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

Nature of Statutory Criteria/Case Summary: An enrollee has requested a referral to a Naturopathic physician for treatment of the enrollees menopause.  Findings:  The physician reviewer found that the review of the submitted documentation and relevant literature fails to demonstrate the medical necessity of the requested referral. There are many options for treatment of menopausal symptoms which include hormonal and non-hormonal therapies. Treatment of menopausal hot flashes, range from symptomatic treatments, over-the-counter supplements, selective serotonin reuptake inhibitors (SSRIs), serotonin and norepinephrine reuptake inhibitors (SNRIs),  gabapentin, clonidine, and various hormonal treatments (Santen, et al). The patient expresses a desire for a compounded bioequivalent hormone therapy. There is a lack of evidence that compounded hormone therapy, which is not U.S. Food and Drug Administration (FDA) approved, is any more effective or safer than FDA-approved options. However, a number of expert groups, including the North American Menopause Society, American College of Obstetricians and Gynecologists, and Endocrine Society, all of whom advise against the use of custom-compounded hormones (Martin and Barbieri). Overall, there is a lack of data in the peer-reviewed literature that supports treatment by a Naturopathic physician in this clinical setting. Accordingly, the request for a referral to a Naturopathic physician has not been established as medically necessary for treatment of the patients medical condition.Final Result: The reviewer determined that the requested referral 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 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: Medical Necessity
Decision: Upheld

A 52-year old female enrollee has requested an electric motorized wheelchair for treatment of her diabetic polyneuropathy.   Findings:  The physician reviewer found that the records forwarded for review do not establish that the patient would be bed or chair confined without a power mobility device. The records do not substantiate any significant neurological or musculoskeletal impairment or pathology affecting the upper limbs, cardiovascular system, pulmonary system, or other relevant organ system to a degree that would preclude her from accomplishing her mobility related activities of daily living in the home using a manual wheelchair. Specifically, the physiatrist noted good strength in the upper limbs and the physical therapist noted functional range of motion and strength in the upper limbs. If necessary, a manual wheelchair could be adapted for simultaneous propulsion using the lower limbs. In addition, this patient has multiple chronic health conditions that would benefit from increased physical activity and exercise. Manual wheelchair use has been shown to provide significant health benefits over power wheelchair use for patients with mobility impairments (Keyser, et al; Valent, et al). Overall, an electric motorized wheelchair is not medically necessary for this patient.
Appeal type: Medical Necessity
Decision: Upheld

