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

A 45-year-old female enrollee requested authorization and coverage of ventral hernia repair and abdominoplasty for the treatment of a ventral incision al hernia  with a large panniculus, with execration which is progressively symptomatic.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 overturned the health plans denial on the basis that the requested services are  medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld

A 48-year-old female enrollee has requested neuromonics for the treatment of her sudden hearing loss and tinnitus. Findings:  The physician reviewer found that neuromonics tinnitus treatment is a relatively new methodology. There appears to be only one research study published in the medical literature to support its use, and this is the same study published in 2007 that is included in the materials submitted with this appeal (Davis, et al.). Given the paucity of data currently available, neuromonics is of yet a medically unproven technology and so remains investigational in the treatment of tinnitus.
Appeal type: Experimental/Investigational
Decision: Overturned

A 59-year-old female enrollee has requested for bilateral breast MRI for evaluation of her breast nodularity.  Findings:  Two physician reviewers found that breast MRI has been proven to be a useful adjunct to mammography. One of the difficulties in patients with prior lumpectomy for breast cancer is the evaluation of a palpable abnormality within the post-surgical breast. Physical exam and mammography are not always adequate to differentiate scar tissue from recurrent tumor. Breast MRI has been shown to be clinically useful in the evaluation of post-operative scar from tumor recurrence. This patients breast cancer has a high rate of recurrence and the complete evaluation of a palpable breast abnormality including MRI of the breast is medically appropriate. Mammography is not 100% in the detection of malignancy; breast MRI used as an adjunct to mammography in this patient will allow the patients physician to properly care for the patient. Breast MRI is likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for blepharoptosis surgery for treatment of the enrollees eye condition. Findings:  The physician reviewer found that the current treating provider had noted evidence of a right sided eyelid ptosis and per the documentation, the Health Plan authorized correction for this side. Based on the photographs provided, there is asymmetric eyelid ptosis on the right but the eyelid margin on the left appears relatively normal and without evidence of ptosis.  The medical literature indicates that there can be cases when excess eyelid skin may obstruct the visual field and thus may be considered a functional problem.  However, in this patients case, there is a lack of evidence in the photographs and in the clinical records to indicate that she has excess eyelid skin that obstructs her visual field. As documented by the current provider, the patient does not have evidence of a left upper eyelid ptosis. Most recent photographs show evidence of a right eyelid ptosis but a relatively normal appearing left lid margin without ptosis. As such, treatment of dermatochalasis on the left side is consistent with aesthetic goals and not functional ones.  There is asymmetry between the two lid margins. Correction of the left sided dermatochalasis is not medically indicated in this patients case. 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. Final Result: The reviewer 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: Medical Necessity
Decision: Upheld

