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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for scar reduction treatment the enrollees possible keloid scar. Findings:  The physician reviewer found that the request for scar reduction treatment is not medically necessary or reconstructive in nature for treatment of the patients medical condition. The patient presented with evidence of a probable hypertrophic scar following resection of a dermatofibroma.  Based on the documentation provided, the Health Plans recommendation for an in-person evaluation is medically reasonable and appropriate for an adequate evaluation of the right forearm. Conservative treatment including scar massage and possible steroid injection should be considered prior to re-resecting the area. Due to the lack of a sufficient evaluation, scar reduction treatment has not been established as medically necessary. In regards as to whether the requested surgery is cosmetic, according to the American Society of Plastic Surgeons (ASPS) Cosmetic surgery is performed to reshape normal structures of the body in order to improve the patients appearance and self-esteem. Reconstructive surgery is performed on abnormal structures of the body, caused by congenital defects, developmental abnormalities, trauma, infection, tumors or disease.  It is generally performed to improve function, but may also be done to approximate a normal appearance. In this case, the patients medical condition constitutes an abnormal structure of the body due to evidence of probable hypertrophic scarring following his right forearm resection. The patients abnormal structure of the body is a result of trauma. However, given the lack of documentation demonstrating a sufficient evaluation of the patients possible keloid scar it would be premature to assess whether the requested surgery is being performed to improve function or create a normal appearance to the extent possible. For the reasons provided, the requested surgery is not medically necessary or reconstructive in nature. Final Result: The reviewer determined that the requested surgery is not medically necessary or reconstructive in nature for treatment of the patients medical condition. 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: Overturned

The patient is a 10-year-old male who was diagnosed with Prader-Willi syndrome (PWS) at the age of eight months. His current growth velocity at age 10 is 16cm/year. In addition, the patient is Tanner Stage 2 and his IGF-1 level is 142. The patients physician indicates the patient has evidence of growth failure dropping from the 95th percentile at age 9 to the 80th percentile by age 10. The physician also states the patient has premature adrenarche and bone age advancement, which compromises his ability to attain his genetic potential of 172.5cm. The physician has recommended Genotropin growth hormone (GH) therapy to preserve the patients height projection and improve muscle mass and function. The Health Plan has denied authorization and coverage for GH therapy on the basis that it is not medically necessary for treatment of the patients medical condition.The Food and Drug Administration (FDA) has approved the use of GH for children with PWS, applying in its determination the data provided in the various submitted articles. In its determination the FDA did not approve GH therapy in PWS solely on the basis of its height promoting effect (which the FDA acknowledged as sufficient), but rather on the multiple benefits of this treatment intervention on these patients, including the beneficial effects of growth hormone on body composition, muscle bulk and tone, respiratory function, cholesterol levels, bone mineral density, etc. Furthermore, the FDA did not require proof of growth deficiency for GH therapy to be implemented in patients with PWS. As such, the use of growth hormone therapy for treatment of this patient is medically appropriate and indicated and should be authorized. Therefore, I have determined that the requested therapy is medically necessary for treatment of the patients medical condition. The Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested Harvoni 90-400 mg for treatment of the enrollees hepatitis C virus.  Findings: The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested medication. According to the recent joint guidelines issued by the American Association for the Study of Liver Diseases and the Infectious Diseases Society of America (AASLD/IDSA), all patients with chronic hepatitis C should be treated except those with limited life expectancy due to non-liver-related conditions.  AASLD/IDSA guidelines cite data showing reduced survival with delayed treatment (Jezequel, et al). The guidelines recommend that all patients should be treated, regardless of fibrosis stage.  The guidelines recommend that non-cirrhotic, treatment-naive, genotype 1a patients should be treated with Harvoni for 12 weeks. These recommendations are based on multiple randomized clinical trials, and the medication is U.S. Food and Drug Administration (FDA) approved for all patients with chronic hepatitis C, genotype 1 regardless of fibrosis stage (Kowdley, et al; Afdhal, et al). Zepatier for 12 weeks is also a recommended regimen, and the guidelines recommend either as acceptable therapy.  Thus, the Health Plans alternative Zepatier is medically appropriate for the treatment of this patient. Therefore, the medical necessity of Harvoni 90-400 mg is not supported for treatment of this patients hepatitis C infection.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 physician 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

