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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Otezla (apremilast) 30 mg.Otezla is an FDA approved oral small molecule (OSM) medication for the treatment of adult patients with moderate to severe plaque psoriasis and active psoriatic arthritis. The efficacy for Otezla for psoriatic arthritis has been supported by multiple studies. In this case, while it is not clear that the patient has evidence of moderate to severe plaque psoriasis, he does have documented active psoriatic arthritis. While Otezla should generally not be used for patients with erosive disease, as the capacity of the drug to prevent joint injury has not been adequately established, there is no radiologic or clinical data provided in this case that established erosive disease. The patient could not tolerate methotrexate due to side effects (though he did actually have some clinical improvement with it), therefore, switching to another OSM medication with a different mechanism of action is a reasonable approach, given a failed prior response to Humira and Taltz. Under these circumstances, the requested medication Otezla (apremilast) 30 mg is medically necessary for the patients medical condition.Final Result: The reviewer determined that the requested medication is medically necessary for 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

A 65-year-old male enrollee has requested skilled nursing facility (SNF) services (including physical therapy and occupational therapy) for treatment of his chronic obstructive pulmonary disease (COPD), diabetes, nephrolithiasis, and arterial hypertension.  Findings:  The physician reviewer found that based on the available medical records, this patient has multiple chronic health conditions, such as obesity, diabetes and hypertension that would benefit from increased physical activity and exercise (Brook, et al; Hagen, et al). He has been undergoing inpatient therapy for deconditioning but plateaued at the end of the year indicated performing transfers and ambulating very short distances with significant levels of assistance. Thus, further therapy for improving self-care and mobility can be provided on an outpatient basis. Additional inpatient physical and occupational therapy at the SNF level of care would not be expected to provide predictable, marginally significant functional gains that could not be attained in the outpatient therapy setting. For these reasons, the requested SNF services (including physical therapy and occupational therapy) are not medically necessary for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested magnetic resonance imaging for evaluation of the enrollees severe major osteoporotic fracture. Findings: The physician reviewer found that there is sufficient support in the medical literature for the requested services in this clinical setting. Studies have shown that at autopsy, as many as 90% of patients with cancer have evidence of spine involvement. A common primary carcinoma, which metastasize to the spine, is breast cancer. Thoracic spine is the most common site of metastasis followed by lumbar and cervical spine. Plain radiographs often fail to detect spine involvement. MRI should be considered for patients with localized back pain of at least six weeks duration, particularly in patients with history of cancer or night pain. This patient has night pain in addition to a prior history of documented carcinoma of the breast. These two criteria of history alone justify obtaining an MRI for further evaluation of this patients medical condition. The need for both thoracic and lumbar studies is dictated by the fact that non-contiguous metastases are common. Moreover, the presence of pain in patients with osteoporosis is unusual unless there are acute pathological fractures present. In summary, the requested MRI is medically necessary and appropriate for this patient.  Final Result: The reviewer determined that the requested services are medically necessary for evaluation of the patients medical condition. Therefore, the Health Plans denial should be overturned.  Credentials/Qualifications: The physician 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: Upheld

The parents of an 8-year-old male enrollee requested authorization and coverage of speech and occupational therapy for the treatment of aspergers syndrome.  The Health Plan denied the enrollees request indicating that the requested treatment 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 services are not medically necessary for treatment of the patients medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary:  An enrollee has requested Botox injections for treatment of her migraine headaches. Three physician reviewers found that the Botox injections were not and are not likely to be more effective for this patient than other available options. Khalil and colleagues studied patients with chronic migraine treated with Botox injections and found that Botox significantly, reduced the number of headache and migraine days, and increased the number of headache free days. However, in this case, there is a lack of documentation provided regarding the frequency and duration of the patients headaches. Moreover, there is a lack of documentation of pain and functional improvement with the use of Botox. For the reasons provided, the Botox injections at issue were not and are not likely to be more effective than other modalities. Final Result: Three reviewers determined that the services at issue were not and are not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld.  Credentials/Qualifications: One reviewer is board certified in neurology and is actively practicing. Two reviewers are board certified in neurology with sub-specialty certification in headache 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: Upheld

