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

The parent of a transgender enrollee has requested authorization and coverage for bilateral mastectomy. The World Professional Association for Transgender Health (WPATH), a worldwide authority on transgender health issues, has stated that medically necessary gender affirming/confirming surgical procedures include bilateral mastectomy. The medical procedures attendant to gender affirming/confirming surgeries are not cosmetic or elective or for the mere convenience of the patient. These procedures are reconstructive surgeries, and chest surgery may be a medical necessity for someone who has had persistent gender dysphoria. The WPATH Standard of Care, version 7, clearly mentions that chest surgery in Female to Male (FTM) patients could be carried out earlier than the age of majority. A recent study of adolescents and young adults showed significant improvement of chest dysphoria in transmasculine youth below the age of 18 years old. The denial of chest masculinization surgery, based only on the age of legal majority, is clinically inappropriate and against current available data and guidelines. In this case, the patient has a persistent and documented diagnosis of gender dysphoria that includes chest dysphoria. The patient has female size breasts, which are resulting in social and personal distress for him. Under these circumstances, the requested bilateral mastectomy is medically necessary to treat 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 psychiatry, with subspecialty 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

The parent of a 15-year-old male enrollee has requested for residential treatment services for treatment of his behavioral health problems. Findings:  The physician reviewer found that There was no documentation of severe aggressive behavior and the records indicate minimal risk of self-harm behavior. The records reflect the absence of significant co-morbidities in that there was no major substance abuse disorder, no major mood disturbance, and no psychosis. Childrens Level of Care Utilization System for Psychiatric and Addiction Services (CALOCUS) and Practice Parameters emphasize that treatment interventions should be carried out in the least restrictive setting possible.
Appeal type: Medical Necessity
Decision: Upheld

A 55-year-old female enrollee requested authorization and coverage of autologous peripheral blood stem transplant and high dose chemotherapy for the treatment of metastatic breast cancer.  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: Urgent Care
Decision: Overturned

The spouse of a deceased female enrollee has requested 24-hour in-home nursing care services for treatment of the enrollee's medical condition. Findings:  The physician reviewer found that at issue in this case is whether a prudent layperson in the patients circumstances would believe he or she was experiencing an emergency medical condition or urgent medical condition for four months. Upon review of the submitted documentation, a prudent layperson would not have believed he or she was experiencing an ongoing emergent situation for four months. Therefore, these services do not meet prudent layperson criteria for an emergency medical condition. However, there can be the possibility of imminent death especially in terminally ill patients with cancer and these patients may require palliative care. Based upon the documentation provided, this patient appeared to be quite ill upon discharge from the hospital. She had a very poor performance status. This would have precluded travel back to the in-Plan service area for palliative care. Although there is not a clear clinical description of the patients performance status or respiratory status, it appears she did experience a significant deterioration of her medical condition while out of the country. A prudent layperson in this patients circumstances would reasonably expect that the worsening of her symptoms constituted an urgent medical situation which precluded travel back to the in-Plan service area.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patients parent has requested authorization and coverage for Grastek tablets. This patient has evidence of allergic asthma that has required treatment with medium dose corticosteroids. He has experienced significant asthma exacerbations. He has positive skin testing for pollens and dust mites. There is evidence that patients with allergic asthma benefit from allergen immunotherapy with improvement in asthma symptoms as well as progression of asthma with age. Treatment with Grastek has the potential to decrease this patients inhaled corticosteroid requirement. For these reasons, the requested Grastek is medically necessary for 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 internal medicine with subspecialty certification in 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

A 59-year-old male enrollee has requested Provigil for treatment of his severe obstructive sleep apnea.  Findings:  The physician reviewer found that according to the scientific data, Provigil is clinically indicated for treatment of patients with obstructive sleep apnia (OSA) who experience daytime sleepiness, such as this patient. Further, this patients provider noted that the patient was consulted regarding possible use of Caffeine, however it was decided that Caffeine would exacerbate his ulcer, so its use was contraindicated. Given that Provigil is an accepted medication for treatment of residual hypersomnia secondary to OSA, its use is medically necessary for management of this patients condition.
Appeal type: Medical Necessity
Decision: Overturned