A 59-year-old female enrollee has requested an electron beam computed tomography (EBCT) scan for an evaluation of her heart. Findings:  Three physician reviewers found that there was no documentation provided necessitating the requested EBCT. There is no evidence that the patient has undergone any standard stress testing. EBCT is not considered a screening tool for the diagnosis of coronary artery disease. To date, there are no controlled, prospective trials of EBCT as a predictor of actual disease events. The patient has complaints of chest pain and shortness of breath and per the recommendations of the American Heart Association, the data are insufficient to recommend EBCT instead of stress testing generally for patients with chest pain.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested Sovaldi and Ribapak for treatment of his hepatitis C. Findings:  The physician reviewer found that according to 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 life expectancy due to non-liver-related conditions.  Per the guidelines, Sovaldi/ribavirin is not a recommended treatment for a genotype 3 unless there is a contraindication to both peg-interferon and Daklinza. In treatment-naive genotype 3 patients who can tolerate peg-interferon, therapy is recommended with Sovaldi, peg-interferon, and ribavirin for 12 weeks.  This patient is reported to have no medical contraindications to peg-interferon.  Additionally, there is no reported contraindication to ribavirin tablets or capsules to support use of RibaPak.  For these reasons, the requested treatment with Sovaldi and RibaPak is not supported as medically necessary for the treatment of this patients hepatitis C infection.  Final Result: The reviewer determined that the requested medications 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 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 female enrollee requested a six to eight week pain management program to increase functionality for chronic pain through medication adjustments and therapy for medical treatment of her chronic pain. The therapeutic environment of a functional restoration program is appropriate to address pain management strategies, and increase physical activity and independence without reliance on medications. Based on the documentation submitted for review, a six-week functional restoration program with concomitant outpatient detoxification from opioids as part of the program is medically necessary. Based on the documentation submitted for review and the peer-reviewed literature cited above, a portion of the requested services are medically necessary for treatment of the patients medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: A enrollee has requested reimbursement for the transcranial magnetic stimulation (TMS). Findings:  The physician reviewer found that TMS provided a reduction of headache days from baseline. Early treatment of migraine with aura by TMS resulted in increased freedom from pain at two hours compared with sham stimulation, and absence of pain was sustained 24 hours and 48 hours after treatment. The records document that this patient has tried multiple abortive and prophylactic treatments for her migraine headaches. Thus, the TMS was likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: Two of the three reviewers determined that the services at issue were likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications:  One reviewer is board certified in neurology with sub-specialty certification in pain medicine and is actively practicing. One Reviewer is board certified in neurology and is actively practicing.  One Reviewer is board certified in neurology and is 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 patient has requested reimbursement for air ambulance transportation. Current medical literature supports spinal cord rehabilitation following traumatic spinal cord injury (SCI). Herzer and colleagues report that earlier rehabilitation after traumatic SCI may improve a patients functional status at discharge. Labruyere and colleagues likewise report that early rehabilitation, defined as within 30 days of injury, improves outcome and recovery for spinal cord trauma patients. The authors further note that in a dedicated SCI rehabilitation setting, effective treatment and proper monitoring of spontaneous and rehabilitation-based motor function improvements is performed with appropriate, valid, reliable, and internationally accepted clinical assessment tools. In this case, the patient suffered a complete spinal cord injury and was an appropriate candidate for spinal cord injury rehabilitation following medical and surgical stabilization. Despite being requested, the submitted records did not include information on whether there was a similarly credentialed spinal cord rehabilitation facility in closer in proximity to Renown Regional Medical Center in Reno, Nev. than the Santa Clara Valley Medical Center in San Jose, Calif. In this clinical setting, given that specialized rehabilitative care for patients with SCI results in better outcomes with fewer complications and as air ambulance was the only reasonable method to transport the patient to Santa Clara Valley Medical Center, the service at issue was medically indicated. Therefore, air ambulance transportation was medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested residential treatment (RTC) services for treatment of the enrollees behavior health condition.  Findings: The physician reviewer found that although patient presents with a chronic and debilitating formal thought disorder characterized by recurrent psychotic episodes, the documentation does not support the medical necessity for RTC services. The patient improved during the recent three-week acute psychiatric hospitalization. She was treated with the gold-standard medication, clozapine, for refractory psychosis. The psychiatrist indicated that the patient was stable enough for outpatient treatment, while at the time of discharge, the patient did not meet residential level of care criteria. During a follow-up visit the day after discharge at her board and care residence, the patient was not distressed, psychotic or suicidal. An overarching goal in contemporary psychiatric practice is to provide evidence-based treatment in the least restrictive setting. In this case, the treatment team devised a reasonable aftercare plan consistent with good medical practice. There is no subsequent medical documentation detailing a symptom burden that would support the necessity of higher of level of care. As there is no evidence that the current plan of care is unsafe or inadequate, the requested services are not 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 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

A 57-year-old female enrollee requested the medication Belviq for medical treatment of the enrollees obesity.  Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested medication.  The cornerstone of the medical management of obesity is behavior modification of exercise and eating habits.  Drug therapy and surgery are other options to consider.  A trial of drug therapy or surgery should be reserved for patients with comorbid conditions such as impaired glucose tolerance, hypertension, dyslipidemia, diabetes mellitus or sleep apnea.  Belviq is a serotonin agonist which may be indicated in treating obese individuals who have at least one comorbid condition.  In this patients case, there is a lack of information regarding details of prior dietary and behavior modification efforts that have been tried or failed.  Further, there is a lack of documentation of any comorbid conditions which would support the requested medication.  All told, Belviq is not medically indicated for the treatment of this patient.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested digital breast tomosynthesis for evaluation of the enrollees risk for breast cancer.  Findings: Two physician reviewers found that tomosynthesis was approved by the U.S. Food and Drug Administration (FDA) for clinical use. Despite the lack of long-term studies proving an increased survival rate when tomosynthesis has been used as part of screening mammography, the American College of Radiology (ACR) urged the technique be removed from the investigational category in 2014 due to the advantages this new tomographic technique brings to radiologists interpreting mammograms. This technique often allows radiologists to separate dense glandular elements from underlying masses and architectural distortion resulting in a decrease in callbacks and increased detection of small cancers. Thus, the addition of tomosynthesis to the usual two-dimensional protocol was likely of greater benefit to this patient than had her exam been done with two-dimensional imaging alone. Accordingly, the breast tomosynthesis that was was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Final Result: Two reviewers determined that the diagnostic procedure 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: All three physician reviewers are board certified in diagnostic radiology 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:   An enrollee has requested facial feminization surgery for treatment of her gender dysphoria. The physician reviewer found that per the World Professional Association for Transgender Health (WPATH) Standards of Care, there is a divergence of opinions regarding whether facial feminization surgery is considered reconstructive. In the absence of definitive guidance on the classification of facial feminization procedures as reconstructive, determinations of medical necessity for such procedures must be made on a case specific basis. In this patients case, review of the submitted clinical documentation including photographic images demonstrates that the patients features are not overtly masculine. The patients nose, jaw/chin, brow, lips and trachea are within the anatomical range of normal of a natal female. The requested procedures are not medically necessary to modify masculine features. The proposed procedures are for the purposes of creating a more aesthetically desirable female appearance and are not medically necessary for treatment of the patients gender dysphoria. Furthermore, the proposed procedures do not meet reconstructive surgery criteria. The patients current facial features do not represent an abnormal structure of the body, as they fall within the anatomical standards for an individual of the female gender. As such, the requested services are not considered reconstructive in nature.  Final Result: The reviewer determined that the requested services are not medically necessary for treatment of the patients medical condition or reconstructive in nature. Therefore, the Health Plans denial should be upheld. 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

