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

A 59-year-old female enrollee has requested spinal fusion surgery services including lumbar spine fusion, removal of spinal lamina, lumbar spine fusion, application of spine prosthetic device and insertion of spinal fixation device for treatment of her lumbar radiculitis.  Findings:  The physician reviewer found that in the most current and comprehensive review of the medical literature pertaining to lumbar fusion for disc herniation and radiculopathy, Resnick and colleagues examined 389 titles and abstracts. The authors evaluated the available scientific data supporting the use of fusion as a treatment for lumbar disc herniations. They concluded of their research that, Neither treatment standards nor guidelines could be formulated due to a lack of high quality studies. In an attempt to provide some guidance in selecting appropriate patients as candidates for fusion procedures, Resnick and colleagues formulated five treatment options. The authors denoted a previous primary disc excision to be a contraindication to spinal fusion and recommended the procedure as a potential surgical adjunct in patients with a herniated disc in whom there is evidence of preoperative lumbar spinal deformity or instability, or with significant chronic axial low-back pain associated with radiculopathy due to a herniated lumbar disc. Overall, reoperative discectomy is indicated as a treatment option in patients with a recurrent lumbar disc herniation or combined with fusion for patients with a recurrent disc herniation associated with lumbar instability, deformity, or chronic axial low-back pain. Applying these criteria, the requested surgical intervention has not been shown to be medically necessary for treatment of this patients condition. Therefore, of the five treatment options detailed by Resnick and colleagues, none of them provide support for any lumbar fusion procedure in this patient.
Appeal type: Urgent Care
Decision: Upheld

A 61-year-old female enrollee requested services provided on an emergent or urgently needed basis.  Findings:  The physician reviewer found that review of the submitted clinical documentation demonstrates that a prudent layperson would not have sought immediate medical attention.  The patient did not suffer from a medical condition necessitating the performance of removal of excess of abdominal dermal adipose tissue, plication of the rectus abdominis muscle, and closure of an umbilical hernia, liposuction of the thigh on an urgent basis.  The patient had normal laboratories and no evidence of an incarcerated umbilical hernia either on exam or on ultrasound. Moreover, she had suffered from discomfort for many years before seeking care in the surgical clinic.  Based on the medical records submitted for review, there was no indication that a prudent layperson in a similar situation would have believed immediate medical attention was necessary to prevent serious deterioration of ones health. Further, there was no evidence that her condition was deteriorating.  In sum, based on the patients clinical presentation she did not meet prudent layperson criteria for urgently needed services.
Appeal type: Medical Necessity
Decision: Upheld

The patient is a 38-year-old female with a diagnosis of Behcets disease. She has had inadequate disease control despite treatment with various agents including azathioprine, cyclosporine, methotrexate, colchicines, and long-term steroids. The patient continues to have oral and genital ulcerations, joint inflammation, and rashes. A history of psoriasis is also noted, but there are no indications of GI symptoms in the records provided. The patients rheumatologist requested authorization for a trial of TNF inhibition to treat the patients Behcets disease and the Health Plan approved a three-month trial of Remicade. The patient and her provider have expressed a preference for Enbrel, and have requested authorization. The Health Plan denied their request based upon a determination that Enbrel is not medically necessary.The diagnosis of Behcets disease is not in dispute and the Health Plan has recognized the need for a trial of TNF inhibition. At issue is the choice of TNF agent. The Health Plans authorization of Remicade is medically appropriate based on the greater number of anecdotal and uncontrolled treatment reports available for Remicade than for Enbrel, and the broader effectiveness of Remicade that has been described in those reports. Remicade has been noted to control the mucosal ulcerations, skin rashes, joint inflammation, uveitis, and constitutional symptoms of Behcets disease.  Reports on the use of Enbrel have noted benefits primarily for mucosal and skin lesions, and it is not yet clear if Enbrel does control the more dangerous aspects of the illness. In addition, given that the diagnosis of Behcets disease is often presumptive, the possibility remains that an alternative diagnosis will become apparent at some point, and that diagnosis is frequently Crohns disease (which confusingly may present without bowel symptoms in its early phases). This possibility lends further support for the choice of Remicade rather than Enbrel.Based upon the information set forth above, I have determined the requested biologic is not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: A transgender enrollee has requested authorization and coverage for facial feminization surgeries including brow lift, frontal bone contouring, genioplasty, autologous fat grafting, and tracheal shave. Gender dysphoria refers to distress that is caused by a discrepancy between a persons gender identity and that persons sex assigned at birth. This often results in depression and anxiety. Treatment for gender dysphoria aims to minimize dysphoria and help patients attain their sought-after gender role. A paper notes that facial feminization procedures are not cosmetic, but rather serve a primarily reconstructive purpose in transgender women whose overall physical appearance otherwise prevents them from being perceived as female. The statement from  multiple organizations including the American Medical Association, American Association of Family Physicians, Endocrine Society, American Psychiatric Association, American Psychological Association, American College of Obstetricians and Gynecologists, and the American Public Health Association notes that the medical procedures attendant to sex reassignment are not cosmetic or elective or for the mere convenience of the patient. These reconstructive procedures are not optional in any meaningful sense, but are understood to be medically necessary for the treatment of the diagnosed condition. A publication notes that gender reassignment is the only treatment for gender dysphoria that has shown significant benefits in numerous research trials and meta-analyses over the past half century. A study concludes that Transwomen have diminished mental health-related quality of life compared with the general female population. However, surgical treatments (e.g. FFS [facial feminization surgery], GRS [gender reassignment surgery] or both) are associated with improved mental health-related quality of life  Further a paper notes that this surgery does not aim to rejuvenate the face but rather it helps transgender women in passing as a female and integrating into everyday society. In conclusion, the submitted documentation demonstrates the patient experiences significant anxiety and distress secondary to her male facial features. There is sufficient scientific literature demonstrating that facial feminization surgery is effective in relieving gender dysphoria in patients such as this patient. Therefore, the requested services are medically necessary for treatment of the patients medical condition.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 with expertise in treatment of gender dysphoria 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 46-year-old male enrollee requested authorization and coverage of transitional living center services for the treatment of traumatic brain injury.  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 upheld the health plans denial on the basis that the requested services are not medically necessary for treatment of the patients medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested breast tomosynthesis for evaluation of her medical condition.   Findings:  Two physician reviewers found that in the peer-reviewed medical literature, Skaane and colleagues found that the addition of three dimensional digital breast tomosynthesis to two dimensional full field digital mammography resulted in a significantly higher cancer detection rate and enabled the detection of more invasive cancers. Thus, although additional studies are needed to confirm these findings, there is adequate data to support the utility of three dimensional digital breast tomosynthesis in this clinical setting. In this case, an additional study was indicated to confirm the abnormal findings seen on a previous study. For these reasons, breast tomosynthesis on both dates in question were likely to be more beneficial for evaluation of this patients medical condition than any available standard therapy. Final Result: Two reviewers determined that the diagnostic procedures at issue were likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned.  Credentials/Qualifications:  All three reviewers are board certified in diagnostic radiology 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

