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

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for a procedure to remove breast implants.Findings:  The physician reviewer found that: in medical literature, Tervaert and colleagues state that, autoimmune/inflammatory syndrome by adjuvants (ASIA), allergies, autoimmune diseases, immune deficiencies and lymphomas occur in patients with silicone breast implants. There is a need for adequately adjusted epidemiological studies to ascertain the frequency of these diseases. Balk and colleagues noted that, the evidence remains inconclusive about any association between silicone gel implants and long-term health outcomes. Chao and colleagues found that following scientific validation of their safety, silicone implants have re-gained widespread acceptance for clinical use. Overall, silicone breast implants are associated with a high degree of patient satisfaction and low rates of complications. This patient presents with generalized complaints, which have not been shown to be associated with the presence of silicone gel implants. Based on the medical information received for review, a procedure to remove breast implants  is not medically necessary for treatment of this patient. Final Result: The reviewer determined that the requested services 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 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

Nature of Statutory Criteria/Case Summary:  An enrollee has requested for 12 weeks for treatment of his hepatitis C virus (HCV). Findings:  Three physician reviewers found that according to the most recent joint guidelines issued by the American Association for the Study of Liver Diseases (AASLD) and Infectious Diseases Society of America (IDSA), all patients with chronic hepatitis C should be treated except those with limited life expectancy (less than 12 months) due to non-liver-related conditions. For treatment-naive genotype 1 patients with cirrhosis, AASLD/IDSA guidelines recommend therapy with Harvoni for 12 weeks. These guideline recommendations are based on multiple randomized clinical trials, and the medication is U.S. Food and Drug (FDA) approved for genotype 1 hepatitis C regardless of fibrosis stage. Based on evidence of safety and efficacy in the published literature, and clinical guidelines, Harvoni is medically necessary for 12 weeks in this case. Final Result:  Three reviewers 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: Two reviewers are board certified in gastroenterology and are actively practicing. One reviewer is board certified in internal medicine with sub-specialty certification in gastroenterology and is actively practicing. All three reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

The parent of an 18-year-old male has requested coverage for past residential treatment services for treatment of his multiple mental health conditions.  Findings:  The physician reviewer found that modern psychiatric practice aims to place patients in the least restrictive treatment setting that is likely to be successful.  In general and if feasible, community intervention settings are thought to offer optimization of treatment gains.  However, due to multiple factors and unique considerations, determination of the appropriate level of care for adolescent patients with psychiatric conditions is challenging. The American Academy of Child and Adolescent Psychiatry (AACAP) practice parameters for the treatment of depression state the clinician, together with the child and parents, should evaluate the appropriate intensity and restrictiveness of care (e.g., hospitalization). The decision for the level of care will depend primarily on level of function and safety to self and others, which in turn are determined by the severity of depression, presence of suicidal and/or homicidal symptoms, psychosis, substance dependence, agitation, childs and parents adherence to treatment, parental psychopathology and family environment. Ultimately the interpretation and application of clinical guidelines and patient placement criteria falls upon physicians and therapists working directly with the patient population.  This patients history indicates that he posed a serious threat to himself and others. The patient had failed outpatient therapy while the home situation was disharmonious and not conducive to effective recovery.  Further, the patient demonstrated significant affective pathology and unrefined intrapsychic defenses and self-defeating coping strategies.  From a developmental perspective, this patient evidenced struggles in achieving identity formation, with role diffusion championing, and a complete lack of formal operational thought.  All told, he lacked the psychological maturity to succeed in a less restrictive environment. Although the submitted documentation does not document prior failure of partial hospitalization or intensive outpatient (IOP), the patient more than likely would have failed such settings, thus incurring undue morbidity and risk. Comprehensive services in a 24-hour setting were required, and residential placement was indeed medically indicated and consistent with accepted medical practice. The documentation provided by the residential facility demonstrates active treatment that was supervised by a physician, guided by an individual treatment plan, and reasonably expected to improve the patients condition.
Appeal type: Experimental/Investigational
Decision: Overturned