Nature of Statutory Criteria/Case Summary: A male enrollee has requested authorization and coverage for bariatric patient battery operated lift for treatment of the enrollees myoneural disorder. Findings:  The physician reviewer found that the requested bariatric patient battery operated lift is not medically necessary for treatment of this patients medical condition. Although an appropriately fitted lift device may be required by this patient, the records do not document extenuating factors that would necessitate a battery operated lift over an electric lift. There is no physician or therapist evaluation of the patients current lift mechanism for his wheelchair with detailed measurements that would indicate what the best lift device for this patient. The documentation does not reveal failure of an appropriately fitted non-electric lift or a detailed evaluation by a therapist indicating failure of his current lift mechanism. Moreover, there are no detailed physician progress notes with a physical examination of the patient including a detailed musculoskeletal and neurological examination to support the medical necessity of this device. Thus, the requested bariatric patient operated battery lift is not medically necessary.  Final Result: The reviewer determined that the requested equipment 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 physical medicine and rehabilitation with sub-specialty 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: Overturned

Nature of Statutory Criteria/Case Summary: The patient has been diagnosed with bilateral knee osteoarthritis. The patient received a right knee cortisone injection and bilateral knee Orthovisc injections. The patient reported significant relief from previous Orthovisc injections with increased activity. The patient requested repeat Orthovisc injections. The patient has requested authorization and coverage for bilateral knee Orthovisc injections. The Health Plan denied the request and reported the requested services are not medically necessary for the treatment of this patient. At issue in this case is whether bilateral knee Orthovisc injections are medically necessary for the treatment of the patients medical condition. Review of the current medical literature pertaining to viscosupplementation reveals mixed results. Although viscosupplementation may relieve knee pain in some patients with osteoarthritis, it is unknown which patients will benefit. Viscosupplementation can only be recommended in patients with a history of lasting benefit from prior injections and in carefully selected cases where the options are limited. A clinical trial by Campos and colleagues found that viscosupplementation increased functional scores in patients with severe osteoarthritis of the knee, especially within three months of injection. In this case, the patient has had lasting benefit from prior viscosupplementation injections. Furthermore, his options are limited. The patient has tried and failed other conservative treatments, with the alternative being total knee arthroplasties. Medical evidence supports the requested services in this clinical setting. Therefore, bilateral knee Orthovisc injections are medically necessary for the treatment of this patient.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: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for left ear cochlear device and implantation with or without mastoidectomy for treatment of the enrollees bilateral sensorineural hearing loss. Findings:  The physician reviewer found that cochlear device implantation (CDI) is well established, and CDI can now be considered the standard of care for patients with severe to profound sensorineural hearing loss and no meaningful benefit from conventional amplification. However, many patients with severe to profound high frequency hearing loss and limited word discrimination retain substantial residual hearing in the low frequencies. In this case, the audiology report demonstrates that the patient has minor residual hearing in the low frequencies with steeply sloping to profound hearing loss in both ears. In addition, the AzBio test in the left ear with the hearing aid confirmed 74% correct responses for words alone, and 35% correct responses in sentences. Thus, the request for left ear cochlear device and implantation with or without mastoidectomy has not been established as medically necessary for treatment of the patients medical condition. 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 otolaryngology 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 authorization and coverage for Prolastin-C infusion augmentation therapy.Findings:  The physician reviewer found that the submitted medical records and laboratory data do not support that the requested intravenous augmentation therapy is medically necessity for the patient. The current peer reviewed literature supports that augmentation therapy is not recommended for patients who are heterozygous and whose serum AAT level exceeds 11 micromol/L or 57 mg/dL (Sandhaus, R., et al.). In this case, the patient is heterozygous with a normal allele and one abnormal allele that is not associated with clinically significant alpha-1 antitrypsin deficiency. Furthermore, the patients serum AAT level of 106mg/dL is well above the threshold of 57mg/dL. Under these circumstances, the requested Prolastin-C infusion augmentation therapy is not medically necessary to treat the patients medical condition.Final Result: The reviewer determined that the requested therapy is not medically necessary to treat the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is board certified in both internal medicine and allergy and immunology, 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 Harvoni for treatment of his medical condition.  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.  Per the guidelines, non-cirrhotic genotype 1 patients who have failed peg-interferon and ribavirin should be treated with Harvoni for 12 weeks. These guideline recommendations are based on multiple randomized clinical trials, and the medication is U.S. Food and Drug Administration (FDA) approved for all patients with chronic hepatitis C, genotype 1 regardless of fibrosis stage.  For these reasons, the requested treatment with Harvoni is supported as medically necessary for the treatment of this patients hepatitis C infection.  Final Result: The reviewer 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: 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

A 49-year-old female enrollee has requested a bilateral mastectomy for treatment of her medical condition. Findings:  The physician reviewer found that the submitted documentation supports the requested services in this patients case.  This patient has a strong family history that puts her at elevated risk for developing breast cancer.  Diagnostic mammography on the said date revealed bilateral dense breast tissue which limits the ability of radiologic surveillance for screening of breast cancer.  There are now multiple studies that demonstrate the benefit of bilateral prophylactic mastectomy in women who are at elevated risk of breast cancer due to a strong family history, even in the absence of genetic testing.  The records document the limited ability of mammography to screen her breasts for early cancer due to the dense tissue.  In this clinical setting, bilateral mastectomy has been demonstrated to be effective at risk reduction for lifetime development of breast cancer.  All told, the requested bilateral mastectomy is medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Overturned