A 41-year-old female enrollee has requested a total abdominal hysterectomy for the treatment of her abnormal vaginal bleeding. Findings:  The physician reviewer found that the patient has been diagnosed with abnormal vaginal bleeding, although the specific characteristics and duration of this condition are not clearly documented. Treatment for abnormal bleeding requires serious consideration of the patients age, medical status and fertility status and includes medical and surgical alternatives. Medical treatment generally involves the administration of progestins, which is contraindicated in this patient due to her history of stroke. Surgical options include endometrial ablation and hysterectomy. With abnormal bleeding and a previous diagnosis of cervical cancer, a hysterectomy would be an acceptable option and medically indicated.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Otezla. Findings:  The physician reviewer found that the available medical records do not document that this patient has been treated with leflunomide for psoriatic arthritis and there are no listed contraindications to treatment with this medication. Additionally, Otezla is not approved for treatment in combination with other agents including Consentyx, as is currently the plan of care for this patient. Final Result: The reviewer determined that the requested medication is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in internal medicine with sub-specialty certification in rheumatology 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

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for prothrombin G20210A mutation test. The Health Plan has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees medical condition.Findings:  There is support in the medical literature for the efficacy of the services at issue in this clinical setting. The prothrombin G20210A mutation is the second most common inherited thrombophilia after the factor V Leiden mutation.  The mechanism by which the prothrombin G20210A mutation increases the risk of thrombosis is not completely understood but is thought primarily to involve an increased concentration of prothrombin in the circulation. The major clinical manifestation of the prothrombin G20210A mutation is venous thromboembolism (VTE). A slight risk of arterial thrombosis may exist in certain settings. A meta-analysis by Kim and Becker evaluated the association of inherited thrombophilias with arterial thromboembolic events (myocardial infarction, ischemic stroke, or peripheral vascular disease) and reported an association between the prothrombin G20210A mutation and arterial events. In summary, prothrombin G20210A mutation test was likely to have been more effective than the standard options available for the evaluation of this patients medical condition. Final Result: Two of the three reviewers have determined that the services at issue were likely to be more beneficial for evaluation of your medical condition than any available standard therapy.Credentials/Qualifications:  All three reviewers are board certified in internal medicine with sub-specialty certification in gastroenterology 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: An enrollee has requested authorization and coverage for Otezla 30 mg, twice daily. The Health Plan has denied this request indicating that the requested medication is not medically necessary for treatment of the enrollees psoriatic arthritis. The American College of Rheumatology does not currently have national guidelines on the recommendations for the treatment of psoriatic arthritis. The European League Against Rheumatism has recently released national guidelines for the treatment of psoriatic arthritis. The guidelines recommend conventional synthetic disease-modifying antirheumatic drugs as an initial therapy after failure of nonsteroidal anti-inflammatory drugs and local therapy for active disease. If additional treatment is necessary, a biologic disease-modifying antirheumatic drug or a targeted synthetic disease-modifying antirheumatic drug is recommended. The initial biologic disease-modifying antirheumatic drug is generally a tumor necrosis factor inhibitor. In this patients case, the records do not document failure or U.S. Food and Drug Administration (FDA) approved package insert contraindication to biological disease-modifying antirheumatic drugs. Anti-tumor necrosis factor agents have been proven very effective for psoriatic arthritis and are disease modifying agents. They prevent progression of disease, erosions and disability and are thus the preferred agent for psoriatic arthritis. The current literature supports the use of conventional and biologic agents (anti-tumor necrosis factor agents)over the use of targeted synthetic biologic (Otezla) for the treatment of psoriatic arthritis.  Although there is some literature to suggest that use of Otezla with other biologic agents may be safe, there is currently no national guidelines or large randomized controlled studies demonstrating this.  As such, Otezla 30 mg, twice daily is not medically necessary for the 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 internal medicine with sub-specialty certification in rheumatology 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. Three physician reviewers 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, regardless of fibrosis, should be treated except for those with limited life expectancy less than 12 months due to non-liver-related comorbid conditions.  The medical evidence supports Harvoni in this clinical setting.  Based on published evidence of safety and efficacy, the requested  Harvoni is medically indicated for the treatment of this patient.  Final Result: Three 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: All three reviewers are board certified in internal medicine with sub-specialty certification in gastroenterology 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

