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

A 60-year-old female enrollee has requested a referral to a cardiologist for treatment of her hypertension and chest pain.  Findings:  The physician reviewer found that this patient has several cardiac risk factors (obesity, diabetes and hypertension) that have not been optimally treated and are associated with intermittent chest discomfort.  There is a reference to stress testing, but there was no documentation of results. In this circumstance of a patient with significant cardiac risk and intermittent symptoms suggestive of possible coronary ischemia, evaluation by a cardiologist is standard accepted practice in the medical community.  Even if stress testing has been performed, cardiologists with specialized training are best able to interpret details of the stress test results in context with the patients ongoing intermittent symptoms to determine the need for additional cardiac evaluation. In this case, the development of chest discomfort in this high-risk patient is an appropriate indication for a referral to a cardiologist.  Several studies have shown that management of angina by cardiologists leads to more effective medical therapy and revascularization procedures with a trend towards improved outcome compared to angina managed by internists.  All told, the requested referral to a cardiologist is medically indicated for this patient.
Appeal type: Medical Necessity
Decision: Upheld

A 60-year-old female enrollee has requested for an increase in Astelin dosage (two sprays in each nostril three times per day, which is more than one inhaler per 25 days) for treatment of her shortness of breath, upper respiratory infection and chronic sinusitis. Findings:  The physician reviewer found that this request exceeds the Food and Drug Administration approved dosage of Astelin. The use of Astelin at the requested dosage has not been studied and therefore its safety and efficacy are unknown. The requested dose would lead to an increase of the local antihistamine which could then be absorbed to increase the system level of antihistamine. This could potentially result in decreased urine flow in some patients.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for myoelectric upper extremity prosthetic device with accessories. This patient is being treated for complete traumatic amputation of right shoulder and upper arm. He was evaluated for a prosthesis for his dominant right upper extremity. He is eager to regain function on his right side with an active grasp. this is reportedly so he can resume activities that bring enjoyment to his life, including returning to work. The recommended prosthetic is an interscapular thoracic level myoelectric prosthesis, with accessories. Carey and colleagues noted the choice of a myoelectric or body-powered upper-limb prosthesis can be determined using factors including control, function, feedback, cosmesis, and rejection. Vujaklija and colleagues commented that, surgical techniques in combination with modern, sophisticated hardware are enabling restoration of dexterous upper limb functionality. Resnik and colleagues concluded that patients who did not use a prosthesis or used a cosmetic prosthesis reported greater difficulty performing activities of daily living when compared to patients who use body-powered and myoelectric devices. Based on the records provided for review, a body-powered prosthesis is inadequate to meet this patients needs since he is unable to generate enough inches of excursion to fully operate the device. A body-powered prosthesis requires sufficient physical ability to produce large movements. This patient has an amputation at the interscapular-thoracic level that reduces his leverage and ability to create cable excursion to fully operate a body-powered prosthesis. For these reasons, the requested myoelectric upper extremity prosthetic device with accessories is medically necessary for treatment of this patient. Final Result: The reviewer determined that the requested equipment 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 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 46-year-old female enrollee has requested  oxycodone 5mg tablets; and butalbital-APAP-CAFF 60-32 (Fioricet); and Dilaudid injections for treatment of her chronic pain syndrome.  Findings:  The physician reviewer found that the requested medications are not medically necessary for the patients medical condition. The standard of care for chronic pain associated with disc herniation is treatment in a multidisciplinary practice to include physical therapy, massage therapy, behavioral therapy, and injections to help reduce pain. There are a variety of anti-convulsants and anti-depressants considered adjunctive to this therapy. If there is poor response to conservative therapy then surgery should be considered. Short release/acting opioids such as oxycodone, Fioricet, and Dilaudid are associated with a high risk of dependence and tolerance; therefore long-term administration is not recommended (Fishman). Baron and McDonald reported that high dose and short acting opiates might contribute to pain sensitization via opioid-induced hyperalgesia, decreasing patient pain threshold and potentially masking resolution of a preexisting pain condition. In this retrospective study, the majority of patients undergoing detoxification of high dose opiates for chronic pain reported a significant decrease in pain at the end of the study, further supporting the theory of opioid-induced hyperalgesia. Therefore, it would be in the best interest of the patient to wean off opioids and continue in a multidisciplinary program. Finally, short-acting opiates are more likely to cause adverse outcomes. Ballantyne and Mao reported that prolonged use of high dose, short-acting opiates might induce tolerance, and abnormal pain sensitivity. Thus, the request for oxycodone, Fioricet and Dilaudid, would be contradictory to providing safe and effective treatment. Based on the documentation submitted for review and the peer-reviewed literature cited above, the requested medications are not medically necessary for treatment of the patients medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld

A 59-year-old female enrollee has requested Avastin and Abraxane combination regimen for the treatment of her breast cancer. Findings:  Two physician reviewers found that the efficacy data of Abraxane with Avastin was presented from a preliminary phase II study at the ASCO 2008 meeting, however, its combination use remains unproven in this setting. As such, it is not possible to conclude that the proposed therapies are likely to result in a better clinical outcome than standard therapies. Based on the evidence available to date, the use of Avastin with paclitaxel would be more appropriate for the treatment of the patients metastatic breast cancer following completion of oral chemotherapy.
Appeal type: Medical Necessity
Decision: Overturned

An enrollee has requested authorization and coverage for HP Acthar Gel, 80 Units daily for 10 days. Acthar Gel is indicated for the treatment of acute exacerbations of multiple sclerosis in adults. In this case, the patient has been diagnosed with relapsing-remitting multiple sclerosis. The patient has advanced disease and has been previously treated with different medication. The patient has not responded well to disease modifying therapy, and records indicate that the patient is not able to tolerate IV steroids. The use of Acthar Gel is indicated in just such circumstances, when a patient is experiencing an acute exacerbation of multiple sclerosis and is not able to tolerate traditional IV steroids. Accordingly, the requested medication, HP Acthar Gel, 80 Units daily for 10 days, is medically necessary to treat the patients medical condition.Final Result: The reviewer determined that the requested medication is medically necessary to treat the patients condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in neurology 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

Nature of Statutory Criteria/Case Summary: The enrollee requested authorization and coverage for a surgical procedure to remove excess skin between the thighs (CPT code 15738). The Health Plan denied the procedure as not medically necessary.Bariatric surgery produces rapid, massive weight loss, often leaving patients with excess skin that can be aesthetically disappointing and can present barriers to physical and psychosocial functioning. Steffen and colleagues reported on a survey of patients approximately two years, or six to 10 years after bariatric surgery. The authors found that a greater BMI at survey completion was independently associated with lower satisfaction with excess skin. The records do not include documentation of skin infections or conservative treatment to address the patients rashes. Thus, the requested surgical procedure to remove excess skin between the thighs (CPT code 15738) is not medically necessary for treatment of this patients excess skin. In addition, the requested procedure is not supported as reconstructive in nature. The records provided for review suggest that the patients excess skin is not an abnormal structure of the body, but is the result of the patients obesity. The excess thigh skin is not related to a developmental abnormality, trauma, tumor, infection or disease. Further, the surgery would not improve the patients function, as she will still likely have excess skin causing the same complaints. The patient already has a normal appearance, so any change in appearance would be performed to meet an aesthetic goal. Therefore, the requested surgical procedure to remove excess skin between the thighs (CPT code 15738) is not medically necessary or reconstructive in nature to treat the patients medical condition.Final Result: The reviewer determined that the requested procedure is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheldCredentials/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: Medical Necessity
Decision: Overturned

The patient is a 46-year-old male with muscular dystrophy and respiratory failure after an episode of pneumonia. He is now on ventilation and can be off the ventilator for a few hours per day. He is tolerating a portable (home) ventilator. Family members have demonstrated the ability to suction and bag with the ventilator. The patients family has requested authorization for home health care services. The Health Plan has determined that discharge to home is not medically appropriate or safe and therefore has recommended placement in a sub-acute facility. There is no data in the records indicating the patient cannot be adequately cared for in an in-home setting. Sub-acute care is not inherently safer or superior to at-home care, especially if the family is appropriately trained. The submitted evidence demonstrates the patients family has received caregiver training and the patient is able to tolerate home ventilation. He is receiving tube feedings. The evidence provided does not identify specific safety concerns necessitating sub-acute care. As such, home health cares services are medically appropriate and should be authorized by the Health Plan. Based upon the information set forth above, I have determined the requested services are medically necessary for treatment of the patients medical condition. The Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Upheld