Nature of Statutory Criteria/Case Summary: An enrollee has requested Harvoni for 12 weeks for treatment of her hepatitis C virus (HCV).  Findings:  The physician reviewer found that as per the American Association for the Study of Liver Diseases (AASLD) and Infectious Diseases Society of America (IDSA) guidelines, Successful hepatitis C treatment results in sustained virologic response (SVR), which is tantamount to virologic cure, and as such, is expected to benefit nearly all chronically infected persons. Evidence clearly supports treatment in all HCV-infected persons, except those with limited life expectancy (less than 12 months) due to non-liver-related comorbid conditions. However, Harvoni for eight weeks was associated with a high rate of sustained virologic response among previously untreated patients with HCV genotype 1 infection without cirrhosis. No additional benefit was associated with the inclusion of ribavirin in the regimen or with extension of the duration of treatment to 12 weeks. Thus, Harvoni for eight weeks in treatment-naive patients without cirrhosis who have a baseline HCV viral level of less than six million IU/mL is indicated based on post-hoc analysis of the clinical data from ION-3 trial. In sum, the medical necessity for Harvoni for 12 weeks has not been established in this clinical setting.  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 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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for H.P. Acthar gel for treatment of the enrollees sarcoidosis. Findings:  The physician reviewer found that the request for H.P. Acthar gel is not medically necessary for treatment of the patients medical condition. There is a lack of peer-reviewed literature supporting the use of H.P. Acthar gel for the treatment of sarcoidosis. Given the lack of peer-reviewed literature and the medical documentation submitted for review, the request for H.P. Acthar gel is not medically necessary for treatment of the patients medical condition. 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: Medical Necessity
Decision: Overturned

A 46-year-old female enrollee has requested acute inpatient detoxification services for treatment of her chemical dependency. Findings:  The physician reviewer found the submitted documentation supports the medical necessity of a portion of the services at issue.  Although the patient had a rather unremarkable physical examination at the time of the admission, she described a history of alcohol use which included blackouts and withdrawal symptoms.  Her concomitant benzodiazepine use elevated her risk for a poor outcome.  The patient was at risk for a complicated withdrawal syndrome, so inpatient treatment was initially medically necessary.  While hospitalized, the primary detoxification modality was a benzodiazepine taper, which is standard of care. Per the medical records, the patient did have hallucinations on a specified date. She was sent to the medical emergency department to rule out the potentially fatal diagnosis of delirium tremens.  She returned to the detox unit and thereafter, there was no mention of concerning signs and symptoms of alcohol withdrawal.  Therefore, inpatient detoxification services were medically indicated.  However, the records fail to demonstrate the medical necessity of inpatient detoxification services.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested breast tomosynthesis for evaluation of her medical condition.  Findings: Two physician reviewers found that breast tomosynthesis provides advantages to radiologists interpreting mammograms.  Often this addition of breast tomosynthesis to two-dimensional mammography allows the reader to separate dense glandular elements from underlying mass/architectural distortion, resulting in a decrease in biopsies, decrease in callbacks and increase in detection of small cancers.  Thus, the addition of tomosynthesis to the usual two-dimensional imaging protocol was likely of greater benefit to the patient than had her examination been done with two-dimensional imaging alone.  Final Result: Two 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: All three physician reviewers are board certified in diagnostic radiology 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 63-year-old female enrollee has requested Teeter EP 960 inversion table for treatment of her sacroiliac joint disorder and back pain.  Findings:  The physician reviewer found that this patient has been diagnosed with scoliosis, neuromuscular disease, myalgias and sacroiliac joint dysfunction. These diagnoses support the medically necessity of the requested Teeter EP 960 inversion table. During a trial treatment period with the inversion table, the provider noted that the patient experienced decreased pain. Further, the patient required fewer chiropractic visits. There is early clinical data on gravity assisted lumbar traction as effective for decreasing lumbar spasm in well selected patients. All told, the Teeter EP 960 inversion table is supported as medically necessary for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary:   The parent of an enrollee requested residential substance use services for treatment of his polysubstance dependence. The physician reviewer found that according to the documentation submitted for review, the patients substance abuse is not clear as there is no admitting psychiatric evaluation, no substance abuse history and no description of what the precipitating factors were leading up to his admission. It is also not clear what treatment he received for substance abuse as there was no documentation regarding the presence or absence of withdrawals, or what substances of abuse were the focus of this admission. There was no documentation provided of any substance abuse counseling, meetings attended or educational groups. There was mention of the patients ongoing desire to use. The documentation submitted for review included individual, group and family psychotherapy notes, which focused around the patients depressed mood, sense of low self-esteem, and triggers.  