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

The patient is a 25-year-old female with a prior history of medications for the diagnosis of bronchial asthma. The patients current provider notes the patient had a trial and failure of Claritin, but no history of trial and failure on Allegra. It appears Zyrtec was originally prescribed by a previous provider after trials of Claritin and Allegra failed. The patient indicates she has used Zyrtec and Advair to help treat her asthma and allergies. In addition, the patient reports that since she has been off Zyrtec and trying other over the counter allergy medications she has had an increase in asthma symptoms and has had to regularly use her rescue inhaler which was down to a minimum when she was taking Zyrtec combined with Singulair and Advair.  At issue is whether Zyrtec is medically necessary for treatment of the patients medical condition.Both the patient and her physician indicate the patients allergic asthma was under control with the use of Zyrtec, a stronger antihistamine than Allegra. The patient indicates a worsening of symptoms with discontinuation of Zyrtec. However, the submitted documentation does not demonstrate the patient has undergone a trial of Allegra. As such, I have determined the requested medication is not medically necessary at this time. The Health Plans denial should be upheld at this time. If the patient provides objective evidence of trial and failure of Allegra, then Zyrtec should be authorized.
Appeal type: Medical Necessity
Decision: Upheld

A 51-year-old female enrollee has requested radiofrequency neurotomy for treatment of her cervical spondylosis.  Findings:  The physician reviewer found that this patient presented with chronic neck pain. The pain generator had not been indentified. The benefit of RF neurotomy in this setting remains the subject of debate in the scientific literature (Carragee, et al.). According to a study by Cohen and colleagues, incidences of failure of RF neurotomy included patients with a history of radiation to the head, opioid use, and pain exacerbated by neck extension or rotation, all of which were present in this case. Further, this patient had not achieved significant relief with facet blocks prior to pursuing RF neurotomy. RF neurotomy should only be considered when diagnostic blocks are more than 50% successful. Given the above literature and the available medical records, RF neurotomy was not medically indicated for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld

The patient is a 60-year-old man who presented with a right supraclavicular node in mid- 2003. Biopsy revealed non-small cell lung carcinoma. At that time, he was also noted to have a large right upper lobe lung mass, along with extensive hilar and mediastinal adenopathy. The positive neck node classified the patient as stage IV and it was clear he was not operable. The patient was seen by radiation therapy and a PET scan was recommended, which most likely would have been followed by treatment with chemotherapy combined with radiation therapy. The patient instead chose an alternative route and received low dose chemotherapy at another institution, to no effect.The patient began a combination of hyperthermia and radiation therapy to his neck. The Health Plan has denied authorization and coverage for hyperthermia and radiation treatment on the basis the therapy is not medically necessary for treatment of the patients medical condition.Hyperthermia is the use of coils to generate high temperatures within a cancer mass. It has been studied for many years, both by itself and in combination with radiation and/or chemotherapy. Though there are certain situations where such therapy might be beneficial in terms of controlling a large specific mass, it is unclear how this would compare to more standard radiation, often combined with radiosensitizing chemotherapy. There is no evidence in the peer-reviewed literature demonstrating the superiority of hyperthermia and radiation treatment over standard radiation. Therefore, I have determined that the requested therapy is not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld

The patient has requested authorization and coverage for fleur-de-lis abdominoplasty. According to the American Society of Plastic Surgeons (ASPS), when surgery to remove extensive skin redundancy and fat folds is performed solely to enhance a patients appearance in the absence of any signs or symptoms of functional abnormalities, the procedure should be considered cosmetic in nature. According to the ASPS, a cosmetic abdominoplasty is sometimes performed at the time of a functional panniculectomy or delayed pending completion of weight reduction. Abdominoplasty, typically performed for cosmetic purposes, involves the removal of excess skin and fat from the pubis to the umbilicus or above, and may include fascial plication of the rectus muscle diastasis and a neoumbilicoplasty. In this patients case, the records do not document functional abnormalities that would be addressed by the requested fleur-de-lis abdominoplasty. Therefore, the requested fleur-de-lis abdominoplasty is not 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, the records document that this patients panniculus hangs below the level of the pubis. The patients hanging panniculus causes recurrent intertrigo in the infrapannicular area despite appropriate medical treatment including proper hygiene and the use of Nystatin cream. The patient has a documented functional problem with the rash that has been demonstrated to be resistant to appropriate medical treatment. A hanging panniculus that causes such a functional problem is considered an abnormal structure of the body caused by a developmental abnormality. However, an abdominoplasty will not address the patients overhanging pannus or improve function. The patients appearance is normal and consistent with gain and loss of weight. Moreover, the requested surgery will not make a more than minimal improvement in the patients appearance. Therefore, the requested fleur-de-lis abdominoplasty is not reconstructive in nature for patient.Final Result: The reviewer determined that the requested services are not medically necessary and not reconstructive in nature for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Harvoni for eight weeks.Findings:  The physician reviewer found that according to the most recent joint guidelines issued by the American Association for the Study of Liver Diseases (AASLD) and the Infectious Diseases Society of America (IDSA), all patients with chronic hepatitis C should be treated except those with limited life expectancy due to non-liver-related conditions. This applies regardless of fibrosis stage or viral load, and advanced fibrosis is not required for treatment. Per guidelines, treatment-naive genotype 1 patients should be treated with Harvoni. Patients with viral load of less than 6,000,000 IU/mL can be treated for eight weeks. These guideline recommendations are based on multiple randomized clinical trials. The AASLD/IDSA guidelines cite data showing reduced survival with delayed treatment. Final Result: The reviewer determined that the requested medication 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 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: Urgent Care
Decision: Upheld

