Persius/imr-appeals huggingface dataset:
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement of autonomic testing. Findings:  The physician reviewer found that although autonomic testing is not required for all patients with diarrhea, it is reasonable for a subset of patients such as this patient. There is a proven association with paraneoplastic processes and antibodies with autonomic dysfunction. This patient had a voltage gated potassium antibody which has specifically been associated with autonomic dysfunction. As part of his work-up it was critical to determine the extent of his symptomatic involvement so that the proper diagnosis could be reached and the proper treatment initiated. Autonomic testing was a reasonable approach to determine what clinical features were associated with his diarrhea and antibody testing. If autonomic abnormalities were detected, this would have also provided insight into his abnormal gastrointestinal findings. Given this support, the autonomic testing was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Findings:  Three physician reviewers found the autonomic testing was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Final Result: The reviewers determined that the autonomic testing was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Credentials/Qualifications: Physician reviewers 1, 2 and 3 are board certified in neurology 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

The patients parent has requested authorization and coverage for combined superficial temporal artery (STA)-middle cerebral artery (MCA) and indirect bypass surgical procedures. Moyamoya disease is a progressive occlusive vasculopathy that involves the supraclinoid internal carotid arteries and Circle of Willis, and results in the formation of collateral vessels at the skull base. The progressive nature of this disease leads to cerebral ischemia and possible intracerebral hemorrhage. The physician reviewer found that  treatment of moyamoya disease is mainly surgical revascularization, using revascularization techniques that include direct, indirect, and combined strategies. This patient is symptomatic. A magnetic resonance imaging (MRI) scan demonstrated severe right supraclinoid ICA stenosis and left internal carotid artery (ICA) occlusion. Therefore, the requested combined STA-MCA and indirect bypass surgical procedures are medically necessary for treatment of this patient.
Appeal type: Medical Necessity
Decision: Overturned

A 48-year-old female enrollee has requested bilateral breast reduction surgery for treatment of her macromastia.  Findings:  The physician reviewer found that the patient is documented in the medical records to have macromastia, which is abnormal enlargement of the breasts. Her photographs clearly demonstrate significant macromastia. Her very pendulous breasts were noted to significantly limit normal breast/chest exam. According to the medical records, the patients cup size was reported as DDD which is greater than size DD, which the Health Plan requires. In addition, the patient is documented to have significant complaints of pain due to her large breasts with exacerbation of her degenerative disc disease from the pressure of her bra. She is documented to have right shoulder impingement syndrome and sensory changes of the hand. The patients plastic surgeon does not consider the size of the patients breasts to be a significant contributor to these symptoms. However, based on the size of the patients breasts and the shoulder grooving as seen in the photographs, the patients breast size could be significantly exacerbating her symptoms. Thus, there are documented functional concerns in this case that can be addressed with breast reduction surgery.Furthermore, the American Society of Plastic Surgeons guidelines indicate reduction mammaplasty is considered reconstructive surgery and medically necessary for symptomatic macromastia patients when the following criteria are met:Documentation of two of the following:-Chronic breast pain caused by weight of the breasts-Intertrigo unresponsive to medical management-Upper back, neck, and shoulder pain -Backache, unspecified -Thoracic kyphosis, acquired -Shoulder grooving from bra straps-Upper extremity paresthesia caused by brachial plexus compression syndrome secondary to the weight of the breasts being transferred to the shoulder strap area-Headache-Congenital breast deformityGiven this patients documented upper shoulder, neck and back pain, as well as shoulder grooving from bra straps, she meets at least two of the above criteria for breast reduction surgery.With regard to the concerns over the patients obesity, complications increase with the weight of the resection and not necessarily with the weight of the patient.  Additionally, a study by Zubowski and colleagues disputes the fact that weight loss to a level other than within 15% of ideal body weight, affects the rate/severity of complications. The authors state, Although weight loss is advisable from an overall health standpoint, there are no data in the surgical literature to support the supposition that weight loss will reduce breast size to such a degree as to relieve the symptoms of macromastia. The authors further note that denial of reduction mammaplasty on the basis of weight alone is not supported by the plastic surgery literature.In summary, the submitted medical record documentation demonstrates breast reduction surgery is medically necessary for this patient.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient is a transgender female with a history of gender dysphoria. The records noted that she has been on hormone therapy.  In a letter dated 12/6/18, the patients representative indicated the patient is seeking laser hair removal to alleviate gender dysphoria. The patient met with their medical provider to discuss laser hair removal, where it was determined by the provider it would be medically necessary to treat her gender dysphoria. The patients symptoms of gender dysphoria include persistent anxiety, depression, agoraphobia, and overall distress. On 9/18/18, the provider noted that the patient was a good candidate for laser hair removal. The patient has requested authorization and coverage for laser facial hair removal. The Health Plan has denied this request and reported that the requested services are not medically necessary for the treatment of this patient. The submitted documentation supports the medical necessity of the requested services. Facial hair removal via laser is likely to enhance this patients psychological and social functioning. The patient has a documented history of gender dysphoria. She has been on hormone therapy. The World Professional Association for Transgender Health (WPATH) states that, in addition to hormonal balancing, medically necessary gender affirming/confirming surgical procedures include facial hair removal. This patients medical records document a history of gender dysphoria. Her mental health evaluation documents an exacerbation of gender dysphoria symptoms due to the presence of facial hair. The medical evidence supports the requested services in this setting. Therefore, the requested laser facial hair removal is medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested procedure 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 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 parent of an enrollee has requested partial hospitalization program (PHP) services for treatment of the enrollees behavioral health condition.   Findings:  The physician reviewer found that PHP treatment is medically necessary in this clinical setting. Based on the documentation submitted for review, the patient has a very severe case of school refusal with diagnosed generalized anxiety disorder. Her re-introduction to school has started, but is going fairly slowly. She is extremely anxious and becomes very agitated when the subject is discussed. The technique the treatment team is using, exposure and response prevention, can be effective for this condition.  It also can take a lot of time and patience on the part of the staff and patient to successfully implement such a program. Therefore, treatment at the PHP level of care is medically necessary, as it is likely she would relapse if she were transitioned to a lower level of care at this time.  Final Result: The reviewer determined that the services at issue were and 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 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: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for a hospital stay for treatment of her chest pain. Findings:  The physician reviewer found that based on the records provided, inpatient admission was not medically necessary for this patient. Inpatient care is necessary when the patients signs and symptoms and general medical condition can only be managed safely in an acute inpatient setting. Inpatient setting is required when the patient requires diagnostic studies in an inpatient setting, or if it is medically necessary for the patient to remain in the acute inpatient setting. Outpatient observation admission is appropriate when the provider is unsure about the patients need for inpatient admission and requires time for short-term treatment, assessment, and reassessment in order to make that decision or the provider anticipates that the patients condition can be evaluated/treated within 24 hours and/or rapid improvement of the patients condition can be anticipated within 24 hours. In this case, the patient was admitted in stable condition with improved symptoms and could have been treated at an observational level of care.  The records note that this this patient was treated with intravenous fluids, Zofran and pain medications in the emergency department. After she was administered treatment, her symptoms improved. At that point, the patient did not require 24 hour inpatient stay. 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 internal 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

