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

A forty year-old male who had bariatric surgery has chronic pain in his neck, upper extremities, mid back and upper back is requesting authorization of breast reduction surgery.Reviewers Findings:  The reviewing physician found that breast reduction surgery is not a cure for degenerative disc problems and other conservative or neurosurgical treatment modalities should be considered to address the etiologies of this pain.  The reviewing physician found that he Health Plan denial should be upheld.
Appeal type: Experimental/Investigational
Decision: Upheld

A 34-year-old female enrollee has requested for Amevive for treatment of her psoriasis. Findings:  Two physician reviewers found that phototherapy and systemic therapies are effective ways to treat psoriasis. A trial of the older systemic therapies and/or phototherapy is medically reasonable prior to the initiation of treatment with Amevive. Should the more established therapies prove ineffective, then the issue of coverage for Amevive should be re-addressed.
Appeal type: Experimental/Investigational
Decision: Upheld

A 51-year-old female enrollee has requested Botox injections for the treatment of her pelvic pain. Findings:  Two physician reviewers found that while there is substantial interest in the use of Botox for various conditions, its efficacy in treating myofascial pelvic dysfunction has not been established. The use of Botox to paralyze pelvic floor muscles as a treatment for chronic symptoms is clearly still in the early stages of investigation. Until further studies document the safety and utility of this therapy, there is no clear clinical indication for the use of Botox in the treatment of persistent pelvic floor pain.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for transcatheter arterial chemoembolization (TACE) for treatment of the enrollees metastatic adenocarcinoma to the liver. Findings: Two of the three physician reviewers found that the patient is diagnosed with oligometastatic adenocarcinoma of the liver in segment 7. She has undergone multiple rounds of chemotherapy in the past which have prevented growth of the lesions, but have not eradicated them. Magnetic resonance imaging performed and confirmed hepatic metastases. Office notes indicate this patient has excellent performance status. In addition, this patient is not being considered for liver transplantation at this time. The provider recommended transcatheter arterial chemoembolization (TACE) for treatment of this patient's hepatic metastases. The Health Plan denied the requested services as investigational. There is a lack of peer-reviewed literature that supports the use of TACE in this particular clinical situation. The documentation submitted does not indicate that she meets the criteria for treatment with TACE. She does not have the specific tumor types that would be covered by TACE. She is not being considered for liver transplantation that may have involved the use of TACE as a bridge. She does not have bulk symptoms for the liver metastases. Instead, other options are available to her for treatment of her tumors. 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: Reviewers 1 and 3 are board certified in diagnostic radiology with sub-specialty certification in interventional radiology and are actively practicing. Reviewer 2 is board certified in diagnostic radiology with expertise in interventional radiology 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

A 54-year-old male enrollee requested Sovaldi (sofosbuvir), Pegasys and ribavirin for medical treatment of the enrollees hepatitis C.  Findings:  The physician reviewer found that the submitted documentation supports the medical necessity of the requested medication combination.  There is sufficient support for the requested medication combination in this clinical setting.  Sovaldi has been included in nationally-accepted joint treatment guidelines of the American Association for the Study of Liver Diseases (AASLD) and the Infectious Diseases Society of America (IDSA).  This patient is motivated to begin interferon-based therapy due to concern that his liver disease may progress.  The proposed treatment regimen meets AASLD/IDSA recommendations for treatment-naive patients with hepatitis C, genotype 1.  All told, Sovaldi (sofosbuvir), Pegasys and ribavirin is medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Sovaldi 400 mg, one tablet per week for 12 weeks for treatment of the enrollees hepatitis C.  Findings:  The physician reviewer found that According to the most recent joint guidelines issued by the American Association for the Study of Liver Diseases and the Infectious Diseases Society of America, all patients with chronic hepatitis C should be treated except those with limited life expectancy due to non-liver-related conditions.  This applies regardless of fibrosis stage or viral load.  However, the guidelines no longer support the use of Sovaldi with ribavirin for treatment-naive genotype 2 patients.  Per the guidelines, the alternative medication regimens which are recommended are Epclusa, and Sovaldi with Daklinza.  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 gastroenterology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patients parent has requested reimbursement for the cranial molding helmet provided. Findings:  The physician reviewer found that In the medical literature, a study  noted that the severity of skull deformation was quantified using the oblique diameter difference index and the cranioproportional index (CPI) of plagiocephalometry. The oblique diameter difference index provides the degree of the plagiocephalic component of skull deformation and is the ratio between the longest cranial diagonal and the shortest cranial diagonal multiplied by 100%, with both located at 40 degrees from the anterior-posterior line. This patients oblique diameter difference index was 108%, which is consistent with moderate deformation. In addition, cut off points used to measure the degree of skull deformity must take into account more than just the CPI as demonstrated by a study. In most cases, positional plagiocephaly can be treated by change in positioning . However, there is Class I evidence from a single study and Class II evidence from several studies that repositioning is inferior to physical therapy and to use of a helmet, respectively. According to the Congress of Neurological Surgeons, helmet therapy is recommended for infants with persistent moderate to severe plagiocephaly after a course of conservative treatment (repositioning and/or physical therapy). This patient presented with moderate deformity in terms of oblique diameter difference index, coupled with the failure of more conservative measures including repositioning, the cranial molding helmet provided was medically necessary for the patients medical condition. Final Result: The reviewer determined that the device at issue was 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 pediatrics with sub-specialty certification in developmental-behavioral pediatrics 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

