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

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for rhinoplasty. The World Professional Association for Transgender Health (WPATH) lists facial feminization surgery as a medically necessary treatment for gender dysphoria. WPATH notes that for certain patients, an intervention like a reduction rhinoplasty can have a radical and permanent effect on their quality of life. In this case, given that the patient has a diagnosis of gender dysphoria and the provider has recommended facial feminization surgery, the requested service is medically indicated. Therefore, rhinoplasty is medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested services 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 psychiatry with expertise in transgender health 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 32-year-old male enrollee requested authorization and coverage of endovenous laser therapy. The Health Plan denied the request indicating that the requested therapy is not medically necessary for treatment of the enrollees varicose veins.One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer upheld the Health Plans denial on the basis that the requested therapy is not medically necessary.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Norco (30 tablets per month). The Centers for Disease Control and Prevention (CDC) guidelines state that, Nonpharmacologic therapy and nonopioid pharmacologic therapy are preferred for chronic pain. Clinicians should consider opioid therapy only if expected benefits for both pain and function are anticipated to outweigh risks to the patient. Per the CDC guidelines, Clinicians should continue opioid therapy only if there is clinically meaningful improvement in pain and function that outweighs risks to patient safety. The Federation of State Medical Boards (FSMB) guidelines recommend opioid therapy for chronic pain that is not cancer-related, or part of palliative care or end-of-life care, only when non-opioid and non-pharmacological options have not been effective and maintain opioid dosage as low as possible and continue only if clear and objective outcomes are being met. In this case, the patient has chronic neck and back pain attributed to a remote motor vehicle accident, which resulted in cervical and thoracic fractures that were managed non-operatively. The patient has been treated with physical therapy for refractory muscle spasms of the trapezius muscles. The provider recommended participation in an integrative pain management program and tapering off Norco. The provider noted that continued opioid therapy for chronic pain management is not indicated. Per the CDC guidelines and current medical literature recommendations, the patients condition should be managed with non-pharmacological treatment modalities. Therefore, the requested Norco (30 tablets per month) is 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 anesthesiology with subspecialty 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: Medical Necessity
Decision: Overturned

The patient is a 49-year-old woman who has experienced pain in her shoulder for 1.5 years. Upon examination, the patients provider indicated the patient had acromioclavicular joint arthritis and a possible rotator cuff tear. The patient has requested authorization for an MRI. The Health Plan has denied her request indicating that an MRI is not medically necessary.An MRI is medically reasonable and appropriate in this case. The patient would benefit from a complete work-up of her shoulder including x-rays and an MRI to determine the cause of her pain. An MRI is medically indicated in order to evaluate the rotator cuff, labrum, and other soft tissue components not visualized by x-rays. Therefore, I have determined that the requested MRI is medically necessary for evaluation of the patients medical condition. As such, the Health Plans denial should be overturned.
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 services including daily wound care and physical therapy. The specialized skill, knowledge and judgment of a skilled professional nurse has not been required to safely and effectively provide medically necessary and reasonable treatment to this patient. This patients wound care is not complex and does not require daily services at the SNF level of care. The patient does not have other skilled nursing needs. The patient has been at a functional level. All told, the skilled nursing facility services including daily wound care and physical 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 physical medicine and rehabilitation with subspecialty certification in neuromuscular 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 55-year-old female who had a weight of 282 pounds and a body mass index (BMI) of 45.5 when evaluated for bariatric surgery. Her comorbid conditions include asthma and sleep apnea. She has completed a psychological evaluation and was deemed an appropriate candidate for weight loss surgery. The patient has selected the Lap Band procedure as her treatment of choice for surgical weight loss. The Health Plan denied authorization and coverage for the Lap-Band procedure citing a lack of medical necessity.With a BMI of approximately 45.5 and comorbid conditions such as asthma and sleep apnea, the patient meets nationally accepted medical necessity criteria for consideration of weight loss surgery. However, the current scientific data shows that the Lap-Band is inferior to other surgical alternatives in terms of excess body weight loss. The weight loss with the Lap-Band is typically 50% of excess, as compared to 60-70% with Roux-en-Y and greater than 60% with the duodenal switch. A patient who weighed 282 pounds would need to lose between 100 and 125 pounds to reach a BMI close to 25 for a successful outcome. If in fact the Lap-Band procedure results in the loss of 50% of excess body weight, the patients BMI would remain at approximately 37, which is still considered morbidly obese by some standards. Given the above information, further investigation of other surgical weight loss procedures would be worthwhile in order to secure optimal weight loss. Based upon the information set forth above, I have determined that the requested procedure is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.
Appeal type: Experimental/Investigational
Decision: Overturned