A 34-year-old male enrollee requested medical treatment at the acute level of care for his sepsis, anemia, tachycardia, and acute renal failure.  Findings:  The physician reviewer found that the records indicate the patient is presently at the skilled nursing level of care. Based on the available records, the skilled nursing level of care is appropriate and transfer to inpatient acute care is not medically necessary. All of the patients problems are chronic. In addition, restorative physical therapy can also be provided at the skilled nursing level of care. Should the patient become acutely ill, then transfer to an inpatient acute facility would be indicated. However, there is insufficient documentation to substantiate the medical necessity of transferring this patient to inpatient acute care based on the documentation provided for review.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement and prospective authorization and coverage for residential treatment. Findings:  The physician reviewer found that, in this clinical setting, the services at issue were not and are not medically necessary for the treatment of the patient. There was no evidence of a post-acute withdrawal stated, nor was there any evidence of suicidality, homicidality, or threat to self or others. There were no emotional, behavioral, cognitive, or impulsive issues to warrant this level of care.  She was psychiatrically stable.  Her hypertension did not need the residential setting for medical management.  She had agreed to try naltrexone.  She was engaged in her treatment plan and had a sponsor.  She had the external stressors of her ex-boyfriends frequent attempts to re-engage with her, and the stress of three children. However, she remained motivated towards recovery.  She had a stable and supportive sober support system. She no longer required the restrictive 24/7 residential setting and could have been stepped down to an ambulatory level of care such as intensive outpatient program. Therefore, the residential services from the date of service in question, forward 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 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: An enrollee has requested Harvoni for treatment of his hepatitis C. Findings: Two physician reviewers found that the current medical evidence supports the requested medication in this clinical setting. As noted by the American Association for the Study of Liver Diseases and Infectious Diseases Society of America, the medical evidence supports treatment in all patients with chronic hepatitis C, except those with limited life expectancy less than 12 months due to non-liver-related comorbid conditions.  Initiation of treatment when patients have early stage disease may help avoid untoward complications from advanced disease, including liver failure and extrahepatic complications.  All told, the requested medication Harvoni is medically indicated for the treatment of this patient. Final Result: Two reviewers determined that the requested medication is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The three reviewers are board certified in internal medicine with sub-specialty certification in gastroenterology and are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for rhizotomy neurosurgical procedure (CPT codes 64635, 64636, and 99152). The patients provider has recommended treatment with bilateral rhizotomies. A systematic review and a meta-analysis by Hansen and colleagues indicated that although sacroiliac joint lateral branch rhizotomy may have potential, there are limited and highly variable data that prevent recommendation for the procedure. Maas and colleagues noted that they found no high-quality evidence suggesting that radiofrequency denervation provides pain relief for patients with chronic low back pain. Schmidt and colleagues noted although radiofrequency ablation may offer a potential benefit as a therapeutic modality, limited data supports its use as a primary treatment modality. There are inadequate data supporting rhizotomy for the treatment of sacroiliac joint pain. Based on the available literature, the requested rhizotomy is not supported as medically necessary for the treatment of this patient. All told, the requested rhizotomy neurosurgical procedure (CPT codes 64635, 64636, and 99152) is not medically necessary for treatment of this patient.Final Result: The reviewer determined that the requested services are not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in neurological 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: The patient is a 14-year-old female who has been diagnosed with a maxillofacial skeletal deformity, specifically maxillary and mandibular hypoplasia. Findings:  The physician reviewer found that s a result of this deformity, the patient has experienced difficulty with mastication. Her orthodontist and surgeon have recommended orthognathic surgery to correct her deformity. She is planning to undergo presurgical orthodontics and the surgical plan at this time is for a multi-piece LeFort osteotomy, BSSO of her mandible and possible anterior mandibular osteotomy (genioplasty). Per the Health Plan, the request for a LeFort 1 surgery CPT code 21147 has been approved. At issue is whether the requested reconstruction of the upper jaw and chin is medically necessary and reconstructive in nature for this patient.The requested reconstruction of the upper jaw and chin is medically necessary to treat the patients medical condition. The patient has a maxillofacial skeletal deformity that cannot be corrected with orthodontics alone. The surgery will result in improved musculoskeletal and dento-osseous relationships, and improvement in mastication and associated temporomandibular joint and associated muscular disorders. Given the patients findings, reconstruction of the upper jaw and chin are medically necessary to optimize functional outcomes.In addition, the requested procedures are reconstructive in nature for treatment of the patients abnormal structure. The patients maxillofacial skeletal deformities were caused by a congenital or developmental deformity. Deformities may be evident at birth or may manifest during subsequent growth and development, creating functional, degenerative, cosmetic, and/or psychosocial problems. Moreover, the requested surgery will provide more than a minimal improvement in the appearance of the patient. For these reasons, requested reconstruction of the upper jaw and chin is supported as medically necessary and reconstructive in nature for treatment of this 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 oral facial and maxillary 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

A 40-year-old female enrollee has requested Xolair for treatment of her asthma. Findings:  The physician reviewer found that the medical literature provides sufficient scientific data on the long-term (greater than two years) safety and effectiveness of Xolair in patients with higher IgE levels than this patient. Further, Wahn and colleagues found that pre-treatment allergen-specific IgE levels was not a reliable prognosis factor in selecting patients most likely to benefit from treatment with Xolair. Moreover, Lowe and colleagues concluded that, Although currently approved dosing tables are close to optimal, it should be possible to treat patients with higher levels of baseline IgE if higher doses can be administered. Thus, this patients elevated IgE level should not be considered a contraindication to her being treated with Xolair, and it is clinically appropriate for management of her condition.
Appeal type: Medical Necessity
Decision: Upheld

A 48-year-old female enrollee has requested for four (4) intensive cognitive behavioral outpatient treatments for treatment of her depression and anxiety.  Findings:  The physician reviewer found that intensive outpatient level of care was not medically indicated. The patient was depressed, but there is no evidence that she could not be managed at a lower level of care, such as outpatient treatment. In fact, the records do not support a finding that the patient required at least three hours of treatment, three days per week in order to safely manage her condition.
Appeal type: Experimental/Investigational
Decision: Overturned