A 30-year-old female enrollee requested authorization and coverage of a UVB light system for in-home therapy for treatment of psoriasis.  The health plan denied the enrollees request indicating that the requested in-home equipment is not medically necessary.One physician reviewer performed a medical necessity Independent Medical Review.  The physician reviewer upheld the health plans denial on the basis that the requested UVB light system is not medically necessary.
Appeal type: Medical Necessity
Decision: Overturned

A fifty-one year-old female with a diagnoses of fibromyalgia and left L5/S1 radiculopathy is requesting authorization of Lyrica.Reviewers Findings:  The reviewing physician found that because of recognized success with the use of Neurontin in many patients with fibromyalgia or neurogenic pain, this patients physician appropriately treated her with Neurontin. This proved to be inadequate, and Lyrica was an appropriate next choice.  The reviewing physician found that the Health Plan denial should be overturned.
Appeal type: Experimental/Investigational
Decision: Upheld

A 40-year-old female enrollee has requested fresh osteochondral allograft transplant of the left knee for treatment of her knee pain. Findings:  Two physician reviewers found that in this patients case, the superior efficacy of the requested services has not been demonstrated.  There is a lack of support for the requested services in this clinical setting.  The records indicate this patient has several osteochondral defects.  Thus, she has significant early degenerative changes to her knee, for which this procedure would not be of significant value.  Additionally, there is a need for further studies to evaluate the overall efficacy and safety of the requested services.  Thus, the requested fresh osteochondral allograft transplant of the left knee is not likely to be more effective than other treatment modalities.
Appeal type: Medical Necessity
Decision: Overturned