Findings:  The physician reviewer found that An enrollee has requested authorization and coverage for lymphovenous bypass surgery. Without effective treatment, extremities with lymphedema, in addition to the distressing symptoms and disfigurement, are subject to recurring episodes of cellulitis often requiring hospitalization. Over the last decade, microsurgical lymphovenous anastomosis for patients with relatively early disease and vascularized lymph node transfer for patients in later stages have become an accepted treatment for symptomatic lymphedema of the upper extremity after breast or axillary operations. On review of the peer-reviewed medical literature, lymphovenous bypass surgery has been shown to result in substantial objective improvement in circumference and similar relief of symptoms in this patient population (Scaglioni, et al.). For these reasons, the requested lymphovenous bypass surgery 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 lymphovenous bypass surgery 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.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for positron emission tomography (PET) scan for evaluation of the enrollees ovarian cancer stage I. Findings:  Two of the three physician reviewers found that the patient who presented with pelvic discomfort associated with her menses and was found to have a right adnexal cyst on ultrasound. A CA125 was elevated. A repeat ultrasound performed 2016 showed that the cyst had increased in size from 2.3 x 1.7 x 1.7 to approximately 3.2 x 2.6 x 2.7. She underwent laparoscopic removal of the cyst with final pathology showing a clear cell carcinoma arising from a mixed serous/clear cell cystadenofibroma. The patient reported that she strongly desires fertility preservation. The patients provider ordered a positron emission tomography (PET) scan. The patient requested coverage for PET scan. The Health Plan denied the requested services as investigational for the evaluation of this patients medical condition.  Although PET scans are not routinely used for preoperative staging of ovarian cancer, there is clinical data to support its use in certain circumstances. Since this patient is young and desires fertility preservation, avoiding a larger surgery could be advantageous towards that goal. The National Comprehensive Cancer Network guidelines endorses the use of PET scan for indeterminate lesions if results would alter management. As this patient has a cancer arising from a benign cyst, it could be considered indeterminate. A positive PET scan for metastatic disease would alter her management. A PET scan is supported in this clinical setting. Final Result: The reviewers determined that the requested services at issue 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: Reviewers 1, 2, and 3 are board certified in internal medicine with sub-specialty certification in medical oncology 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:  An enrollee has requested authorization and coverage for pembrolizumab (Keytruda) 100 mg/4 ml every three weeks for eight cycles.The U.S. Food and Drug Administration (FDA) states, Pembrolizumab, as a single-agent, is indicated for the treatment of patients with metastatic non-small cell lung cancer (NSCLC) whose tumors express PD-L1 (TPS greater than or equal to 1%) as determined by an FDA-approved test, with disease progression on or after platinum-containing chemotherapy. The National Comprehensive Cancer Network (NCCN) indicates that the combination of carboplatin, pemetrexed, pembrolizumab, and bevacizumab with low dose Tagrisso (osimertinib) is not considered a standard of care. In this case, the patient has progressed after use of Tagrisso and requested use is for combination therapy with carboplatin, pemetrexed, bevacizumab and low dose Tagrisso. The coverage criteria is not met and this combination of drugs is not considered a standard of care with use not supported by major drug compendia or the medical literature. Therefore, pembrolizumab (Keytruda) 100 mg/4 ml every three weeks for eight cycles is not medically necessary for treatment of the patients medical condition.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 internal medicine with sub-specialty certification in medical oncology 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 parent of a 17-year-old female enrollee has requested residential treatment services for the treatment of the enrollees eating disorder. Findings:  The physician reviewer found that although the patient clearly has anorexia nervosa, the chart notes indicate progress in recovery, with expected weight gain and relative relinquishment of her calorie restriction.  Based on the notes included, there was a clear-cut progression as of her admission, and it appears that she was quite a bit improved. Additionally, some of the subsequent notes also point to the sustainment of this improvement, inclusive of other passes. As such, residential treatment beyond the date in question was not medically indicated.
Appeal type: Experimental/Investigational
Decision: Upheld