A 43-year-old female enrollee has requested a temporomandibular occlusal splint for treatment of her temporomandibular joint pain. Findings:  The physician reviewer found that pre-auricular facial pain in the absence of ear pathology is almost always directly associated with acute and chronic intracapsular TMJ pain. This is true even in the absence of joint pathology noted on MRI. The combination of medical management with pharmacologic agents and the daily use of a dental occlusal splint is the most common form of therapy for this type of TMJ dysfunction.
Appeal type: Medical Necessity
Decision: Upheld

A 59-year-old male enrollee requested authorization and coverage of acupressure treatment. The Health Plan denied the request indicating that the requested therapy is not medically necessary for treatment of the enrollees fibromyalgia and trapezius spasms.One acupuncture reviewer performed a medical necessity Independent Medical Review. The acupuncture reviewer upheld the Health Plans denial on the basis that the requested therapy is not medically necessary.
Appeal type: Experimental/Investigational
Decision: Upheld

An enrollee has requested reimbursement for perirectal spacers. The National Comprehensive Cancer Network (NCCN) guidelines recommend prostate localization using image guided radiation therapy (IGRT) with either three-dimensional conformal radiation therapy (3D-CRT) or intensity modulated radiation therapy (IMRT) for target margin reduction and treatment accuracy. The guidelines do not recommend on use of perirectal spacers, such as the SpaceOAR system, for prevention of rectal complications. Similarly, the American Urological Association (AUA) do not comment on the use of perirectal spacers to be used during IMRT or IGRT. Therefore, the perirectal spacers were not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Findings:  Three of the three physician reviewers found that the perirectal spacers were 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 medical device at issue was not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: Physician reviewers 1, 2, and 3 are board certified in urology 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 reimbursement for residential treatment center services. The submitted documentation fails to demonstrate the medical necessity of the services at issue. At the time of discharge from the residential treatment center on, the patient had not shown evidence of suicidality for several weeks, had participated actively in therapy, engaged in the treatment program, was motivated to make progress and was future oriented. Persistent problems involved the parent-child relationship. The American Academy of Child and Adolescent Psychiatry and the American Association of Community Psychiatrists Child and Adolescent Level of Care Utilization System (CALOCUS) assists in determining the appropriate level of care. In terms of risk of harm, the records support a score of 2. Although he denied suicidal ideation for some time, the patient had a history of suicidal behavior with medical consequences. With regards to functional status, the records support a score of 1. The patient was functioning academically and socially. In terms of comorbidity, the records supported a score of 2. The patient had used cannabis the past, and parent-child relational problems persisted. With regards to level of stress of the recovery environment, the records supported a score of 2. The patient had a mildly stressful environment. The family home may be a trigger for memories of traumatic loss at the death of his mother. In terms of level of support for the recovery environment, the records support a score of 2. The patients father was engaged in treatment. With regards to resiliency and treatment history, the records support a score of 2. The patient had engaged and embraced treatment, demonstrated motivation, and continued to cooperate in treatment, even after the disappointment of being referred once again to a residential placement. In terms of acceptance and engagement of the patient, the records support a score of 1. The documentation noted optimal engagement and acceptance. With regards to acceptance and engagement of the parent, the records support a score of 2. The patients father demonstrated some resistance to having the patient outside of the residential setting. Thus, the patient has a composite score of 14. This score correlates with outpatient treatment. Therefore, residential treatment center services provided from were not medically necessary for the treatment of this patient.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 psychiatry with sub-specialty certification in child and adolescent psychiatry 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

