.  The submitted documentation does not demonstrate that the requested bilateral breast MRI is likely to be superior over other available methods of evaluating this patient.  If evaluation is needed based upon the palpable abnormality in the left breast, a biopsy is the preferred method of evaluating this patient.  Per the current medical evidence, the requested diagnostic procedure is not likely to be of benefit and involves a high degree of false positive results.  This patient does not have at least two first-degree relatives with breast cancer, and there is no genetically-proven predisposition to the disease.  Therefore, bilateral breast MRI is not likely to be more efficacious than other modalities for evaluating this patient.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary:  An enrollee has requested transcranial magnetic stimulation for treatment of her major depressive disorder.  Findings:  Two physician reviewers found that the American Psychiatric Association has endorsed transcranial magnetic stimulation for the acute phase treatment of major depressive disorder after failure of at least one antidepressant trial.  There is sufficient evidence in the peer-reviewed medical literature to support the use of transcranial magnetic stimulation in this patients case.  The record reflects that the patient is enduring significant affective impairment consistent with the acute phase of a depressive episode.  She has pursued evidence-based non-pharmacologic interventions and has failed at least one antidepressant trial.  Considering the case in its entirety within the context of the most current practice guidelines, transcranial magnetic stimulation is reasonably expected to improve the patients condition and prevent a more serious episode of illness.  Therefore, the requested transcranial magnetic simulation is likely to be of greater benefit than other treatment options. Final Result:  Two 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: All three reviewers are board certified in psychiatry 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: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Aimovig and Botox (taken together). To date, there is a paucity of literature evaluating the use of Aimovig or any CGRP-based agents in patients concurrently receiving Botox injections. The trials of Aimovig and other CGRP agents have evaluated patients who did not receive Botox for a few months prior to the start of therapy. Furthermore, recent practice guidance from professional societies does not support the use of the CGRP drugs with Botox. Guidance from the American Headache Society suggests that there may be a role for the use of Aimovig or other CGRP drugs in combination with oral prophylactic therapies. However, the AHS was silent on the use of multiple injectable agents in the treatment of migraines. Therefore, the requested Aimovig and Botox (taken together) are not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Final Result: Two of the three reviewers determined that the requested medication regimen is 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:  One reviewer is board certified in neurology and is actively practicing. One Reviewer is board certified in neurology with subspecialty certification in sleep medicine and is actively practicing.  One Reviewer is board certified in neurology and subspecialty certification in pain management 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: Upheld

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested reimbursement for an echocardiogram. Findings:  The physician reviewer found that According to the current medical literature, heart murmurs are common in the pediatric population in otherwise healthy children. Typically they result from normal blood flow through the heart and great vessels. A murmur may also be the only indication of structural heart disease. In evaluating a child with a heart murmur, a detailed history must be obtained and physical examination performed. Historical findings such as feeding difficulty in infancy, shortness of breath, fatigue, and chronic cough, chest pain, and syncope may be present. There may also be a family history of congenital heart disease. Physical examination may reveal abnormal breath sounds such as crackles, hepatomegaly, abnormal peripheral pulses, heart murmur with characteristic location and/or duration, and edema. Characteristics most likely associated with an innocent murmur include systolic timing, soft sound, short duration, and low pitch quality, varying intensity with phases of respiration and posture, as well as murmurs that become louder during exercise or anxiety. The most common innocent murmur is called the Still murmur, which is thought to represent vibrations of the left outflow rest. This patients clinical information provided for review report that she was born prematurely, but there is no indication that she has abnormal vital signs, cyanosis, or poor growth. Further, the character and location is the murmur was not described by the provider. Further, there is no reason to expect a child born prematurely to be more likely to have a heart murmur than a child born full term unless there were additional abnormalities. Final Result: The reviewer determined that the services at issue were not medically necessary for evaluation of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in pediatrics with sub-specialty certification in pediatric critical care 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