A 55-year-old female has requested transgluteal approach for neuroplasty of the superior gluteal nerve and exploration and partial section of the sacroiliac ligaments for treatment of her low back pain with radiation to the left lower extremity.  Findings:  The physician reviewer found that this patient has chronic back pain and left buttock pain and left thigh pain. Her pain generator has not been identified. Two MR neurography studies have not demonstrated abnormalities of the left superior gluteal nerve. In the medical literature, Halpin and Ganju noted that the existence of the piriformis syndrome is controversial. These findings are reiterated by Tiel in his publication on piriformis syndrome. Since this patient does not have an indication for the proposed procedure, the requested surgery is not medically necessary.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for bilateral knee replacement surgery. Current medical literature supports total knee arthroplasty for well-selected patients with arthritis who have not improved despite adequate conservative treatment. Accepted indications include pain that interferes with activities of daily living and sleep, physical findings of advanced osteoarthritis, imaging evidence of advanced osteoarthritis, failed non-operative treatment, and absence of relative contraindications. In this case, there is evidence of severe pain rated 8/10, a history of frequent locking, and imaging studies demonstrating advanced osteoarthritis in both knees with associated deformity. In addition, the patient has exhausted conservative treatment modalities and there are no reported major contraindications to surgery. Given these findings, the requested bilateral knee replacement surgery is medically necessary for 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: Overturned

A 53-year-old female enrollee requested authorization and coverage for the revision of previous gastric bypass surgery.  The enrollees health plan denied the request indicating the requested surgery 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 surgery is medically necessary.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested Harvoni for eight weeks for treatment of his hepatitis C. Findings:  The physician reviewer found that the submitted documentation supports the medical necessity of the requested medication.  This patients records do not support advanced fibrosis.  However, American Association for the Study of Liver Diseases and Infectious Diseases Society of America guidelines support treatment irrespective of fibrosis score.  Per the guidelines, the medical evidence supports treatment in all patients with chronic hepatitis C, except those with limited life expectancy less than 12 months.  There is sufficient support for the requested medication in this clinical setting.  All told, Harvoni for eight weeks is medically indicated 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 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: Upheld

The patient is a 53-year-old woman with chronic hepatitis C. She was treated with Peg-Intron and ribavirin for 48 weeks. It appears she did not respond to the therapy. Another course of therapy with Peg-Intron and ribavirin has been recommended by the patients provider. The patient has stated that she is seeking treatment with Infergen and ribavirin. The Health Plan has denied authorization and coverage for Peg-Intron and ribavirin on the basis it is not medically necessary for treatment of the patients condition.It is not standard of care to treat patients who have failed an initial course of Peg-Intron and ribavirin with a repeat course of the therapy. The submitted records indicate the patient failed to achieve viral clearance after 48 weeks of therapy. There is no prospective, peer-reviewed study showing benefit in retreating patients such as this patient. Thus, a repeat course of Peg-Intron and ribavirin is not likely to benefit the patient and is not medically indicated. However, use of Infergen in this situation would be medically reasonable and appropriate as Infergen has been approved by the Food and Drug Administration for patients who have not responded to prior therapy. Based upon the information set forth above, I have determined that treatment with Peg-Intron and ribavirin is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. However, if the patient and her provider request treatment with Infergen and ribavirin, such therapy would be medically indicated and should be authorized.