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

A 43-year-old female enrollee has requested a bilateral revision of breast reconstruction for treatment of her nipple-areolar complex. Findings:  The physician reviewer found that the abnormal structure of the body was initially caused by treatment of tumors (fibroadenomas and cysts). The patient had bilateral mastectomies, followed by bilateral breast reconstruction and capsular contractures that are painful and are a known complication of implant surgery. Thus, surgical corrections are used to try to treat this. In this case, the first surgery to correct the high-riding implant and painful contracture was unsuccessful, in that it may likely have been overcorrected or as a result of the patients poor tissue quality. As noted by Baxter in the 2003 publication, treatment after mass resection can require reconstruction. Moreover, the requested surgery is being performed to create a normal appearance to the extent possible. While the patients function may not be improved with the surgery, this is more of a case of trying to recreate a more normal appearance as a result from remote breast reconstruction. In addition, the requested surgery offers more than a minimal improvement in the patients appearance. Secondary reconstruction may be performed by re-elevating the implant and performing a capsulorraphy or some other means to recreate the appropriate inframammary fold. This could be considered treatment of bottoming out, which can occur regardless whether the implants were placed for reconstructive or cosmetic purposes.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollees parent has requested reimbursement for allergy testing services. The patient has a history of food allergies, and the provider has recommended treatment with oral immunotherapy. The provider recommended laboratory testing to help direct the patients treatment program. Currently, the American Academy of Allergy Asthma and Immunology (AAAAI) does not recommend oral immunotherapy as a standard of care treatment for patients with food allergies due to uncertainty whether the potential therapeutic benefits outweigh the risks of treatment. Although several studies have reported positive outcomes, according to the AAAAI, the interventions and endpoints used in clinical trials are too inconsistent to establish oral immunotherapy as superior to allergen avoidance. Furthermore, there is significant potential for adverse events including oropharyngeal, respiratory, and gastrointestinal symptoms. For these reasons, the allergy testing services was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Findings:  Two of the three physician reviewers found the allergy testing services were not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Final Result: The 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 1 is board certified in allergy and immunology and is actively practicing. Physician reviewer 2 is board certified in allergy and immunology and is actively practicing. Physician reviewer 3 is board certified in pediatrics with subspecialty certification in allergy and immunology 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: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement and prospective authorization and coverage for sclerotherapy services. The records provided for review document that this patient presented with spider veins of bilateral lower extremities and lymphedema. Evaluation with ultrasound ruled out reflux and deep vein thrombosis. The patients providers impression included was that the patients leg swelling was not likely due to the spider veins. The provider recommended treatment with compression stockings and elevation. The patient underwent two treatment sessions with sclerotherapy, at which time their pain score was 0/10. As discussed in medical literature, sclerotherapy is not likely to be more beneficial than standard treatment modalities for treatment of spider veins without evidence of venous reflux. Based on the documentation provided for review, the sclerotherapy services were not and are 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 services at issue were not and 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. Credentials/Qualifications: Physician reviewer 1 is board certified in general surgery with subspecialty certification in vascular surgery and is actively practicing. Physician reviewer 2 is board certified in general surgery with subspecialty certification in vascular surgery and is actively practicing. Physician reviewer 3 is board certified in general surgery with subspecialty certification in vascular surgery 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: Medical Necessity
Decision: Upheld

The parent of a 14-year-old female enrollee has requested for psychiatric residential treatment for treatment of the enrollees medical condition.      Findings:  The physician reviewer found that A review of the medical records shows that the patient did not meet medical necessity criteria for continued residential treatment. The submitted documentation indicates that the patient was stable, did not have any imminent safety risk, and did not have medical or emotional complications that required a residential level of care. The patient showed substantial progress in her symptoms and behavior and was functioning close to her baseline. Thus, she could have been effectively treated at a lower level of care during the period in question.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for surgical implantation of a hypoglossal nerve neurostimulator device (CPT 64568 and 0466T). This patient has obstructive sleep apnea (OSA) and no nasal obstruction. The patients drug induced sleep endoscopy (DISE) showed no concentric collapse at velum and primarily anterior posterior collapse with improvement using jaw thrust. The patient has not been able to tolerate treatment with continuous positive airway pressure (CPAP) and oral appliances have not been substantially effective. The Inspire device is a U.S. Food and Drug Administration (FDA) approved device for the treatment of OSA device. This patient is a candidate for the Inspire hypoglossal nerve neurostimulator device given his intolerance to CPAP, anterior posterior collapse, and no central apnea. Moreover, the patient has an apnea/hypopnea index (AHI) of 41.7, and a body mass index (BMI) of 29, which meet the current FDA criteria. For these reasons, the requested surgical implantation of a hypoglossal nerve neurostimulator device (CPT 64568 and 0466T) is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Findings:  Two of the three physician reviewers found the requested surgical implantation of a hypoglossal nerve neurostimulator device (CPT 64568 and 0466T) 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 are likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: Physician reviewer 1 is board certified in otolaryngology and is actively practicing. Physician reviewer 2 is board certified in otolaryngology with subspecialty certification in sleep medicine and is actively practicing. Physician reviewer 3 is board certified in otolaryngology 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: Medical Necessity
Decision: Overturned