enrollee has requested reimbursement for liposuction breast reduction. Per the World Professional Association on Transgender Healths (WPATHs) current Standard of Care, creation of a male chest surgery is appropriate for female-to-male transgender patients with persistent, well-documented gender dysphoria who have the capacity to make a fully-informed decision and to consent for treatment. The patient must be the age of majority in the country/state where the procedure will be performed. If the patient has other significant medical or mental health concerns, then they must be well controlled.  Per California Family Code Section 6500, a person reaches the age of majority when he or she turns 18 years of age.Here, this female-to-male transgender patient was at the age of majority (18 years) at the time of the procedure. There is no evidence suggesting that this patient lacked the capacity to make a fully-informed decision regarding the procedure. Letters from the patients mental health provider and endocrinologist confirm the patients diagnosis of gender dysphoria and readiness for the procedure in question. There is no evidence suggesting the presence of other, uncontrolled medical or mental health concerns. WPATH criteria for creation of a male chest in a female-to-male transgender patient have been met. The fact that this patient elected to have the less-invasive liposuction procedure in lieu of a mastectomy should have no bearing on whether the procedure was necessary for treatment of the patients gender dysphoria.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for islet cell transplant. Hypoglycemia, typically the result of the interplay of therapeutic hyperinsulinemia and compromised defenses resulting in hypoglycemia-associated autonomic failure in diabetes, is a serious problem for people with type 1 diabetes mellitus that causes recurrent morbidity and is occasionally fatal. Beta cell replacement therapy through islet transplantation provides a potential alternative to exogenous insulin. Gamble and colleagues note that intraportal islet transplantation has proven effective in preventing severe hypoglycemia and restoring insulin independence in selected patients with type 1 diabetes. Hering and colleagues conclude that transplanted purified human pancreatic islets provide glycemic control, restoration of hypoglycemia awareness, and protection from severe hypoglycemic events in subjects with intractable impaired awareness of hypoglycemia and severe hypoglycemic events. In this case, the patient has diabetes type 1 with frequent episodes of severe hypoglycemia, greatly increasing her risk of morbidity and mortality. In this clinical setting, current medical literature supports the use of the requested service. Therefore, islet cell transplant is likely to be more beneficial for treatment of the patients condition than any available standard therapy.Findings:  Two of the three physician reviewers found the requested islet cell transplant 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 services 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 internal medicine with sub-specialty certification in endocrinology, diabetes and metabolism 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 authorization and coverage for upper arm and breast lift procedures for treatment of the enrollee who has a history of excess skin due to weight loss. Findings:  The physician reviewer found that the requested services are not medically necessary and are not reconstructive in nature. Overall, there has been insufficient documentation to support that there is a functional deficit related to this patients excess soft tissue.  As such, the requested services are not medically necessary. Based on the submitted records, the patient has generalized skin laxity consistent with her history of massive weight loss. Correction of skin laxity following massive weight loss is not medically necessary in the absence of clear and compelling documentation of specific signs and symptoms. The medical literature states that the requested services must clearly be related to the excess skin, are health threatening or cause significant functional disability and have failed to improve despite reasonable attempts at conservative therapy. The submitted medical records do not include, over time, documentation of a series of office notes, dermatology consultations, pharmacy prescription records of skin fold, and photographs documenting cellulitis, ulcerations or rashes.  In addition, the medical records do not provide any documentation in the form of a primary care provider or dermatology progress notes that describe ongoing clinically significant dermatologic problems that have either never responded to topical therapy given or despite initial response, have recurred and caused significant functional impairment. With regards to whether the proposed surgeries are to correct an abnormal body structure, the records do not support that this patients loose arm skin and breast ptosis are abnormal body structures. Skin laxity and breast ptosis are findings with aging, breastfeeding and weight fluctuation. As such, these proposed procedures do not meet the criteria for reconstructive surgery. Therefore, upper arm and breast lift procedures are not medically necessary for treatment of this patients medical condition and are not reconstructive in nature. Final Result: The reviewer determined that the requested services are not medically necessary for treatment of the patients medical condition and are 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.