Persius/imr-appeals huggingface dataset:
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for genetic laboratory testing. Generally, patients with venous thromboembolism (VTE) with at least one first degree relative with documented VTE before a certain age should be tested for the presence of all five inherited thrombophilia. Bhatt and colleagues note that factor V Leiden, along with factor II genetic testing, remains an important testing option in VTE. In visit notes, the patient reported a diagnosis of deep vein thrombosis (DVT), and that a family member was affected by DVT. In this clinical setting, identification of a factor V Leiden variant is unlikely to change management of the patients course. Therefore, genetic laboratory testing was not likely to have been more beneficial for treatment of the patients condition than any available standard therapy.Final Result: The reviewers determined that the service at issue was not likely to have been more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: Physician reviewers 1 and 2 are board certified in internal medicine with sub-specialty certifications in medical oncology and hematology and are actively practicing. Physician reviewer 3 is board certified in internal medicine 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

A 45-year-old male enrollee has requested the combination therapy of Pegasys Proclick 180mg (approved), Sovaldi 400mg and Ribavirin (Ribapak) 400mg for treatment of his hepatitis C. Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested medication combination.  There is very little data on the treatment of hepatitis C, genotype 6 and most of the recommendations extend from trials on other genotypes.  Per the current medical evidence, the requested medication combination of Sovaldi, Ribavirin and Pegasys Proclick may be medically appropriate for patients with hepatitis C, genotype 6.  However, there is a lack of support for the requested medication combination in his case.  Per the clinical notes, evidence of significant fibrosis supporting the requested medication combination was not documented.  Therefore, the requested combination therapy of Pegasys Proclick 180mg (approved), Sovaldi 400mg and Ribavirin (Ribapak) 400mg is not medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld

This case involves a female enrollee who requested authorization and coverage of 200mg of Celebrex twice per day.  The health plan denied the request, indicating that the requested prescription is not medically necessary for treatment of the enrollees bilateral hip osteoarthritis.One physician reviewer performed a medical necessity Independent Medical Review.  The physician reviewer upheld the health plans denial on the basis that the requested prescription is not medically necessary.
Appeal type: Medical Necessity
Decision: Upheld

The parents of a 10-year-old female enrollee requested authorization and coverage of a Convaid Cruiser wheelchair for the treatment of cerebral palsy.  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: Experimental/Investigational
Decision: Overturned

A 52-year-old female enrollee has requested Nuvigil for treatment of her multiple sclerosis related fatigue. Findings:  Two physician reviewers found that fatigue is common in MS and can be debilitating and interfere with the patients ability to participate in a healthy lifestyle. Thus, despite the fact that Nuvigil is an off-label use for this patient with MS related fatigue, it is a longer lasting isomer of Provigil and has support in the scientific data as being effective in managing daytime somnolence in this patient population. Moreover, Nuvigil has been more effective in this patients care than any other medication. With emerging literature supporting Nuvigil in MS related fatigue and this patients success with the medication, its use should not be considered investigational for treatment of her fatigue secondary to MS.
Appeal type: Medical Necessity
Decision: Overturned