A 30-year-old male enrollee has requested emergency services provided at Scripps Mercy Chula Vista for the treatment of his condition. Findings:  The physician reviewer found that this patients Health Plan covers emergency services according to the prudent layperson definition. This states that a patient must be suffering from the sudden onset of symptoms of such severity (including severe pain) that a prudent layperson would believe the lack of immediate medical attention would result in serious jeopardy to his health. Although this patient did report pain, the pain was not acute in onset. His testicular pain had been present for two months. Further, the patient did not require any pain control in the emergency department. He did not present with any other acute symptoms such as abdominal pain. While his ongoing testicular pain warranted medical evaluation, this care did not need to be provided on an emergent basis. Because this patient was not experiencing the sudden onset of acute symptoms, his symptoms do not meet criteria for an emergency.
Appeal type: Experimental/Investigational
Decision: Overturned

A 58-year-old female enrollee requested authorization and coverage of the continuation of chemotherapy. The Health Plan denied the request indicating that the requested therapy is considered experimental for treatment of the enrollees chronic lymphocytic leukemia (CLL).Three physician reviewers performed a medical necessity Independent Medical Review. All three physician reviewers concluded that the requested therapy is likely to be more beneficial for treatment of the enrollee's medical condition than any available standard therapy. Because all three  physician reviewers concluded that the requested procedure is likely to be more beneficial for the treatment of the enrollee's medical condition than any available standard therapy, the Health Plans denial has been overturned.
Appeal type: Medical Necessity
Decision: Upheld

A 49-year-old male enrollee has requested inpatient care services for treatment of his substance abuse. Findings:  The physician reviewer found that the records reviewed suggest that the patient had attained sobriety while in the IOP program. There is also evidence of a co-morbid psychiatric condition, which was not adequately treated and may have been interfering with his recovery. However, the data reviewed fails to support the conclusion that he met dimensions 5 and 6 of the American Society of Addiction Medicine (ASAM) patient placement criteria for residential treatment. Further, the records do not indicate that he could not have been safely and effectively managed in a less intensive setting with adjunctive psychiatric follow-up. Hence, the residential treatment at issue was not medically necessary according to both ASAM and American Psychiatric Association (APA) practice guidelines. Therefore, the services at issue were not medically necessary for treatment of the patients medical condition
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for magnetic resonance imaging (MRI) or positron emission tomography (PET) scan of her throat for evaluation of the enrollee, who has a history of globus sensation of her throat. Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested services. This patient has been evaluated by multiple providers, including oral maxillofacial surgery, otolaryngology, family practice, and neurology, all of whom had evaluated the patient but were unable to determine any source of abnormal lesion that required further examination or biopsy. Multiple oropharyngeal nasal endoscopies and laryngeal examinations were documented in the clinical records, demonstrating that there was no evidence of any lesions of concern that warranted consideration of further biopsy.  The prior biopsy of the tongue also demonstrated no evidence of inflammation, infection or malignancy. Further imaging is not medically necessary in this patients case. All told, the requested MRI or PET scan of the throat are not medically necessary for the evaluation of this patient. Final Result: The reviewer determined that the requested services are 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 otolaryngology 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 71-year-old male enrollee has requested a positron emission tomography (PET) scan for evaluation of his progressive cognitive difficulties.  Findings:  Two physician reviewers found that the requested diagnostic procedure is likely to be more effective than other methods of evaluation.  Although a PET scan is not indicated in all cases of dementia, it is very useful in cases where frontotemporal dementia versus Alzheimers disease is suspected.  It can differentiate between these two diseases.  This is important as the treatment is very different for these two conditions.  Therefore, the use of a PET scan in this particular case is likely to be of greater benefit than standard diagnostic tools.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for Game Ready cooling device with pneumatic pressure. Findings:  The physician reviewer found that the physician reviewer found the submitted documentation fails to demonstrate the superior efficacy of the device at issue in this clinical setting. Generally, cold compression is recommended as an option for home rental for up to seven days following major knee surgery, but not for routine arthroscopic procedures or nonsurgical treatment. The available literature has not demonstrated long-term functional improvement outside the acute postoperative period to support the use of this unit over traditional cold therapy with ice packs and compression. Therefore, these more complex devices are recommended to be reserved only for more complex and painful knee procedures such as periarticular fractures and revision arthroplasty. In this case, the patient underwent an arthroscopic anterior cruciate ligament reconstruction and medial meniscus repair.  Therefore, the Game Ready cooling device with pneumatic pressure was not likely to have been more effective than other treatment options.  Final Result: Two of the three reviewers determined that the device at issue was 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: Physician reviewers 1, 2 & 3 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: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The enrollee has requested reimbursement for prenatal screening for microdeletions using cell-free fetal DNA that she received. The Health Plan has denied the service at issue as investigational for evaluation of the enrollees fetus.Findings:  Two out of three physician reviewers found that according to the American College of Obstetricians and Gynecologists (ACOG) and the Society for Maternal Fetal Medicine (SMFM) joint practice bulletin, cell-free DNA screening tests for microdeletions have not been validated clinically and are not recommended at this time. In a study, the positive predictive value of microdeletion testing does not support its routine use. One physician reviewer found that researchers conducted a study with an extended range of chromosomal anomalies. The authors reportedly obtained an incremental diagnostic yield of 50%, with rare autosomal trisomies and duplication copy-number variations found to be significant causes of fetal pathology.Final Result: The reviewers determined that the service at issue was 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 reviewers 1, 2 and 3 are board certified in genetics 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