The parent of a female enrollee requested psychiatric inpatient hospitalization services for medical treatment of the enrollees major depressive disorder and generalized anxiety disorder.   Findings:  The physician reviewer found that the notes indicate that the patient was accepting of the idea of transfer to aresidential treatment center (RTC) after discharge from acute care. She was compliant with her treatment and no longer expressed any thoughts of hurting herself or others. Overall, there is a lack of documentation supporting continued treatment at an inpatient level of care while waiting for transfer to a RTC. Thus, she would have been safe for transfer to a lower level of care and the psychiatric inpatient hospitalization services were therefore not medically necessary.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary:An enrollee has requested authorization and coverage for lumbar medical branch blocks for treatment of the enrollees lower back pain. Findings:  The three physician reviewers found that the documentation available for review, the provider does not document an examination that is consistent with facet mediated spine pain. In addition, the medical literature does not recommend medial branch blocks and subsequent radiofrequency ablation when a patient has active radicular pain, as in this patients case. Moreover, it is likely the patient would get the same relief from a steroid injection alone without also having the increased risk from a radiofrequency ablation procedure. The records do not demonstrate a prior failure from facet injections or an epidural injection. There is a lack of support in the medical literature for the recommended services. As such, lumbar medial branch blocks are not likely to be of greater benefit than the standard options available for the treatment of this patients medical condition.  Final Result: All three reviewers determined that the requested services are not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld. Qualifications of Physician reviewer number one is board certified in anesthesiology with sub-specialty certification in pain medicine 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 anesthesiology with sub-specialty certification in pain medicine 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 anesthesiology with sub-specialty certification in pain medicine 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:  The parent of an enrollee has requested authorization and coverage for esophagogastroduodenoscopy endoscopy with capsule (wireless capsule endoscopy). Findings:  Two of the three physician reviewers found there is sufficient support for the requested services in this clinical setting. Based on the history of abdominal pain and weight loss, she may have an undiagnosed Crohns disease. Further, around 10 to 15% of patients with inflammatory bowel disease may have normal inflammatory markers. Per the medical records, the previous esophagogastroduodenoscopy/colonoscopy with biopsies was normal except Helicobacter pylori. Wireless capsule endoscopy is the appropriate next step in this setting. Therefore, the requested esophagogastroduodenoscopy endoscopy with capsule (wireless capsule endoscopy) is likely to be of greater benefit than other methods of evaluating this patient. Final Result: The reviewers determined that the requested services are 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: Physician reviewers 1 and 2 are board certified in pediatric gastroenterology and are actively practicing. Physician reviewer 3 is board certified in pediatrics and is 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: Overturned

Nature of Statutory Criteria/ Case Summary:  The enrollee requested reimbursement for nitric oxide expired gas determination. The enrollee has asthma. She has been on Albuterol, Advair, and Combivent. She was evaluated by her pulmonologist due to complaints of a dry cough and shortness of breath with exertion. She has a history of vocal cord polyps and hoarseness, secondary to increased coughing. Her pulmonologist reported scattered bilateral expiratory wheezing. He performed pulmonary function testing and fractional exertion of nitric oxide testing. The enrollees pulmonologist reports the nitric oxide was used to assess eosinophilic airway inflammation and reports the enrollee does not need allergy reevaluation. This enrollee has a history of moderate, persistent asthma in the setting of severe rheumatoid arthritis. Exhaled nitric oxide measurement is helpful in determining whether there is inflammatory airway disease which is being caused by eosinophils. This type of asthma has specific biologic agents which are approved for use in such cases. The measurement of exhaled nitric oxide in this enrollee was appropriate to individualize and optimize her treatment. Professional societies support the use of nitric oxide measurement in selected individuals to help guide therapy.Final Result: Two of the three reviewers determined that the requested services are 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 pulmonary diseases 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 patient is a 19-year-old female who has a history of bilateral breast macromastia. She underwent bilateral breast reduction surgery in July 2001. The patient also has a history of myelomeningocele and is wheelchair bound. The patient wishes to undergo another breast reduction procedure. The Health Plan has determined the requested procedure is not medically necessary for treatment of the patients medical condition.The patients complaints represent a special circumstance in which the usual indications for breast reduction surgery (i.e., low back pain, bra strap trauma) do not adequately apply. She is wheelchair bound and requires multiple transfers to and from her chair. Her ambulation is entirely dependent upon upper body movements. While the amount of breast tissue removed would not be of significant volume compared to most breast reduction procedures, this patients case is exceptional. The sheer volume of the patients breasts may be a hindrance to her ability to navigate her wheelchair and perform transfers. Therefore, I have determined that 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: Overturned

The parent of a 16-year-old male enrollee has requested  residential treatment services for treatment of the enrollees alcohol and drug addiction.  Findings:  The physician reviewer found that based on Child and Adolescent Level of Care Utilization System (CALOCUS) criteria, the patient was a candidate for residential level of care during the period at issue. The submitted documentation reveals significant risk of harm due to excessive use of drugs resulting in potentially harmful behavior. The evidence demonstrates the patient had moderate functional impairment and co-morbid psychiatric disorders were present. In addition, the patient had a history of poor response to treatment. Previous intensive outpatient treatment had not achieved remission or optimal control of the patients symptoms.  Furthermore, residential treatment level of care in this situation was consistent with American Academy of Child and Adolescent Psychiatry (AACAP) practice parameters for Children and Adolescents with substance abuse disorder. All told, the submitted evidence supports the patients length of stay during the timeframe at issue.