A 62-year-old female enrollee has requested for a magnetic resonance imaging (MRI) of the breast for evaluation of her breast cancer.   Findings:  Two physician reviewers found that she has multiple risk factors including atypical ductal hyperplasia and LCIS. She also has dense breasts and a family history of breast cancer. Based on these factors, this patient meets the recommendations for breast MRI screening as defined by the American Cancer Society (see Saslow). According to the current literature, BI-RADS category 3 mammogram results (probably benign with short interval follow-up) is an approved assessment category for MRI (see Erguvan-Dogan, et al.). Since the abnormality described as probably benign was only apparent on an MRI, it is appropriate and reasonable to allow for such follow-up utilizing this same modality.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for nystatin compound suppository. There is sufficient support for the requested medication in this clinical setting. This patient is likely to benefit from an antifungal preparation. Given her current medications, there is concern that oral antifungals would interfere with the absorption and metabolism of those agents. Although the use of oral fluconazole weekly for several months is typically the first-line of maintenance regimen, if this regimen is not feasible, then topical treatments should be considered. This patient reported that over-the-counter medications and prior prescriptions medications were ineffective, but the requested medication has been effective. Thus, nystatin compound suppository is medically appropriate in this clinical setting. Therefore, the requested nystatin compound suppository is medically necessary for the treatment of this patient. 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 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.
Appeal type: Urgent Care
Decision: Overturned

A 57-year-old female enrollee has requested emergency services for the treatment of her body aches. Findings:  The physician reviewer found that records from the ED note patient complaints of generalized body ache, low grade fever and mild headache for the previous three days. She had a past medical history remarkable for insulin dependent diabetes, hypertension and high cholesterol. The patient also complained of numbness to the legs and left face. Her pain level on presentation was 5/10.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a one-year-old male enrollee has requested occupational therapy for treatment of the enrollees developmental delay and microcephaly.  Findings:  The physician reviewer found that the submitted medical records from the patients pediatrician, neurologist and geneticist contradict this finding. The workup performed by these providers clearly documents anatomic defects in the patients brain resulting in a global delay, thereby affecting his cognitive skills. Additionally, the fact that the patient has spasticity is a sign of physical pathology.Studies have shown that occupational therapy can prevent a deterioration or reversal of function and result in significant improvement in activities of daily living for children with developmental delay. A systematic review by Riethmuller and colleagues concluded that nearly 60% of the studies reported statistically significant improvements in motor development at follow-up. Their findings suggest that developmental therapy treatment affected gross motor gains for preschool children who exhibited moderate motor delays. In the case of this patient, there is documented evidence of significant developmental delay that requires therapeutic intervention. As such, the patient is an appropriate candidate for the requested occupational therapy.
Appeal type: Medical Necessity
Decision: Overturned

A 59-year-old male enrollee has requested Humatrope 6 mg for the treatment of his multiple medical conditions.  Findings:  The physician reviewer found that Dercums disease is a very rare disorder about which little is known but seems to be associated with hormonal problems, especially of the thyroid, but not exclusively so. There is reported objective shrinkage of the lipomas with human growth hormone as well as partial ameliorations of the pain, depression, and other symptoms associated with Dercums disease. The submitted documentation confirms that the patient has benefitted from the growth hormone and a superior alternative for the disabling symptoms of the patients Dercums disease has not been proposed in this case.
Appeal type: Experimental/Investigational
Decision: Upheld

A 36-year-old female enrollee requested authorization and coverage of a terbutaline pump for the treatment of preterm labour. The health plan denied the enrollees request indicating that the requested treatment is experimental.Three physician reviewers performed an experimental/investigational Independent Medical Review.  Each of the three physician reviewers concluded that a terbutaline pump is not likely to be more beneficial for treatment of the enrollees preterm labour than any available standard therapy.  Because all three physician reviewers concluded that the requested treatment is not likely to be more beneficial for treatment of the enrollees medical condition than any available standard therapy, the review organization upheld the health plans denial.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for Oncotype DX gene expression testing for evaluation of the enrollees prostate cancer. Findings:  Two physician reviewers found that once prostate cancer is diagnosed in a pathologic specimen, risk stratification is performed by the analysis of certain features such as the grade of tumor and PSA level. This helps guide the most appropriate therapy for patients taking into account their age and co-morbidities because many patients will not require therapy and may be followed closely instead. The important features to recognize are Gleason score and PSA but these are imperfect. Thus, current biomarkers are inadequate for risk stratification and better prognostic biomarkers are needed. The Oncotype DX is a gene expression analysis of target genes in the biopsy specimen that generates a genomic prostate score (GPS). A validation study was presented at the American Urological Association meeting in 2013 involving 395 patients. The GPS identified patients that had very low risk disease that could be followed rather than referred for surgery. In addition, the National Comprehensive Cancer Network (NCCN) guidelines suggest the Oncotype DX test to better stratify such patients with localized disease. Final Result: The reviewers determined that the testing at issue was 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.