A 37-year-old female enrollee has requested laparoscopy for evaluation of her chronic pelvic pain. Findings:  The physician reviewer found that according to the American College of Obstetricians and Gynecologists (ACOG) practice bulletin, a definitive diagnosis of endometriosis can only be made surgically. In the medical literature, Howard noted that about one-third of outpatient laparoscopic surgical procedures in women are performed because of abdominal/pelvic pain. The author stated that after a two- to three-month course of empiric medical treatment, laparoscopy is offered to women who have not achieved relief of symptoms and have no strong contraindications to laparoscopic surgery. Schenken reported that the diagnosis of endometriosis may require laparoscopy. A clinical diagnosis is sufficient to initiate therapy that is safe and easily tolerated such as estrogen-progestin contraceptives. The author cautioned that surgical diagnosis may be advisable before treating with medications with a high risk of adverse effects such as gonadotropin-releasing hormone (GnRH) agonists. Thus, although a trial of Lupron is an option in situations where patients have chronic pain and suspected endometriosis, it is not a required first-line therapy before undergoing laparoscopy, as there are risks and benefits to both treatment options that must be individualized for the patient. All told, the laparoscopy performed on this patient on the date indicated was medically necessary and consistent with the current medical standard of care.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for digital breast tomosynthesis for the evaluation of the enrollee, who was asymptomatic with respect to her breasts. Findings:  The 3 physician reviewers found that the patient is a female who was asymptomatic with respect to her breasts.  She underwent a routine screening mammogram consisting of a combination two dimensional and three dimensional digital breast tomosynthesis examination.  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 being heterogeneously dense. The Health Plan has denied reimbursement for digital breast tomosynthesis used.  Per the Health Plan, the service at issue was investigational for the evaluation of this patient. Breast tomosynthesis is a technique that was developed several years ago as a problem solving adjunct to routine mammography.  Applying the same basic concept as computed tomography scanning, the logic is that by separating the various layers of breast tissue, one can better detect abnormalities. This has been shown to be most useful in the evaluation of dense breasts.  In this particular patient, the patients breast tissue has been described as being heterogeneously dense. While her mammogram has not changed since the last study, it is specifically those patients who have dense breasts that can benefit most from digital breast tomosynthesis. The ability to separate out the overlapping structures enables the possibility of demonstrating an otherwise occult tumor. Therefore, digital breast tomosynthesis used was likely to have been of greater benefit than other methods of evaluating this patient.  Final Result: The 3 reviewers determined that the service 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.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for full abdominoplasty and bilateral lipectomy/thighplasty for treatment of the enrollee who has had rashes, intertrigo and yeast infections due to excess skin. Findings: The physician reviewer found that as noted, the patient has well-documented functional issues related to recurrent rashes of the upper and lower abdomen. However, this medical condition is not clearly documented for the patients thighs. It is unclear if the same open sores and chronic fungal infections affect the medial thighs. The photographs do not show evidence of a significant condition, as the skin-to-skin contact appears mild. Also, the providers letter appears to address only the upper and lower abdominal pannus but not the thighs. Further, the literature notes that only in rare circumstances will thigh lifts be needed to treat functional abnormalities. According to the records, this patient does not require treatment for a functional abnormality. Further, the excess skin of the patients thigh does not constitute an abnormal structure of the body. Based on the overall documentation provided, bilateral lipectomy/thighplasty is not medically necessary and is not reconstructive in nature. In summary, a portion of the requested services is medically necessary and is reconstructive in nature. Specifically, full abdominoplasty is medically necessary and reconstructive in nature while bilateral lipectomy/thighplasty is not medically necessary and is not reconstructive in nature. Final Result: The reviewer determined that a portion of the requested services is medically necessary and is reconstructive in nature for treatment of the patients medical condition. 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: Experimental/Investigational
Decision: Upheld

A 58-year-old female enrollee has requested sacroiliac joint fusion (CPT 27280) for treatment of her sacroiliac joint pain.  Findings:  Two physician reviewers found that the requested sacroiliac joint fusion is not likely to be more beneficial for this patient than any available standard therapy. Based upon review of the submitted medical records, this patient has multiple pain generators including changes above levels of fusion, central spinal stenosis, facet arthrosis and trochanteric bursitis. A specific diagnosis supporting sacroiliac joint fusion procedures is not demonstrated by the clinical findings. In addition, there is a lack of Level I or Level II studies in the scientific literature supporting sacroiliac joint fusion. Further studies are needed before the efficacy of sacroiliac joint fusion is established. As such, neither the patients clinical findings nor the relevant scientific evidence demonstrate that  the requested surgery is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.
Appeal type: Medical Necessity
Decision: Overturned

A 59-year-old female enrollee has requested for Raptiva for treatment of her psoriasis.  Findings:  The physician reviewer found that it is indisputable that Raptiva is an effective treatment for many patients with psoriasis who are resistant to standard therapies. The safety profile of Raptiva in patients with a negative TB skin test is much more favorable than methotrexate, cyclosporine or Soriatane. The providers letter lists a number of appropriate references to support this conclusion. A case study presented to the American Academy of Dermatology demonstrated Raptiva was particularly effective in treatment-resistant hand and foot psoriasis.
Appeal type: Medical Necessity
Decision: Upheld

A 58-year-old female enrollee requested abdominoplasty for medical treatment of her excess skin.  Findings:  The physician reviewer found that the requested abdominoplasty is not medically necessary for treatment of the patients medical condition. The patient presents with significant weight loss following gastric surgery for gastric cancer. She is documented to have excess abdominal skin following this weight loss. However, there is a lack of documentation demonstrating the patient has a functional deficit related to this extra skin.  The skin excess related to the patients weight loss is relatively mild.  Surgical treatment with an abdominoplasty would attempt to improve on a relatively normal appearance, which is consistent with cosmetic surgery.  Thus, the requested procedure would only offer a minimal improvement in the abnormal appearance of the patient. Therefore, the requested abdominoplasty does not meet reconstructive surgery criteria.
Appeal type: Medical Necessity
Decision: Upheld

The patient is a 46-year-old female who has undergone transanal excision of a rectal tumor.  She has completed postoperative chemotherapy and radiation therapy.  The patient is now one year out from her surgery and is due for a follow-up colonoscopy.  She has requested that the colonoscopy be performed by her out-of-network colo-rectal surgeon. The Health Plan denied her request based on a determination that it is not medically necessary that the out-of-network surgeon perform the procedure.There is no evidence in the record of any specific issue that would require the same surgeon that performed the patients surgery to also perform the surveillance colonoscopy. Any experienced colonoscopist can perform a routine surveillance colonoscopy. If a problem is encountered, reevaluation by the out-of-network surgeon should be authorized.   As discussed above, I have determined the requested provider is not medically necessary for evaluation of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld

A 46-year-old female enrollee has requested  for a custom knee brace for treatment of her right knee patellofemoral syndrome.  Findings:  The physician reviewer found that custom knee braces are most effective when there is ACL instability present. This patients records indicate the ACL is intact and there is no evidence of instability. The patient had a posterolateral corner repair and partial meniscectomy. Based on the type and degree of this patients complaints, it is unlikely that a custom brace will result in a superior result in terms of symptom improvement. A standard device with medial and lateral hinges is medically appropriate in this clinical setting.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested partial hospitalization program services for treatment of her behavioral health conditions. Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the services at issue.  The patient attested to suicidal thoughts without intent or plan.  The homicidal thoughts noted in the summary do not constitute true homicidal ideation, in that the patient inappropriately seemingly verbalizes all that she is thinking.  She did not suffer from grave disability.  Family therapy was occurring, and her parents were receiving education.  She was medically stable and compliant.  No new problems had arisen.  Exposure had begun, the patient had improved, and her ability to be in public had increased.  All told, partial hospitalization program services were not and are not medically indicated for the treatment of this patient.   Final Result: The reviewer determined that the services at issue were not and are not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.  Credentials/Qualifications: The reviewer is board certified in psychiatry and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested breast tomosynthesis for evaluation of her medical condition.   Findings:  Three physician reviewers found that breast tomosynthesis is a technique that was developed several years ago as a problem solving adjunct to routine mammography.  Applying the same basic concept as computed tomography (CT) scanning, the logic is that by separating the various layers of breast tissue, one can better detect abnormalities.  This has been shown to be most useful in the evaluation of dense breasts.   The ability to separate out the overlapping structures enables the possibility of demonstrating an otherwise occult tumor.  Therefore, breast tomosynthesis was likely to have been of greater benefit than other modalities for evaluating this patient.  Final Result: Three 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 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 32-year-old transgender female enrollee requested laser facial hair removal or electrolysis for medical treatment of the enrollees gender identity disorder. Findings:  The physician reviewer found that as defined in a paper by Elghblawi, Hirsutism is the excessive and increased bodily and facial hair growth in women in locations where hair is normally minimal or absent. It refers to the growth of hair in a pattern normally occurring only in men, and therefore primarily raises psychological, cosmetic and social concerns. According to Blume-Peytavi, unwanted facial hair is a particular concern, due to its negative impact on perceived femininity. There may not always be a direct correlation between degree of severity diagnosed objectively by the physician and level of concern and impact upon the patient. For a female with hirsutism, it is necessary to remove hair for psychological and social reasons. The negative perception of excessive hair on an individuals femininity would have an even greater impact on a transgender female. Therefore, facial hair removal utilizing laser or electrolysis is medically necessary for treatment of this patients condition.
Appeal type: Medical Necessity
Decision: Overturned

The patient has requested authorization and coverage for physical therapy three times per week and occupational therapy three times per week. Without optimization in functional status, this patient is at increased risk of a compromised functional status. Based on the available records, the patient partially improved with physical and occupational therapies. Specifically, the patients bed mobility improved from maximum assistance to moderate assistance, her bed rolling improved from maximum assistance to moderate assistance, and her walking improved from unable to dependent at 10-49 feet. Based on these reports, the patient demonstrated adequate progress, yet she continues to have functional goals that are reasonably expected with formal physical and occupational therapies. Ongoing efforts toward physical rehabilitation are within standard practice, and are appropriate to keep the patient on a pathway to functional recovery. All told, the requested physical therapy three times per week and occupational therapy three times per week are 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 internal medicine with subspecialty certifications in pulmonary disease and critical care 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 has requested endoscopic sinus surgery and nasal septum reconstruction for treatment of the enrollees medical condition.   Findings:  The physician reviewer found that the submitted documentation supports the medical necessity of a portion of the requested services.  This patient has been treated for recurrent sinus infections.  Per the records, he has been treated with antibiotics and steroids.  He has tried several medical therapies and continues to be symptomatic.  He has undergone formal allergy evaluation as well, with negative findings. As such, there is support for the requested endoscopic sinus surgery, which is designed to improve sinus drainage with the goal of reducing acute flares of symptoms and need for antibiotics.  However, the medical records do not support nasal septum reconstruction in this patients case.  The documentation does not show that septal deviation is symptomatic.  Nasal septum reconstruction would only be indicated if it resulted in obstruction to access during endoscopic sinus surgery.  All told, the requested endoscopic sinus surgery is medically indicated for the treatment of this patient.  However, the requested nasal septum reconstruction is not medically necessary for the treatment of this patient.  Final Result: The reviewer determined that a portion of the requested services is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be partially overturned.  Credentials/Qualifications: The reviewer is board certified in otolaryngology 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.