A 45-year-old female enrollee has requested for duodenal switch for treatment of her obesity. Findings:  The physician reviewer found that the Rabkin study concludes, LapDS [duodenal switch] is not associated with broad nutritional deficiencies. Annual laboratory studies, which are required following any type of bariatric operation, appear to be sufficient to identify unfavorable trends. In selected patients, additional iron and calcium supplementation are effective when indicated. Thus, the available scientific literature demonstrates the duodenal switch procedure is an accepted procedure and is clinically indicated for this patient. It is considered to be an appropriate and standard primary treatment for obesity, and is approved by the American Colleges of Surgeons, ASMBS, SAGES and CMS based on available medical evidence and long-term follow-up of over 10 years.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the genotype testing for evaluation of the enrollees bipolar disorder. Findings:  Three physician reviewers found that in the peer-reviewed medical literature  noted that, in some circumstances in clinical practice, phenotyping of cytochrome P450 enzymes may be relevant. However, sufficient high-quality, replicated, and controlled studies demonstrating that pharmacogenetics and pharmacogenomics reliably improve health outcomes are not yet available. In addition, a study reported that genetic testing may not be reporting relevant clinical information and that no head-to-head comparisons have not been done proving that genetic studies are of clinical benefit. Overall, there is a lack of evidence to show improved health outcomes due to genetic testing. Final Result: All three reviewers determined that the testing at issue was 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: All three physician reviewers are board certified in psychiatry 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

A 57-year-old male enrollee has requested Avodart for treatment of his prostate cancer and benign prostatic hyperplasia with urinary obstruction. Findings:  The physician reviewer found that this patient presents with benign prostatic hyperplasia and prostate cancer. His provider has prescribed Avodart indicating that the patients enlarged prostate and irritative and obstructive voiding symptoms may interfere with potential brachytherapy for treatment of his prostate cancer. The Health Plan has offered Proscar as an alternative for this patient. Proscar and Avodart are two 5-alpha reductase inhibitors blocking the conversion of testosterone to the active form dihydrotestosterone. This action results in decreased glandular activity. The decreased glandular activity results in decreased prostate volume over many months. The Health Plans requirement that Avodart be approved only after treatment failure with Proscar is medically appropriate. There is a lack of evidence suggesting that Avodart has a clinical superiority over Proscar for treatment of the patients condition.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary:  An enrollee has requested genetic testing for evaluation of her medical condition.   Findings:  Three physician reviewers found that the submitted records fail to demonstrate the superior efficacy of the services at issue.  The genetic testing will not alter the clinical course of this patient.  She has known antithrombin deficiency and will need lifetime anticoagulation.  She can be switched to an alternate medication to avoid the complications of her current medication, and genetic testing does not alter this decision.  All told, genetic testing was not likely to have been of greater benefit than other methods of evaluating this patient. Final Result: Three 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: All three reviewers are board certified in internal medicine and are actively practicing. All three reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for left hip replacement surgery. Findings:  The physician reviewer found that total hip arthroplasty (THA) is a very successful and effective orthopedic operation with very good immediate and long-term results to alleviate pain and improve function and the quality of life. Total hip arthroplasty is indicated in end-stage hip osteoarthritis with a high degree of persistent pain, limitation of motion and associated difficulties with activities of daily living, when conservative treatment has failed and in patients who wish to have surgery. With regard to patients with BMI of 40 or above, it has been documented in literature that the cardiovascular risk is slightly greater, and the operative time is slightly longer. However, it does not constitute a contraindication to total hip arthroplasty.In this case, the patients medical history, clinical examination, and radiographic findings establish that she has severe osteoarthritis of the left hip, severe pain, limited motion, and an altered gait that affects other joints as well. The timing of the requested THA is based on the patient's discomfort. The mid-term survival rate of total hip and knee arthroplasty is not adversely affected by obesity. Review of the literature reveals that obese patients were satisfied with the results of their surgery and have an equivalent mid-term survival rate. Under these circumstances, the requested left hip replacement surgery is medically necessary for the patients medical condition.Final Result: The reviewer determined that the requested 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 orthopedic surgery and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary:  An enrollee has requested authorization and coverage for a Synvisc One injection to the left knee.An exhaustive review of the current medical literature pertaining to viscosupplementation reveals mixed results. Evidence from eight systematic reviews and six randomized controlled trials indicates that although viscosupplementation may relieve knee pain in some individuals with osteoarthritis, it is not known as to which individuals will benefit. Different studies have tried mixing hyaluronic acid with corticosteroids, platelet rich plasma, and other agents to make it more effective. The current evidence is limited, and guidelines from organizations such as the American Academy of Orthopedic Surgeons indicate that the evidence is not conclusive. In light of the foregoing, viscosupplementation can only be recommended in individuals with a history of lasting benefit from prior injections, and in carefully selected cases where everything else has been tried, and the options are limited. In this case, the patients options are limited. The patient has tried and failed other conservative treatments, including corticosteroid injections, with the alternative being a total knee arthroplasty. Therefore, Synvisc One injection to the left knee is medically necessary for the treatment of the patients medical condition. Final Result: The reviewer determined that the requested service is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in orthopedic surgery and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.