The parent of a 17-year-old female enrollee has requested acute intensive psychiatric inpatient services and partial hospital program (PHP) care for treatment of the enrollees behavioral health issues.  Findings:  The physician reviewer found that this patients records document that she had been treated for severe, recurrent major depression with suicidal ideation for two years prior to the onset of her eating disorder. She also has had a history of self harm with cutting. Following the above described admission, the patient cycled into a manic episode while being treated on an antidepressant. She was readmitted as an inpatient, and subsequently discharged to the partial hospitalization program(PHP) on the date in question. Her team of treating providers indicated that the patient was thought to require this level of care as she was not safe to be at a lower level of care at that point. Clearly, with a new diagnosis of bipolar disorder, accompanied by a recent diagnosis of anorexia nervosa and a co-morbid diagnosis of PTSD, an adjustment period was necessary. It is important to achieve full resolution of symptoms of the current episode in an attempt to improve the patients behaviors (Thomas and colleagues). Given the patients recent history of purging anything consumed and loss of 12 pounds within 1 month prior to admission, both psychopharmacologically and psychologically, the medical necessity has been established for her treatment at the acute inpatient level of care and follow-up therapy in the PHP through the requested dates.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for reduction mammoplasty. The Health Plan has denied this request and reported that the services at issue were not medically necessary and were not reconstructive in nature. At issue in this case is whether reduction mammoplasty was medically necessary to treat the patients medical condition.Findings:  The physician reviewer found that the American Society of Plastic Surgeons (ASPS) states that reduction mammoplasty should be based on documentation of the severity of the symptoms of macromastia and impact on health-related quality of life with at least two of the following signs: chronic breast pain due to weight of the breast, intertrigo unresponsive to medical management, upper back, neck, and shoulder pain, unspecified, thoracic kyphosis, acquired, shoulder grooving from bra straps, upper extremity paresthesia due to brachial plexus compression syndrome secondary to the weight of the breasts being transferred to the shoulder strap area, headache and congenital breast deformity.In this case, the patient reported back, shoulder and neck pain, and shoulder grooving is documented in the submitted photographs. There is no report of chronic breast pain due to weight of the breasts, intertrigo unresponsive to medical management, thoracic kyphosis, upper extremity paresthesia, headache, or congenital breast deformity. Since there are at least two quality of life signs, the requested reduction mammoplasty was medically necessary for the treatment of this patients medical condition. The condition of breast hypertrophy is an abnormal structure of the body caused by a developmental abnormality. The reduction mammoplasty was performed to improve function of the body. The reduction mammoplasty was likely to have offered more than a minimal improvement in the appearance of the patient. Therefore, the reduction mammoplasty performed was reconstructive in nature.Final Result: The reviewer determined that the requested services were medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in plastic surgery and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld

The parent of a four-year-old female enrollee has requested for DIR/Floortime therapy for treatment of the enrollees autism. Findings:  Three physician reviewers found that review of the relevant medical evidence reveals no peer-reviewed studies demonstrating that DIR/Floortime therapy is efficacious for the treatment of autism. There are no definitive studies proving the therapy at issue results in an improved clinical outcome. Without further study and research, it is not possible to predict whether the proposed therapy will benefit this patient.
Appeal type: Medical Necessity
Decision: Upheld