A 61-year-old female enrollee has requested adult eating disorder partial hospitalization program services for treatment of her eating disorder. Findings:  The physician reviewer found that the services at issue were and are medically necessary for treatment of the patients medical condition. This patient has several diagnoses including major depressive disorder and eating disorder NOS. According to the documentation submitted for review, her depression began many months prior to her eating disorder and has been poorly managed. Her depression progressed to the point that she did not eat and lost sufficient weight, which developed into an eating disorder. In addition, the presence of her gastroparesis presents a unique challenge that does not seem to be amenable to treatment in a standard PHP in which the patients are only treated for 6 or 7 hours daily on weekdays. It is likely that the patient will not improve in her depressive symptoms until she is able to tolerate nutritious food and can get into a positive nutritional balance. In order for this to occur, she will need the support of the structure and skills found only in a specialized eating disorders unit. Therefore, based upon the documentation submitted for review, the services at issue were and are medically necessary for treatment of the patients medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned

A 39-year-old male enrollee requested authorization and coverage of gastric bypass with duodenal switch. The Health Plan denied the request indicating that the requested procedure is considered investigational for treatment of the enrollees morbid obesity.Three physician reviewers performed an experimental/investigational Independent Medical Review. All three physician reviewers concluded that the requested procedure is likely to be more beneficial for treatment of the enrollee's medical condition than any available standard therapy. Because all three physician reviewers concluded that the requested procedure is likely to be more beneficial for treatment of the enrollee's medical condition than any available standard therapy, the Health Plans denial has been overturned.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for chest computed tomography (CT) scan. Findings:  The physician reviewer found that the American Lung Society and the American Cancer Society have developed guidelines for lung cancer screening CT chest scans.  The patients should be between the ages of 55-74 years old, at least have a 30 pack-year history of smoking (equal to smoking a pack a day for 30 years, or 2 packs a day for 15 years), still smoking or have quit in the past 15 years and no current symptoms.  This patient does not qualify for a chest CT scan based on the guidelines provided by the American Lung Society and the American Cancer Society regarding age or pack-year smoking history. The records do not indicate if the patient is still smoking.  While there may be a desire to screen for lung cancer in this patient, he does not currently meet the recommended guidelines. Final Result: The reviewer determined that the requested services are not medically necessary for evaluation of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in diagnostic 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: Experimental/Investigational
Decision: Upheld

An enrollee has requested reimbursement for DecisionDx-Melanoma test. This patients tumor was pT1a, which by American Joint Committee on Cancer (AJCC) staging is the lowest risk category. Class 1 result does not provide any more information than was already known about the patients tumor. Specifically, based on routine risk analysis, the patients prognosis is exceptionally good. Overall, there is a paucity of evidence from a randomized controlled clinical trials demonstrating that the information garnered from the DecisionDx-Melanoma can improve patient outcomes. All told, the DecisionDx-Melanoma test was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Final Result: The 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: Physician reviewers 1, 2, and 3 are board certified in dermatology 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

The patient is a 33-year-old female who is status post laparoscopic Roux-en-Y gastric bypass in 2001 with significant weight loss (207 pounds).  She has since had weight regain and several bowel obstructions requiring laparoscopic lysis of adhesions and reduction of internal hernias.  Her providers request for authorization of a revisional duodenal switch procedure was denied by the Health Plan based upon a determination that the procedure is not medically necessary.The biliopancreatic diversion with duodenal switch is not an investigational procedure.  However, the surgical conversion from a Roux-en-Y gastric bypass to biliopancreatic diversion with duodenal switch is a technically demanding procedure as it requires complete take down of the Roux-en-Y gastric bypass, jejunojejunostomy, gastrogastrostomy, sleeve gastrectomy and small bowel reconstruction.  In the case of this patient, there has not been sufficient workup to determine why the Roux-en-Y gastric bypass failed.  The record did not include an upper gastrointestinal series with small bowel follow through (UGI/SBFT), reports of endoscopic examinations or details of the original surgery to determine what was done previously.  It is not medically appropriate to proceed absent a comprehensive workup of the failed Roux-en-Y gastric bypass.  The problems of anemia and weight regain can be addressed non-surgically.Based upon the information set forth above, I have determined the requested procedure is not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned

A thirty-four year-old female with previously diagnosed major depression, recurrent and fibromyalgia is requesting authorization of Provigil.  The patient has been treated with a number of antidepressants, but they were ineffective.  Reviewers Findings:The reviewing physician found that this patient has tried various antidepressants and dosage adjustments without sustained improvement in her depressive symptoms and that Provigil is a reasonable approach.  The reviewing physician found that the Health Plan denial should be overturned.