A 57-year-old female has requested a durable WalkAide for treatment of her multiple sclerosis.  Findings:  Three physician reviewers found that the patient has documented relapsing remitting multiple sclerosis (MS) and difficulty walking secondary to a foot drop. The patient has had falls secondary to this weakness. In the past, the patient has had a trial of the WalkAide device, with documented improvement of her walking. In this particular case, the patient has documented foot drop and gait impairment secondary to her MS. In addition, the records document that the patient experienced benefit with a trial of the WalkAide. Given the provided literature, the WalkAide is likely to be of benefit to the patient. It is anticipated that the device will at least help the patient maintain her current level of function, and could improve the patients independence, function, and most importantly prevent future falls.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a 17-year-old male enrollee has requested inpatient psychiatric hospitalization for treatment of the enrollees behavioral health condition. Findings:  The physician reviewer found that the services at issue were medically necessary for treatment of the patients medical condition. The medical records submitted for review document a slow, but steady, improvement in this patients mood. Upon admission, he wanted to hurt himself. His course was complicated by his long history of migraine headaches and dependence upon pain medications. During the dates in dispute the patient had poor insight, judgment and impulse control with continued impulses to harm himself. On the date indicated the patient did show improvement and was discharged as soon as he was safe to do so. Therefore, based upon the documentation submitted for review, the services at issue were medically necessary for treatment of the patients medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned

A 52-year-old male enrollee has requested a PET scan for evaluation of his stage IIIc malignant melanoma. Findings: Three physician reviewers found that the peer-reviewed literature supports the use of PET scans for surveillance of patients at high risk for developing recurrent/metastatic melanoma. The National Comprehensive Cancer Network guidelines for melanoma advocate for serial follow-up PET scans for patients with a history of stage III melanoma. PET scans are superior for the detection of distant metastases in both the staging and surveillance of melanoma patients (Xing and colleagues). The requested diagnostic procedure demonstrates high accuracy for the diagnosis of both regional and distant disease in cutaneous malignant melanoma and frequently changes patient management (Falk and colleagues).  Therefore, the requested PET scan is likely to be more efficacious than other methods of evaluating this patient.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for laboratory services (CPT code 86677).Findings:  Two of three physician reviewers found that this patient presented to her provider and reported right upper quadrant pain and epigastric pain. She denied nausea or vomiting. Her provider ordered a Helicobacter pylori serology panel. The records noted positive Helicobacter pylori immunoglobulin M (IgM) serology and negative immunoglobulin A (IgA) and immunoglobulin G (IgG) serology. Treatment with omeprazole, clarithromycin and Flagyl was initiated for presumptive Helicobacter pylori infection. Consistent with standard of care, Braden noted that 13C urea breath test or the stool antigen test can be used for noninvasive screening for Helicobacter pylori in a test and treat strategy in younger patients presenting with dyspepsia without alarm symptoms without the need for endoscopic prelude to therapy or retreatment. Braden did not support serologic testing as the study of choice or standard of care. Per the medical evidence, serologic testing sensitivity and specificity falls short when compared with standard test modalities, such as detection of active infection with stool antigen or urea breath assays. In sum, laboratory services (CPT code 86677) were not likely to have been more beneficial than any available standard method of evaluating this patient. Final Result: The reviewers determined that the services at issue were not likely to have been 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 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

