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

The patient is a 58-year-old female with morbid obesity, pulmonary hypertension, cardiac arrhythmias, and arthritis. She has failed medical management. The submitted records indicate the patient is receiving anticoagulants because of cardiac disease. She has been deemed appropriate for bariatric surgery. It does not appear the patient has undergone a psychological evaluation to determine if she is an appropriate candidate for weight loss surgery. She wishes to undergo gastric bypass with duodenal switch. The Health Plan has denied authorization for the procedure on the basis it is not medically necessary.In light of the severity of the patients cardiac disease and her need for continued anticoagulants, a malabsorptive procedure such as the duodenal switch procedure is more appropriate than conventional gastric bypass. There is a significant risk of marginal ulceration with the standard gastric bypass that does not appear to be present in the duodenal switch procedure. Furthermore, there is sufficient data to show that duodenal switch has a superior long-term outcome when compared to the gastric bypass procedure. However, although medically the patient meets criteria for consideration of the duodenal switch procedure there is no evidence the patient has undergone a psychological evaluation to determine whether she is an appropriate candidate for weight loss surgery. Therefore, I have determined that the requested procedure is medically necessary for treatment of the patients medical condition depending upon the results of a psychological evaluation. As such, the Health Plans denial should be overturned. If the psychological evaluation indicates the patient is an appropriate candidate for weight loss surgery, the requested procedure should be authorized. If the psychological evaluation indicates the patient is not an appropriate candidate for weight loss surgery the requested procedure should not be authorized.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary:  The parent of an enrollee has requested  residential treatment center (RTC) level of care services for treatment of the enrollees major depressive disorder and anorexia nervosa.  The physician reviewer found that based on the documentation provided, specialty services at the residential level of care were and are indicated for this patient struggling with the developmental stage of identity formation who has yet to consolidate the treatment gains necessary to succeed in a less restrictive setting. Further, considering her previous suicidality, recent acute psychiatric hospitalization and medical comorbidity, a conservative treatment course is to be expected. The patient has been engaged in active treatment based on an individual treatment plan that includes psychiatric and nutritional services, pharmacotherapy, and family counseling as well as individual and group therapies. Despite these interventions, the patient continues to subscribe to eating disordered schemas and distorted beliefs. Indeed, during her psychiatric appointment, the patient indicated she was not finishing her meals for fear of becoming fat. In the week prior, she had reported suicidal ideation and had her antidepressant increased. She remained nervous during family sessions and was described as depressed during process group. In such a state, the patient remains at elevated risk for undue morbidity and admission to a higher level of care in the absence of residential programming. In sum, the services in dispute were and are reasonably expected to improve the patients condition and prevent a more serious illness. Accordingly, the RTC services were and are medically necessary for treatment of this patients medical condition. 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

The enrollee is requesting authorization and coverage for dehydroepiandrosterone (DHEA). The enrollee was diagnosed Sjogrens syndrome. The enrollee reports weakness and episodes of an inability to move his body or limbs for timespans of two to four hours. He also has pinkness of the face and redness over the knuckles of his fingers. Medical records show the enrollee has undergone multiple tests, but has not received a definitive diagnosis for his leg weakness. Repeat laboratory testing showed the enrollee was negative for Sjogrens syndrome. Because of the test results, the physician was not willing to prescribe an immunosuppressive medication. Professional society criteria standardize the definition of lupus for study purposes. It is possible to meet the criteria and not have systemic lupus erythematosus, or not meet the criteria yet still have the disease. It is unusual to have active systemic lupus erythematosus with a negative result for anti-nuclear antibody, as is the case with this enrollee. This enrollee is currently serologically negative without overt signs of systemic lupus erythematosus. The benefit of dehydroepiandrosterone (DHEA) is not established. It has potentially feminizing side effects in men. There are also concerns about high blood pressure and an increased risk of heart disease, and an increased risk of prostate or other cancers.Final Result: The reviewer determined that the requested service is not medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The physician reviewer is board certified in internal medicine and 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 similar medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned

A 57-year-old female enrollee has requested ambulatory phlebectomy surgery for the treatment of her varicose veins. Findings:  Two physician reviewers found that this patient had tried compression therapy, but the symptoms persisted. Phlebectomy was performed, as there was no role for radiofrequency ablation or other saphenous treatment in this setting. Given the lack of alternatives, this was the appropriate approach.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a male enrollee requested Onfi (clobazam) for medical treatment of the enrollees epilepsy.  Findings:  The physician reviewer found that the patient has a diagnosis of medically refractory epilepsy, characterized by head drops.  Empirical evidence has demonstrated a clear indication for clobazam as an efficacious antiepileptic drug (AED). Montenegro and colleagues retrospectively reviewed the use of clobazam (CLB), in terms of efficacy, retention, and tolerability in patients with epilepsy over a five-year period. The authors concluded In this population of patients with highly refractory epilepsy at a US center, 11% of patients became seizure-free for at least 6 months after addition of CLB, and the 1-year retention rate was 61%. As such, the use of clobazam demonstrates best clinical practice for this patient, and the available literature supports this decision.
Appeal type: Experimental/Investigational
Decision: Overturned