A 36-year-old female enrollee has requested for physical therapy (PT) for treatment of her cervical pain. Findings:  The physician reviewer found that a TENS unit and electrical stimulation are not typically utilized for the treatment of cervical degenerative disc disease. These passive modalities are not the standard for first-line treatment of degenerative disc disease.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the FoundationOne Heme test. FoundationOne is a molecular assay that explores the mutations of an individual patients cancer cells. The goal of the assay is to identify a specific mutation or target which could guide the provider as to which chemotherapeutic agent would be useful. However, there is a paucity of evidence that the FoundationOne assay adds to decision making ability, or yields a result that is reliably clinically beneficial. There are non-randomized studies exploring the value of molecular profiling, but the results have not been convincing as to the efficacy of such an approach to treatment. A randomized trial did not demonstrate a significant clinical benefit from choosing therapy based on molecular targets versus by the providers clinical judgment. Currently, the data suggests that finding a mutation does not support treatment directed at that target to produce a clinically meaningful response. All told, the FoundationOne Heme test was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Final Result: Two of the three reviewers determined that the service at issue was 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:  One reviewer is board certified in internal medicine with sub-specialty certification in medical oncology and is actively practicing. One reviewer is board certified in internal medicine with sub-specialty certification in medical oncology and is actively practicing.  One reviewer is board certified in internal medicine with sub-specialty certification in medical oncology 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: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for a Stretta procedure. In a systematic review to evaluate the efficacy of Stretta for the management of gastroesophageal reflux disease (GERD), Lipka and colleagues reported no evidence of significant changes, compared with sham therapy, in physiologic parameters, including time spent at a pH less than 4, lower esophageal sphincter pressure, ability to stop proton pump inhibitors, or health-related quality of life. Thosani and colleagues noted adverse events from the Stretta procedure included aspiration pneumonia, permanent gastroparesis, esophageal perforation, cardiac arrest, and four deaths. Nabi and colleagues reported that long-term follow-up studies and randomized comparison with anti-reflux surgery were required for a clear understanding of the endoscopic modalities in treating GERD. Katz and colleagues noted in guidelines for the management of GERD that endoscopic therapies have not demonstrated long-term efficacy. Fass reported that with the Stretta procedure, up to 42% of patients experienced recurrence of GERD symptoms. In this clinical setting, current medical literature does not support the use of Stretta as likely to be more beneficial than standard treatments for GERD. Therefore, the Stretta procedure is not likely to be more beneficial for treatment of the patients condition than any available standard therapy.Findings:  Three of the three physician reviewers found the requested Stretta procedure is 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 service 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: Physician reviewers 1, 2, and 3 are board certified in internal medicine with sub-specialty certification in gastroenterology 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: Overturned

A 28-year-old female enrollee requested authorization and coverage of orthognathic surgery. The Health Plan denied the request indicating that the requested procedure is not medically necessary for treatment of the enrollees temporomandibular joint dysfunction. One oral surgeon reviewer performed a medical necessity Independent Medical Review. The oral surgeon reviewer overturned the Health Plans denial on the basis that the requested procedure is medically necessary.
Appeal type: Medical Necessity
Decision: Upheld

The parents of a 17-year-old female patient have requested authorization and coverage for a plastic surgery consultation for possible otoplasty. The Health Plan has denied this request indicating that the requested consultation is not medically necessary for treatment of the patients protruding ears. The submitted materials include photographs of the patients ears. No measurements have been provided in the submitted records. The submitted materials also include a letter from the patients therapist describing the patients concerns regarding her ears.The Health Plans denial should be upheld. There is no evidence that the requested consultation is medically indicated. The submitted photographic evidence demonstrates normal appearing ears with slight to moderate protrusion from the patients head. There is no evidence of any functional deformity of the ears. The submitted information does not establish that an otoplasty would be reconstructive in nature. Therefore, I have determined that the requested consultation is not medically necessary for the treatment of the patients medical condition. The Health Plans denial should be upheld.