A 45-year-old male enrollee has requested total disc arthroplasty (artificial disc) with a one-day inpatient stay for treatment of his neck pain. Findings:  Three physician reviewers found that although cervical disc fusion has been an accepted procedure for the treatment of appropriate patients with disc disease, the risk of adjacent level degeneration has led to interest in artificial disc replacement. Although some reports have been encouraging, and a large number of the procedures have been done, the effectiveness of the prosthesis remains uncertain. The results of many studies were inconclusive, and there is a need for reports of long-term outcomes. Heterotopic ossification has been reported in studies followed over time, and an even higher rate with long-term follow-up has been suspected. The necessity for long-term follow-up to confirm the potential benefits in minimizing adjacent segment degeneration remains as well. All told, the superior efficacy of the requested services in this clinical scenario has not been established.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: A transgender enrollee has requested authorization and coverage for laser hair removal for treatment of the enrollees gender dysphoria. Findings:  The physician reviewer found that the requested services are medically necessary for treatment of the patients medical condition. Excessive facial hair in a female would be considered abnormal and is referred to as hirsutism. Hirsutism is a medical diagnosis where terminal hair grows in female in areas that are normally found in males.  Accordingly, facial hair removal is within accepted standards of practice and clinically appropriate for treatment of gender dysphoria. This would include the face and parts of the genitalia. This patients excessive facial hair is more consistent with the male gender. Additionally, hormone therapy has not been effective in improving this patients medical condition. Therefore, facial hair removal is medically necessary for the treatment of this patients gender dysphoria. With regard to whether the requested services are considered reconstructive in nature, excessive facial hair in a female is an abnormal body structure.  Hirsutism is a condition that is congenital in that the hair growth is determined by the genetic and hormonal makeup of the patient. As such, the requested facial hair removal can provide substantial improvement in the appearance of terminal hair and in the appearance in this patient. Moreover, the requested services are going to improve emotional function for this patient. Final Result: The reviewer determined that the requested services are medically necessary and are reconstructive in nature 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:  The enrollee has requested authorization and coverage for Tremfya 100mg/ml injections. According to the medical record, the enrollee was initially seen by a dermatologist complaining of a rash on his body that was not responding to Benadryl or cortisone cream. He was diagnosed with psoriasis vulgaris with 50% of body surface area involvement including his arms, legs, feet, back, and buttocks. He was not a good candidate for Methotrexate or Soriatane due to their effects on the liver. In addition, the enrollee is unable to go to the office for ultraviolet therapy. A Quantiferon TB gold test was negative. He was given a sample injection of Tremfya with plans for his next injection in four weeks. He also used topical steroids. At follow-up, his psoriasis has improved to one percent body surface area involvement. His physician has recommended continued treatment due to his significant response to therapy. The health plan indicates the requested medication, Tremfya 100mg/ml injection is not medically necessary for treatment of the enrollees medical condition. Per the health plan, it has not been determined the enrollee has tried methotrexate, cyclosporine, and acitretin. They will not cover Tremfya until the enrollee has tried two other treatments first, including Enbrel, Humira and Cosentyx. They may also cover Tremfya if there is physician documentation as to why the enrollee cannot take the other medication. National consensus guidelines advocate for the use of biologics after first-line therapy has failed. Humira, Enbrel, and Cosentyx are all Food and Drug Administration (FDA) approved for the treatment of plaque psoriasis. In fact, Humira has amassed the longest published safety data of any drug FDA approved medication for the treatment of plaque psoriasis since 2008. There are insufficient head to head trials showing superiority of Tremfya to the other biologics. Current medical literature does not support the use of Tremfya over the available formulary alternatives. The record indicates the enrollee has tried and failed topical steroids. However, there is insufficient documentation of the enrollees trial and failure of methotrexate, cyclosporine, acitretin, Enbrel, Humira, and Cosentyx. The records do not document reasons why the preferred medications cannot be used. Final Result: The reviewer determined that the service at issue is not medically necessary for treatment of the enrollees condition. Credentials/Qualifications: The physician 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 similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

A 54-year-old female enrollee  requested spinal fusion (20930  allograft, morselized, or placement of osteopromotive material, for spine surgery only; 22552  arthrodesis, anterior interbody, including disc space preparation, discectomy, osteophytectomy and decompression of spinal cord and/or nerve roots; cervical below C2, each additional interspace; 22845  anterior instrumentation; 2 or 3 vertebral segments; 22851  application of intervertebral biomechanical device)  for medical treatment of the enrollees spine.  Findings:  The physician reviewer found that the current medical evidence does not support the requested services in this clinical setting.  According to Bambakidis and colleagues, strict prospective studies are needed to determine when a fusion of the degenerative cervical and lumbar spine is indicated.  Patients with severe radicular pain may be considered for surgery after a comprehensive trial of conservative management.  The authors noted that surgery should only be considered after conservative measures have been exhausted and a radiographic abnormality is present at the symptomatic level.  As per the documentation submitted, the most recent physician progress notes were provided, however, the patients physical examination at that time was not provided for this review.  Therefore, there was no objective evidence of a significant musculoskeletal or neurological deficit.  There was no documentation of instability upon flexion and extension view radiographs or electrodiagnostic evidence of cervical radiculopathy.  Without objective evidence of an abnormality and imaging evidence of instability and neurocompression, the medical necessity of the requested services cannot be established.  Therefore, the requested services are not medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Overturned

A 55-year-old female enrollee has requested bariatric surgery for treatment of her morbid obesity.  Findings:  The physician reviewer found that review of the submitted documentation reveals that this patient meets the criteria for weight loss surgery as set forth by the National Institutes of Health (NIH) recommendation guidelines. In addition, the patient has documented co-morbidities associated with morbid obesity. The overwhelming scientific evidence supports the position that weight loss surgery is the most effective method for sustained weight loss and should resolve or improve many of the patients co-morbidities that are associated with obesity. Further attempts at standard weight loss measures are not likely to allow this patient to achieve adequate weight loss. As such, bariatric surgery is medically appropriate and indicated in this particular setting.