A 43-year-old female enrollee has requested cryosurgical ablation of fibroadenoma of the right breast for treatment of her benign neoplasm.   Findings:  Two physician reviewers found that The American Society of Breast Surgeons (ASBS) state that, several multi-institutional trials have demonstrated cryoablation to be successful option for resolution of fibroadenomas without surgical excision. The ASBS has provided specific criteria for patient selection. The ASBS indicate that evidence of the fibroadenoma should be visible on ultrasound or confirmed on biopsy by histology, and measure less than 4 cm in diameter. Further, there is compelling evidence that cryoablation can be effective in the treatment of breast fibroadenoma. The studies by Kaufman and colleagues reported success of the cryoablation to several years post-procedure. This patient had a right breast core biopsy on the said date showing fibroadenoma without atypia or cancer. Given the support in the peer-reviewed medical literature, the requested cryoablation is likely to be a better alternative than standard therapies.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for excision of excessive skin, tissue and suction assisted lipectomy in both upper extremities for treatment of the enrollees overgrowth of her upper arms and are not reconstructive in nature.  Findings:  The physician reviewer found that Based on the documentation provided, the patient has sufficient evidence of functional impairment related to severe excess soft tissue of bilateral upper arms.  The patient reports shoulder and neck pain that appears to be attributed to the excess soft tissue. This is supported by a review of the photographs submitted as well as the provider documentation. In addition, the record indicates that conservative management via physical therapy and medical management have not been effective. The patients excess soft tissue of the bilateral upper arms is a functional impairment. Accordingly, the requested excision of excess skin and tissue is medically necessary for treating this patients medical condition. However, suction assisted lipectomy is not medically necessary. Liposuction would not address functional impairment.With regards to whether the alleged abnormality constitutes an abnormal structure of the body, the patient has evidence of abnormal excess of skin and fatty tissue of the upper extremities as demonstrated by the photographs and documentation. The excess tissue was caused by obesity, which is considered a disease. The requested excision of excess skin and tissue (brachioplasty) will improve function and assist to create a normal appearance to the extent possible.  Moreover, brachioplasty will provide more than a minimal improvement in the patients appearance. However, this would not be the case with liposuction of the bilateral upper extremities. The functional impairment and abnormal appearance of her bilateral upper extremities should be adequately treated with resectional technique and not liposuction. Therefore, excision of excess skin and tissue in both upper extremities is reconstructive in nature.  However, suction assisted lipectomy does not meet the criteria under the expanded concept of reconstructive surgery.Final Result: The reviewer determined a portion of the requested services is medically necessary for treatment of the patients medical condition and are not reconstructive in nature. Therefore, the Health Plans denial should be partially overturned.Credentials/Qualifications: The reviewer is board certified in plastic surgery and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

The parent of a 12-year-old male enrollee has requested authorization and coverage for IVIG (Gamunex), 60mg intravenously, once per month, for six months for treatment of the enrollee, who is status post kidney transplant. Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested therapy in this clinical setting.  IVIG has been shown to be efficacious in reducing donor specific antibodies prior to renal transplantation and in treating acute humoral rejection following renal transplantation.  However, there is a lack of data demonstrating that IVIG improves any outcome (renal function, allograft survival, or other) in patients whose donor specific antibodies become positive but whose renal allograft biopsy shows no acute rejection.  The significance of positive donor specific antibodies in the absence of rejection following transplantation is not known, and there is no consensus that this requires treatment.  This patients renal biopsy showed no humoral rejection.  Therefore, the requested IVIG (Gamunex) 60mg intravenously, once per month, for six months, is not medically indicated in this patients case.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the Guardant360 Circulating Tumor DNA test. The treatment of advanced non-small cell lung cancer has been revolutionized by the finding of epidermal growth factor receptor (EGFR) mutations in certain adenocarcinomas. The Guardant360 test is commonly referred to as a liquid biopsy since it involves sampling of tumor cells that may be circulating in the peripheral blood. Current data reports that the Guardant360 assay can analyze up to 70 genes for mutations.Guardant360 is known for high specificity, but low sensitivity. According to the NCCN guidelines, the Guardant360 test is associated with false negative rates of up to 30%. The NCCN guidelines support limited use of Guardant360 for patients who are unfit to pursue more invasive methods for tumor sampling. The Guardant360 test was reasonable for this patient since the disease was inaccessible without subjecting the patient to a highly invasive procedure. In conclusion, the Guardant360 Circulating Tumor DNA test was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Findings:  Two of the three physician reviewers found the Guardant360 Circulating Tumor DNA test 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 services at issue were 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: Physician reviewer 1 is board certified in internal medicine with subspecialty certification in medical oncology and is actively practicing. Physician reviewer 2 is board certified in medical oncology with subspecialty certification in hematology and is actively practicing. Physician reviewer 3 is board certified in internal medicine with subspecialty certifications in medical oncology and hematology and is 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: Experimental/Investigational
Decision: Overturned