While in need of continuing care, the patient did not require substance use services at the residential level of care. The patients treatment could continue at a lower level of care. Therefore, residential substance use services were not medically necessary for treatment of the patients medical condition.  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: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested digital breast tomosynthesis for evaluation of the enrollees breast cancer screening. Findings: Three physician reviewers found that tomosynthesis is a technique that was developed as a problem solving adjunct to routine mammography. In this case, the patient has breasts that have been described as heterogeneously dense.  In addition, there have been prior masses that have been felt to be benign. Tomosynthesis is a valuable tool in better characterizing masses. While one could make the argument that her mammogram has not changed since the last study, it is specifically those patients who have dense breasts that can benefit most from tomosynthesis. The ability to separate out the overlapping structures enables the possibility of demonstrating an otherwise occult tumor. Accordingly, the breast tomosynthesis was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Final Result: Three 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 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: Medical Necessity
Decision: Upheld

The representative of an 18-year-old female enrollee has requested a partial hospital program (PHP) for treatment of the enrollees behavioral health condition. Findings:  The physician reviewer found that the patient appeared to be stable with no substantive changes in her weight or depression. The titration of her medication appeared to be excessively conservative for a patient with severe depression, and there is no evidence that she was at risk for hospitalization. Her weight fluctuated, but overall her weight was above 80% of her ideal body weight of 130 pounds. In addition, there is no indication of physiological compromise related to her eating disorder such as abnormal labs or vital signs.In summary, the submitted records do not demonstrate that the patient was seriously at risk or could not have been safely treated in an alternate level of care during the period at issue. All told, in this patients particular clinical situation, American Psychiatric Association practice guidelines for PHP treatment were not met during the dates of service at issue.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for cervical area/lumbar injections. Findings:  The physician reviewer found that systematic review of therapeutic lumbar, cervical, and thoracic facet joint interventions for the treatment of chronic spinal pain, Manchikanti and colleagues concluded that evidence supporting the use of cervical facet joint nerve blocks for relief lasting significantly longer than the pharmacological duration. The authors noted that an 80% or greater pain relief report was a criterion standard. In this case, the patient reported 80% pain relief following cervical medial branch blocks bilaterally, with the relief lasting 28 hours, which would indicate that the patients neck pain is originating from the cervical facet joints. In this clinical setting, the requested services are medically indicated. Therefore, cervical area/lumbar injections are medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested services are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in anesthesiology with sub-specialty certification in pain 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: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the digital breast tomosynthesis for evaluation of the enrollees breast cancer screening. Findings:  2/3 of the physician reviewers found that the patient is asymptomatic with respect to her breasts. She has a family history of breast cancer, and a cousin. In addition, the patient has had a prior core biopsy of her right breast, which was benign. She also has had a prior augmentation mammoplasty. She underwent a routine screening mammogram consisting of a three-dimensional (3D) tomosynthesis study with synthetically reconstructed two-dimensional (2D) views. In addition of routine views, implant displacement views were also obtained. The current images were compared to prior mammograms and no interval changes were noted. There were no masses, areas of suspicious calcifications, or areas of architectural distortion. Her breasts were described as heterogeneously dense. The patient has requested reimbursement for the digital breast tomosynthesis performed. The Health Plan has denied this request as investigational. Tomosynthesis is a technique that was developed as a problem solving adjunct to routine mammography. In this case, the patient has heterogeneously dense breasts. While one could make the argument that her mammogram has not changed since the last study, it is specifically those patients who have dense breasts that can benefit most from tomosynthesis. The ability to separate out the overlapping structures enables the possibility of demonstrating an otherwise occult tumor. Accordingly, the digital breast tomosynthesis performed 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 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: 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.Physician reviewer number two 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.Physician reviewer number three 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.