Nature of Statutory Criteria/Case Summary: an enrollee has requested authorization and coverage for ultraviolet B (UVB) phototherapy treatment twice per week. Findings:  The physician reviewer found that it is unreasonable for the patient to be changed to an alternative systemic therapy with increased potential of side effects rather than continuing a therapy that has been effective for the patient. The request for coverage of narrow band UVB should be approved for this patient, as it has been a proven treatment and is one with fewer potential side effects than the other systemic therapies available for treatment of her plaque psoriasis. Final Result: The reviewer determined that the services are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in dermatology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested assistant surgeon services during breast reconstruction surgery for treatment of her breast deformity status post bilateral mastectomy and reconstruction.   The physician reviewers found that this patient underwent breast reconstruction revision with replacement of a tissue expander with permanent prosthesis, removal of an intact mammary implant and revision of a reconstructed breast. In the medical literature, Slezak noted that complication can occur with breast reconstruction that requires varying degrees of revision. While an assistant surgeon may be indicated for complex primary breast reconstruction and possibly for revision, the level of difficulty of this surgical revision/reconstruction has not been established, as the operative report has not been provided. As such, the available medical documentation does not support the medical necessity for the assistant surgeon services provided during breast reconstruction surgery.   Final Result:  The reviewer determined that the services at issue were 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 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

A 54-year-old male enrollee has requested an external cardioverter defibrillator (LifeVest) for treatment of his history of severe ischemic cardiomyopathy. Findings:  Three physician reviewers found that survival in ischemic cardiomyopathy is greatly diminished in patients with cardiomyopathy with ejection fractions of less than 35% and mild or moderate congestive heart failure. This is due to the risk of serious arrhythmias including ventricular tachycardia and ventricular fibrillations. Clinical trials have shown a survival benefit for patients with low ejection fraction treated with ICDs compared with patients treated without such devices. Following a myocardial infarction, the initial impairment in left ventricular function may sufficiently improve such that a device is no longer needed. For this reason, a 40 day waiting period is indicated prior to implanting an ICD. While the risk of serious arrhythmias is highest following a myocardial infarction, ICD or WCD has not been shown to improve survival during this period. All told, the device at issue was not likely to have been more beneficial than standard therapies including medical management for treatment of this patients medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld

A 34-year-old female enrollee has requested for autologous platelet concentrate for treatment of her knee pain. Findings:  Two physician reviewers found that there is a lack of well-controlled, randomized studies supporting the use of platelet rich plasma injections for this patients medical condition. Studies showing promising results were laboratory studies, poorly designed clinical studies or clinical studies with significant limitations. In this patients case, autologous platelet concentrate is not likely to be the most efficacious treatment option.
Appeal type: Medical Necessity
Decision: Overturned

A 54-year-old female enrollee requested authorization and coverage of a lightweight power scooter. The Health Plan denied the request indicating that the requested equipment is not medically necessary for the enrollees mobility.One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer overturned the Health Plans denial on the basis that the requested equipment is medically necessary.
Appeal type: Urgent Care
Decision: Upheld

Nature of Statutory Criteria/Case Summary:  An enrollee has requested ambulance services on an emergent basis.  The physician reviewer found that review of the submitted documentation demonstrates that a prudent layperson would not have sought ambulance transport services on the date in question. Upon review of the submitted medical records, the patient presented with complaints of being unable to sleep for the last three weeks without reported chest pain, shortness of breath, pain, weakness, headache, loss of function, nausea, vomiting, or diarrhea. The patients pain scale was 0 out of 10. In a letter from the patient, he indicated that he felt like he was having a heart attack. Although the notation on the EMT report notes that there were heart problems this was from the patients history and not an acute complaint on the date in dispute. In sum, the patient was not suffering from a serious medical condition that was likely to place the patients health in serious jeopardy, cause serious impairment to body functions or cause serious dysfunction to a body organ or part. Thus, the services in question did not meet prudent layperson criteria for emergent care. Final Result: The reviewer determined that the patients symptoms did not meet prudent layperson criteria for emergent care. Therefore, the Health Plans denial should be upheld.  Credentials/Qualifications: The reviewer is board certified in emergency 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: Medical Necessity
Decision: Upheld