A 39-year-old male enrollee has requested bronchial thermoplasty for treatment of his asthma. Findings:  Three physician reviewers found that in this patients case, the services at issue were likely to be more effective than other available treatment options. Based on the medical records submitted for review, the patient meets the criteria for severe persistent asthma. Bronchial thermoplasty is an accepted modality for reduction in exacerbations of severe persistent asthma. It has been shown to reduce hospitalizations, reduce emergency room (ER) visits and reduce exacerbations. Bronchial thermoplasty treatments also improve a patients quality of life and he would benefit from this procedure. Therefore, for the reasons provided above the services at issue were likely to be more beneficial than other treatment alternatives in this patients case.
Appeal type: Medical Necessity
Decision: Upheld

A 44-year-old female enrollee has requested the Elite Traveler Plus scooter for treatment of her foot pain and back pain.  Findings:  The physician reviewer found that the submitted records do not substantiate the presence of impairments that would preclude the patient from accomplishing her mobility-related activities of daily living within an appropriate community setting using an optimally configured manual wheelchair.  The records do not document any significant, objective neurological or musculoskeletal impairment or pathology affecting the upper limbs and thorax to the degree that would preclude manual wheelchair use.  In addition, the patient does not have a documented cardiovascular or pulmonary condition that is severe enough to preclude the use of a manual wheelchair to accomplish her mobility-related activities of daily living.  Generalized pains and lack of strength or endurance should be treated with appropriate exercise and training, not with disuse.  The records forwarded for review do not establish that the patient would be confined to a bed or chair without a power mobility device.  In addition, there are no indications that her home is wheelchair accessible.  There is reported to be an entry with 15 steps, but no documented ramp or other accessible entry.  All told, the submitted documentation fails to establish the medical necessity of the requested Elite Traveler Plus scooter.
Appeal type: Medical Necessity
Decision: Upheld

The representative of a 47-year-old male enrollee requested authorization and coverage of acute rehabilitation therapy. The Health Plan denied the request indicating that the requested therapy is not medically necessary for treatment of the enrollees medical condition.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.
Appeal type: Medical Necessity
Decision: Overturned

A 33-year-old female enrollee has requested for acute psychiatric inpatient for treatment of her major depression, recurrent, severe, non-psychotic. Findings:  The physician reviewer found that she was not having any suicidal ideation, she had a clear thought process, no hallucinations, no delusions, and had independent activities of daily living skills. Disturbances in the above are usually considered a minimum requirement for continued acute inpatient psychiatric stay. An evidence-based, objective, instrument such as the Level of Care Utilization System is indispensable in determining the necessary level of care for adults to insure the level of care meets individual needs safely and effectively in the least restrictive setting.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for magnetic resonance imaging (MRI).Findings:  The physician reviewer found that the documentation submitted for review does not support a medical indication for MRI. The records demonstrate the patients back pain is localized to the right flank. He does not have radicular symptoms, tingling, or numbness. The patient does not have symptoms associated with a herniated disc, for which an MRI would be indicated. In addition, the patient has not been treated with conservative therapy with physical medicine or pain management. In sum, there is a lack of clinical documentation supporting MRI in this clinical setting. All told, the requested MRI is not medically necessary for evaluation of the patients medical condition.  Final Result: The reviewers determined that the requested diagnostic procedure is not medically necessary for evaluation of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: Physician reviewer number one 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: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient presents with transtibial and transfemoral amputations. The submitted documentation fails to demonstrate the medical necessity of the requested equipment. A plan for implementation of a power wheelchair has not been documented, and there is no physician order or rationale for a power wheelchair in this patients case. The patient must be able to safely use the device. Per the documentation, the patient reports painful contractures in hands that limit usage of a manual wheelchair. However, the records do not adequately document these contractures and their impact, if any, on mobility. All told, the requested power wheelchair is not medically necessary for the treatment of this patient.MD AnalysisFinal 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:  An enrollee requested a 12-week course of Harvoni for treatment of his hepatitis C.  Findings:  Two physician reviewers found that per American Association for the Study of Liver Diseases and Infectious Diseases Society of America guidelines, patients with chronic active hepatitis C should be treated with antiviral therapy regardless of fibrosis score.  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.  The goal of treatment is to reduce liver-related health adverse consequences, including end-stage liver disease and hepatocellular carcinoma.  Therefore, the requested 12-week course of 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. 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

The parent of a ten-year-old male enrollee has requested for occupational therapy for treatment of the enrollees pervasive developmental disorder and Aspergers syndrome. Findings:  The physician reviewer found that multiple evaluations have indicated significant delays in fine motor skills, attention span and communication abilities. The patient has failed to show improvement in these areas over a two-year interval. During this time period, he received weekly occupational therapy in the school setting.