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for Breast Ultrasound (CPT 76641) services.Annual screening mammography reduces mortality from breast cancer in women over the age of 40. The sensitivity of screening mammography in women with non-dense breast tissue is approximately 85%, however, the sensitivity of screening is significantly decreased in women with dense breast tissue to approximately 48-64%, as cancers can be obscured by the dense tissue. There is also a 4.7 fold increased risk of breast cancer in women with dense tissue compared to non-dense counterparts. Therefore, screening ultrasound in this population can be used to detect mammographically occult cancers.Women with dense breast tissue are considered at intermediate risk for breast cancer. ACR guidelines state that screening breast ultrasound can be used to detect more cancers in this population in addition to screening mammography. Melinkow and colleagues state that evidence suggests that more breast cancers will be diagnosed with the addition of ultrasound or MRI screening in women with dense breast tissue. Also, most of these additional detected cancers will be invasive cancers. According to the ACR appropriateness criteria for breast cancer screening, mammography is recommended as a first line screening tool. In patients with dense tissue, ultrasound can be used as an additional screening tool. Additional screening with ultrasound in the patient population with dense breast tissue will increase the sensitivity of invasive cancer detection. In this case, the patient had a personal history of dense breast tissue and had bilateral mammography screening performed. Upon referral, the patient had bilateral breast ultrasound performed one year later due to dense breast tissue. Under these circumstances, the Breast Ultrasound (CPT 76641) services at issue were medically necessary for this patients medical condition.Final Result: The reviewer determined that the services at issue were medically necessary for this patient's medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in diagnostic radiology 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 60-year-old female enrollee has requested total hip replacement at a facility with a comprehensive hemophilia program and a coordinated team of experts experienced in performing complex orthopedic surgical procedure on individuals with von Willebrands disease for treatment of her von Willebrands disease.  Findings:  The physician reviewer found that this patients laboratory values are consistent with type I von Willebrands disease (Haberichter, et al). The records indicate that she is in need of hip arthroplasty which is a surgical intervention that can produce significant blood loss. For this surgery to be safely performed, the patient needs effective hemostasis, which requires rigorous and emergent monitoring of her von Willebrands disease factor levels and aggressive transfusion of factor concentrates (Federici, et al). These two critical medical interventions can be provided by UCSF while the network provider has not indicated the amount of factor concentrate available to the patient, nor have they shown that ristocetin cofactor activity assays or factor VIII assays may be performed continuously. For these reasons, the requested total hip replacement at a facility with a comprehensive hemophilia program and a coordinated team of experts experienced in performing complex orthopedic surgical procedure on individuals with von Willebrands disease is medically necessary for treatment of this patients medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned

A 41-year-old female enrollee requested authorization and coverage of Botox injections for the treatment of debilitating headaches.  The health plan denied the enrollees request indicating that the requested treatment is experimental.Three physician reviewers performed an experimental/investigational Independent Medical Review.  Each of the three physician reviewers concluded that Botox injections are likely to be more beneficial for treatment of the enrollees debilitating headaches than any available standard therapy.  Because all three physician reviewers concluded that the requested treatment is likely to be more beneficial for treatment of the enrollees medical condition than any available standard therapy, the review organization overturned the health plans denial.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested autologous chondrocyte implantation for treatment of the enrollees medical condition.  Findings: Three physician reviewers found that the current medical evidence supports the requested services in this patients case.  The peer-reviewed literature supports autologous chondrocyte implantation for large patellar lesions in patients who failed operative and nonoperative treatment.  This patient presents with persistent and worsening right knee pain that significantly limits her activities of daily living.  There is imaging evidence of full thickness chondral loss of the medial facet of the patella.  She has failed long-term comprehensive operative and nonoperative treatment.  Detailed evidence of long-term comprehensive treatment and failure has been submitted.  In sum, the requested autologous chondrocyte implantation is likely to be more efficacious than other treatment options.Final Result: Three 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 physician reviewers are board certified in orthopedic surgery 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: The patient has requested authorization and coverage for a left knee arthroscopy. In a trial to determine if exercise therapy was superior to arthroscopic partial meniscectomy for knee function in middle-aged patients with degenerative meniscal tears, Kise and colleagues found that there was no clinically relevant difference between exercise therapy and arthroscopy at two-year follow-ups. Katz and colleagues found that patients who underwent arthroscopic partial meniscectomy for a degenerative meniscal tear generally did not show more improvement than those who underwent sham meniscal resection or an intensive course of physical therapy. In this case, the records do not document a history of frequent locking or other mechanical problems associated with the degenerative tear, and an arthroscopic partial meniscectomy that removes  cushioning from the meniscus may result in progression of osteoarthritis. Therefore, a left knee arthroscopy is not medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested service 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 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 a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

A 53-year-old female enrollee requested the zoster vaccine for medical treatment of her medical condition.  Findings:  The physician reviewer found that the current medical evidence does not support the requested zoster vaccine in this clinical setting.  The Advisory Committee on Immunization Practices of the Centers for Disease Control and Prevention has recommended the zoster vaccine only for patient 60 years of age and older.  In this patients case, the rationale for the vaccine is not clear.  She does not appear to have had a history of zoster, and the relationship between development of leg pain and a chest rash is not obvious.  There is a lack of evidence suggesting that neuropathic pain would be reduced by vaccination.  All told, the requested zoster vaccine is not medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Supartz injections in both knees. Findings:  The physician reviewer found that evidence based medical peer reviewed literature supports the use of repeat viscosupplementation injections for the treatment of pain in patients with osteoarthritis of the knee. Studies concluded that hyaluronic acid was the best pharmacologic intervention for knee osteoarthritis in their meta-analysis of 137 studies with 33,243 participants. Hyaluronic acid was found to be better than injected placebo or injected corticosteroids. Studies conducted a systematic review on the efficacy and safety of repeat courses of hyaluronan therapy in patients with osteoarthritis of the knee and concluded that repeat courses of the hyaluronans were safe and effective in the treatment of pain associated with osteoarthritis of the knee. Studies concluded that repeated cycles of intra-articular sodium hyaluronate treatment to delay time to total knee replacement in patients with knee osteoarthritis which failed conservative treatment was found efficacious during a 54-month follow up period. The medical literature and evidence support hyaluronic acid injections to potentially delay total knee replacement for patients with pain that interferes with functional activities. The literature also states that if there is documented significant improvement in symptoms for six months or more, and symptoms recur, it may be reasonable to do another series. High quality scientific evidence does not appear to place a maximum amount of injections that an individual may receive for treatment of osteoarthritis of the knee. Moreover, viscosupplementation has been found to be safe and effective and allow for delay of total knee replacement. In this case, the patient has been diagnosed with bone on bone arthritis of both knees. He has significant bilateral knee pain and functional impairment in mobility that have failed to respond adequately to other conservative treatment, including activity modification, corticosteroid injection, and medications. The patient reported benefit with prior viscosupplementation lasting for at least six months. Therefore, Supartz injections in both knees is medically necessary for treatment of the patients medical condition. 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 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 a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

A 29-year-old female enrollee requested authorization and coverage of abdominoplasty and panniculectomy. The Health Plan denied the request indicating that the requested procedures are not medically necessary for treatment of the enrollees excess stomach tissue.One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer overturned the Health Plans denial on the basis that the requested procedures are reconstructive in nature and medically necessary.