The enrollee is requesting authorization and coverage for a tracheal shave and subsequent post op visits to treat gender dysphoria. The patient is a male-to-female woman. She began her transition at age 17 and started hormone therapy nine years ago. The patient was referred to a voice and swallowing center for vocal cord evaluation. She does not have complaints about her voice but feels her gender is misidentified because of her Adams apple. Her voice and laryngeal evaluation were consistent with gender dysphoria. A rigid video stroboscopy noted vocal fold motion was normal. There was mild mid-vocal fold fullness bilaterally; however, she had no associated dysphonia. The evaluating otolaryngologist has requested authorization for tracheal shave surgery. The patient has expressed a persistent desire for tracheal shave to alleviate her gender dysphoria. Her symptoms have manifested as anxiety, depression, agoraphobia, and overall distress. The patient has met with her medical provider and mental health provider for clearance to pursue gender-affirming surgery. Both providers agree that tracheal shave is medically necessary to treat her gender dysphoria. The patients male-appearing Adams apple severely limits her ability to be perceived as female and negates her female gender identity. Seeing reflections of herself in the mirror is a distressing reminder that her body is not yet aligned with her identity. Because the Adams apple is one of the most visible indicators society uses to identify a person as female or male, tracheal shave surgery is necessary for the patient to survive and thrive in this world as a woman.  The health plan has denied authorization and coverage for vocal cord surgery and speech therapy. The medical literature indicates transfeminine individuals who had completed procedures including tracheal shave or Adam's apple removal reported lower social anxiety than those planning to undergo the intervention. Body-gender congruence and body image satisfaction were higher, while depression and anxiety were lower, among individuals with more extensive gender confirmation treatments compared to those who received less treatment or no treatment. This treatment is part of the patients overall reconstructive plan for her gender dysphoria.                                                         Final Result: The reviewer determined that the requested services are medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The physician 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 similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

The parent of a four-month-old female enrollee has requested Synagis injection for treatment of the enrollees medical condition. Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested services.  The current medical literature does not support the requested services in this clinical setting.  This patient was born at 33 1/7 weeks gestation and does not have a diagnosis of chronic lung disease or significant congenital or acquired heart disease.  The current guidelines do not support the requested Synagis injection in this patients case.  There is a lack of support for the requested services for the treatment of this patient.  All told, the requested Synagis injection is not medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld

A 32-year-old female enrollee requested authorization and coverage of gastric bypass surgery for the treatment of morbid obesity.  The health plan denied the enrollees request indicating that the requested procedure 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 procedure is not medically necessary.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a 13-year-old male enrollee has requested a computed tomography (CT) scan of the sinuses for evaluation of the enrollees sinusitis and ocular pain. Findings:  The physician reviewer found that review of the submitted documentation and relevant literature demonstrates the medical necessity of the diagnostic procedure at issue. In this case, the patients symptoms included eye pain, with no other associated findings compatible with the diagnosis of sinusitis. If the patient had other associated symptoms such as nasal discharge or postnasal drip then the diagnosis would be more obvious and one could conclude without the use of imaging that he actually has sinusitis and begin treating empirically. However, the patient had isolated eye pain without any other symptoms of sinusitis and therefore one could not have made the diagnosis of sinusitis without the CT scan. Based on the medical literature cited above and the documentation submitted, the CT scan of the sinuses was medically necessary for evaluation of the patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned

A parent of a five-year-old female enrollee has requested a referral to an ear, nose and throat (ENT) specialist for evaluation of her tonsillar hypertrophy.   Findings:  The physician reviewer found that review of the submitted documentation demonstrates the medical necessity of the requested service. Adenotonsillar hypertrophy is not a benign condition. According to Tatlipinar and colleagues, Patients with adenoid and tonsil hypertrophy are at a higher risk for cardiopulmonary complications, poorer quality of life, and more severe upper airway obstruction (UAO) symptoms and should have priority for surgical treatment to prevent cardiopulmonary complications. This patient has had persistent cough, exacerbation of her asthma and clinical obstructive sleep apnea with an examination revealing hypertrophic tonsils. The peer-reviewed literature supports ENT evaluation with potential intervention in cases such as this patient, to prevent long-term complications. For the reasons provided above, the requested referral to an ENT specialist is medically indicated.