A 51-year-old female enrollee has requested a revisional duodenal switch procedure for the treatment of her morbid obesity. Findings:  The physician reviewer found that there is no medical evidence to suggest that the patients has experienced medical complications as a result of Roux-en-Y gastric bypass. There is nothing in the operative report from the original procedure, the recent air-contrast study or any of the submitted medical records to suggest the patient is experiencing a medical complication. In the absence of objective evidence of medical complications, it is presumed that the patients weight regain has resulted from non-compliance. Furthermore, revision to duodenal switch in the presence of a small gastric pouch can potentially be harmful unless the gastric pouch is to be increased in size to that of roughly a 150 cc pouch (a risky procedure, functionally similar to gastric bypass reversal) and should be avoided to prevent risk of malnutrition (malabsorption combined with a small pouch is equivalent to a distal or long limb gastric bypass which is generally considered a risky procedure). With regard to whether the requested revisional duodenal switch procedure meets the requirements of Californias Reconstructive Surgery Statute, I find that the patients obesity does not constitute an abnormal structure of the body. Obesity is the result of an abnormal accumulation of body fat rather than a structural abnormality. As such, the patients condition does not meet criteria for reconstructive surgery under California law.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a four-year-old female enrollee has requested speech therapy and occupational therapy for treatment of the enrollees speech delay and gross motor delay. Findings:  The physician reviewer found that this patient has expressive language delay and articulation disorder. Her skills fall below those of other children her age. These deficits negatively impact her ability to communicate effectively with peers and adults, resulting in behavioral difficulties. She has demonstrated improvement with speech and language services. Studies have shown that speech and language therapy can result in significant improvement in such children. Therefore, the requested speech and language therapy is medically indicated for this patient. Furthermore, with its focus on developing motor planning skills, fine motor skills, processing information and regulating the response to incoming information, occupational therapy is well-suited to affect positive change in this patient. She has demonstrated improvement with occupational therapy intervention, but she continues to have deficits that impact her ability to successfully accomplish the daily occupations of childhood. Thus, the requested occupational therapy is also medically indicated for this patient.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for platelet-rich plasma injection.Findings:  Two of the three physician reviewers found that the medical evidence has not established the superior effectiveness of the requested services in this patients case. There is a lack of high-quality clinical evidence supporting the efficacy of platelet-rich plasma injections in this clinical setting. There is insufficient evidence to support the use of platelet-rich plasma injections for treating musculoskeletal soft tissue injuries. The authors noted that there is a need for standardization of platelet-rich plasma injection preparation methods. In this case, platelet-rich plasma injections are not recommended as first-line treatment for the patients elbow condition. There is some lower quality evidence supporting a single injection as a second-line treatment following failed attempts at physical therapy with eccentric loading stretching and strengthening exercises. The submitted documentation does not indicate a failure of such a trial. Therefore, the requested platelet-rich plasma injection is not likely to be of greater benefit than other treatment options. Final Result: The 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.Credentials/Qualifications: Physician reviewers 1, 2 and 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: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement and prospective authorization and coverage for skilled nursing facility (SNF) services. Findings:  The physician reviewer found that stroke can significantly affect functionality across many body systems. Interventions can range from exercise to cognitive retraining to learning compensatory strategies. The primary purpose of rehabilitation is to enable patients to function at the highest possible level despite physical impairment. Functional independent measure scores are used in the rehabilitation to assess a patients level of function and scores are compared to assess for response to restorative therapies. The patients functional independent measure score included complete dependence in a majority of factors. Repeat scores on the patients functional independent measure examinations were essentially unchanged. Rehabilitation services should be continued until a patient reaches a plateau. This patients records do not document continued positive response to therapy to support a continuation of services. Furthermore, data on continued rehabilitation interventions are not recommended in the clinical setting of persistent neurological dependence when a patient reaches a plateau or shows no progress. Given these findings, continued SNF services including physical therapy and occupational therapy were not and are not medically necessary for treatment of this patient. Final Result: The reviewer determined that the services at issue were not and are 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 neurology with subspecialty certification in vascular 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

A 62-year-old male enrollee has requested a power wheelchair for treatment of his paraplegia. Findings:  The physician reviewer found the submitted documentation and relevant literature fails to demonstrate the medical necessity of the requested equipment. The patient has adequate strength to use a manual wheelchair as he is noted to have good upper limb strength and therefore does not require power mobility for ambulation within the home. The patient can perform his ADLs at the manual wheelchair level and therefore does not require power mobility for ADLs. Thus, the requested power wheelchair is not medically necessary in this clinical setting.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Norco. The Health Plan has denied this request indicating that the requested medication is not medically necessary for treatment of the enrollees chronic pain.Findings: There is a lack of peer reviewed evidence based studies, which support Norco as an effective treatment in this clinical setting. The stepwise World Health Organization (WHO) ladder for pain relief is considered the reasonable approach for pain control in the palliative setting. However, in the documentation available for review, there were no objective treatment goals for pain and function noted. Thus, the need to use an opioid as the primary medication treatment strategy for pain has not been established, in this patients case. The Centers for Disease Control and Prevention (CDC) recommends that when opioids are started, clinicians should prescribe the lowest effective dosage. In addition, CDC states epidemiologic studies suggest that concurrent use of benzodiazepines and opioids might put patients at greater risk for potentially fatal overdose and so, clinicians should avoid prescribing opioids and benzodiazepines concurrently whenever possible. The records indicate that this patient is also prescribed benzodiazepines.Additionally, the records do not mention if behavior therapy has been performed, despite much research to support its use. There are other non pharmacological ways of addressing the patients pain that have not been exhausted. In this case, no clear objective goals have been established by the provider or the patient. Moreover, the requested medication is not considered evidence based treatment for fibromyalgia. Also, not all non opioid medications classes have been optimized or tried. It is also reasonable to consider alternatives to opioids and weaning the patient to a lower dose of opioids or even off opioids. There are relevant guidelines regarding the most appropriate method for weaning and terminating opioids for this patient.  In addition, this patient should not be using opioids with sleep related problems. As such, the medical necessity of Norco for treatment of this patients medical condition has not been established. For all these reasons, Norco is not medically necessary for treatment of the patients medical condition. Final Result: The reviewer determined that requested medication is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.