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested reimbursement and prospective authorization and coverage for intravenous immunoglobulin (IVIG). There is insufficient documentation in the medical records provided to support a diagnosis of a hypogammaglobulinemia, or PANDAS, based on the documentation provided for review. PANDAS has been described as the acute onset of obsessive compulsive disorder and/or motor tics in children following recent streptococcal infection. Symptoms frequently relapse and remit, and may respond poorly to psychotropic medications. A study demonstrated the efficacy of plasmapheresis and IVIG in patients with refractory symptoms. The proposed disease mechanism suggests that PANDAS should respond to immunomodulatory therapies, such as oral steroids, IVIG, and therapeutic plasmapheresis. A randomized controlled trial that compared IVIG against plasmapheresis and placebo found that at one month, neuropsychiatric symptom severity was reduced by 45% in the IVIG group, by 58% in the plasmapheresis group, and by 0% in the placebo group. Another randomized placebo controlled trial of IVIG in children with PANDAS failed to demonstrate a benefit of treatment with IVIG. This patients records do not support an underlying immunodeficiency. The patients immunoglobulin titers are normal. The patient has immunogenic responses to diphtheria, tetanus and pertussis. Although the patients titers to several pneumococcal serotypes were low, it is unclear when the pneumococcal vaccine was administered in relation to the titers being drawn. Based on these findings, the IVIG provided was not and is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.One reviewer found that the IVIG provided was and is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: Two of the three reviewers determined that the medication at issue was not and is not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications:  One reviewer is board certified in pediatrics and neurology with special qualification in pediatric neurology and is actively practicing. One reviewer is board certified in pediatrics with sub-specialty certification in pediatric critical care and is actively practicing.  One reviewer is board certified in pediatrics with sub-specialty certification in pediatric critical care 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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for panniculectomy. In this patients case, the records document a moderately overlapping symptomatic lower abdominal pannus. She is documented to have functional impairment with chronic rashes as well as periodic open sores.  She has attempted conservative management with typical topical dermatologic treatment, including powder. In this clinical setting, a panniculectomy would likely significantly improve her functional impairment and is medically necessary. Additionally, the patients condition constitutes an abnormal structure of the body. She has direct evidence of active rashes around the umbilicus that are noted to be chronic. The treatment of her obesity has led to an excess skin overlap around the umbilicus. Obesity is considered a disease. The requested surgery is planned to improve her function as the result of pain and chronic rashes/open sores. Per the records, the requested panniculectomy is likely to create a normal appearance to the extent possible and would provide more than a minimal improvement in the appearance of the patient. Thus, the requested panniculectomy is reconstructive in nature. Final Result: The reviewer determined that the requested services are medically necessary for treatment of the patients medical condition and are reconstructive in nature. 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: Overturned

A 66-year-old female has requested Xolair injectable therapy, every month for 6 months, for treatment of her urticaria of the idiopathic type.  Findings:  Two physician reviewers found that  the patient has severe chronic urticaria.  Per the submitted documentation, she is currently on high doses of several antihistamines, and she continues to have debilitating hives.  Her provider noted that the patient has experienced significant weight change, behavior change, and sleep difficulties due to her exposure to high doses of prednisone.  The provider has recommended Xolair injectable therapy, every month for 6 months.  In this patients case, Xolair injectable therapy, every month for 6 months, is likely to be more efficacious than other treatment alternatives.  She has severe urticaria despite daily, high doses of several antihistamines.  Numerous studies have demonstrated the efficacy of Xolair therapy for the treatment of patients with chronic urticaria.  The current medical evidence supports Xolair injectable therapy in this clinical setting.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested Viekira Pak and ribavirin (24 weeks of treatment for treatment of the enrollees chronic hepatitis C virus genotype 1a. Findings: The physician reviewer found that according to the most recent joint guidelines issued by the American Association for the Study of Liver Diseases (AASLD) and the Infectious Diseases Society of America (IDSA), all patients with chronic hepatitis C, regardless of fibrosis, should be treated except those with limited life expectancy due to non-liver-related comorbid conditions. The AASLD and IDSA guidelines do not support extension of therapy solely based on detectable viral load at four weeks into treatment. However, this patient does have early cirrhosis per recent ultrasound. Per the AASLD and IDSA guidelines, cirrhotic treatment-naive genotype 1a patients should be treated with Viekira Pak and ribavirin for 24 weeks. This recommendation is based on multiple high-quality clinical trials showing cure rates of over 90% and safety (Feld, et al; Poordad, et al; Ferenci, et al). For these reasons, the requested treatment with Viekira Pak and ribavirin for 24 weeks (an additional 12 weeks) is supported as medically necessary for the treatment of this patients hepatitis C infection.Final Result: The reviewer determined that the requested medications 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 internal medicine with sub-specialty certification in gastroenterology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

The parent of a thirteen-year-old female enrollee has requested for residential psychiatric care  for treatment of the enrollees condition. Findings:  The physician reviewer found that there is no documentation pertaining to an imminent perceived return to drug use.
Appeal type: Medical Necessity
Decision: Overturned

The patient has requested reimbursement for fertility preservation services. The American Society of Clinical Oncology and the American Society for Reproductive Medicine consider sperm and embryo as well as oocyte cryopreservation are considered standard practice for patients with cancer planned to undergo treatment with chemotherapy. This patient has a history of Hodgkins lymphoma. Treatment planning included chemotherapy. The provider referred the patient for fertility preservation services. With current technology, fertility preservation services have been shown to be successful. In this case, the patients fertility status after treatment for Hodgkins lymphoma with chemotherapy is uncertain. Given the treatment plan outlined for the treatment of her Hodgkins lymphoma, her fertility will be suboptimal. All told, the fertility preservation services were medically necessary for treatment of this patient.Final Result: The reviewer determined that the services at issue 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 obstetrics and gynecology 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.