The patient is a 56-year-old female who is requesting reimbursement for a CT scan of the abdomen and pelvis, which was performed in January 2006. The progress notes dated January 2006 state that the patient was having left lower quadrant pain for the past last three weeks. There was no bleeding and no fever. On physical examination there was left lower quadrant tenderness on firm pressure. A CT scan of the abdomen and pelvis was ordered at that point. The results of the scan were mostly unremarkable. The Health Plan has denied reimbursement for the CT scan on the basis that it was not medically necessary.Review of the submitted clinical information indicates the description of pain was rather vague. There is no evidence of any red flags requiring a CT scan as a first choice in the workup of this patients abdominal pain. A pelvic ultrasound would have been appropriate as the first diagnostic procedure in this clinical setting. Given the absence of documented indications for a CT scan, and the availability of other diagnostic procedures, I have determined the CT scan at issue was not medically necessary for evaluation of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Experimental/Investigational
Decision: Upheld

A 44-year-old female enrollee requested bronchial thermoplasty for medical treatment of her asthma.  Findings:  Two physician reviewers found that bronchial thermoplasty may be considered as a treatment option for patients with uncontrolled severe asthma despite maximal medical therapy.  Although this patient may have asthma, other diagnoses, such as vocal cord dysfunction or lisinopril-induced cough, have not been excluded.  She is not on maximum medical therapy because her regimen does not include a long-acting beta-agonist.  The current medical evidence does not support bronchial thermoplasty because the diagnosis of asthma is uncertain and she is not on maximal medical therapy.  All told, the requested bronchial thermoplasty is not likely to be more efficacious than other available treatment options.
Appeal type: Experimental/Investigational
Decision: Overturned

A 64-year-old female enrollee has requested for acellular dermal allograft for treatment of her capsular contracture.   Findings:  Two physician reviewers found that a study by Spear of 100 patients undergoing implant expander coverage with Alloderm has shown no incidence of hematoma, seroma, infection, or implant exposure as well as a decreased incidence of capsular contracture.  Other studies show that Alloderm can prevent rippling, symmastia, implant malposition, and bottoming out. These are all common problems with expander-based breast reconstruction when Alloderm is not used. Alloderm is incorporated into the surrounding tissue, and late re-operative biopsies show that over time Alloderm takes on the histologic characteristics of fascia.  Immediate breast reconstruction with Alloderm is a standard of care for post-mastectomy breast reconstruction.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a 15-year-old female enrollee has requested child/adolescent psychiatric residential treatment for treatment of the enrollees mood disorder, not otherwise specified, oppositional defiant disorder, post-traumatic stress disorder and parent-child relational problems.  Findings:  The physician reviewer found that the record indicates that the patient was largely oppositional and impulsive, culminating in an elopement attempt on the said date. However, a few weeks thereafter, she had shown significant improvement, and precautions were removed. She showed continued improvement during the course of her stay at the facility and did not show evidence of impulsivity or severe oppositional behavior. There is no indication of risk to self or others at any time during the course of her stay. She appeared to be participating avidly in the program and was motivated for recovery. American Psychiatric Association practice guidelines indicate that patients should be treated in the least restrictive setting which is likely to be safe and effective. The data submitted for review indicate that discharge prior to the said date would not likely have resulted in a positive treatment outcome due to the patients impulsivity. The patient could not have been safely managed on an ambulatory basis prior to the date in question.  All told, child/adolescent psychiatric residential treatment provided from during this time was medically indicated for the treatment of this patient.  The medical necessity of child/adolescent psychiatric residential treatment going forward has not been established.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Combigan 0.2%-0.5% eye drops. This patient has progressive peripheral vision loss with a diagnosis of primary open angle glaucoma of both eyes. The records provided for review do not document that the patient has tried and failed, or has a contraindication to, treatment with the standard available eye drops on the Health Plans formulary to support an indication for Combigan. The medical literature has provided data demonstrating the safety and efficacy of several medical therapies for the treatment of open angle glaucoma. All told, the requested Combigan 0.2%-0.5% eye drops are not medically necessary for treatment of this patient.Final Result: The reviewer determined that the requested medication 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 ophthalmology 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.