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

Nature of Statutory Criteria/Case Summary: An enrollee has requested Harvoni for treatment of his chronic hepatitis C virus genotype 1a. Findings: Two physician reviewers found that as per the American Association for the Study of Liver Diseases (AASLD) and Infectious Diseases Society of America (IDSA) guidelines, all patients with chronic active hepatitis C are eligible for treatment and should be treated with U.S. Food and Drug Administration (FDA) approved antiviral therapy regardless of fibrosis score. Successful hepatitis C treatment results in sustained virologic response (SVR), which is tantamount to virologic cure, and is expected to benefit nearly all chronically infected patients. The fixed dose combination ledipasvir-sofosbuvir (Harvoni) is FDA approved for the treatment of chronic hepatitis C genotype 1 in both treatment-naive and treatment-experienced patients. Therefore, the requested Harvoni is supported as medically necessary for treatment of this patients chronic hepatitis C virus.  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. 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 twenty-eight year-old female who has undergone gastric bypass surgery is requesting authorization of mastopexy, brachioplasty and thigh lift.  Reviewers Findings:  The reviewing physician found that correction of skin laxity following massive weight loss is typically considered cosmetic in the absence of clear and compelling documentation of specific signs and symptoms that 1) are clearly related to the excess skin 2) health threatening or cause significant functional disability and 3) have failed to improve despite reasonable attempts at conservative treatment.  The reviewing physician found that the records do not establish that the proposed procedures are medically necessary.  The reviewing physician found that the Health Plan denial should be upheld.
Appeal type: Experimental/Investigational
Decision: Upheld

A 61-year-old female enrollee has requested radiofrequency neurolysis for treatment of her chronic pain syndrome, lumbar radiculopathy, and failed back surgery syndrome.  Findings:  Three physician reviewers found that facet joint radiofrequency neurotomy is indicated for patients with proven facet joint pain (Falco, et al). Facet joint pain is diagnosed by controlled diagnostic blocks with concordant relief. Contraindications to facet joint neurotomy include fusion, inconclusive results with diagnostic blocks, and systemic infection. Considering multiple issues and the available literature, radiofrequency neurolysis is not likely to provide this patient with a greater benefit than standard available therapies for her medical condition.
Appeal type: Medical Necessity
Decision: Overturned

A female enrollee requested or Harvoni 84 tablets for treatment of her hepatitis C.  Findings:  Three physician reviewers found that according to the most recent joint guidelines issued by the American Association for the Study of Liver Diseases and the Infectious Diseases Society of America, all patients with chronic hepatitis C, regardless of fibrosis, should be treated, except those with life expectancy less than 12 months due to non-liver-related comorbid conditions.  Patients who have failed treatment with pegylated interferon-based regimens are recommended to be re-treated with daily Harvoni for 12 weeks.  Based on published evidence of safety and efficacy and current guidelines, the requested Harvoni 84 tablets are medically indicated for the treatment of this patient.
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. Findings:  Two physician reviewers found that the patient presented for a bilateral screening mammogram with digital breast tomosynthesis. There was no mammographic evidence of malignancy. The report noted average breast tissue density and scattered areas of fibroglandular density. The Health Plan has denied the request for reimbursement for the digital breast tomosynthesis. Per the Health Plan, the service at issue was investigational for the evaluation of this patient. There is clinical support for the service at issue. According to a study, the use of mammography plus tomosynthesis in a screening environment resulted in a significantly higher cancer detection rate and enabled the detection of more invasive cancers. Another study noted that integrated two dimensional and three dimensional mammography improves breast cancer detection and has the potential to reduce false positive recalls. Thus the literature supports the use of breast tomosynthesis over conventional mammogram due to improved cancer detection rate.  All told, digital breast tomosynthesis performed was likely to be more effective than other options of evaluating this patient. Final Result: The reviewers have 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: 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: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for a high frequency chest compression device (HCPCS E0483). The goal of therapy for patients with bronchiectasis is to improve airway mucus clearance. In this case, the patient has progressive bronchiectasis despite adherence to a daily mucous clearance program and use of an acapella flutter valve. Given the persistent and progressive nature of the patients disease, escalating therapy from daily hypertonic saline nebulizer and acapella flutter valve to a high frequency chest compression device represents standard practice. Therefore, a high frequency chest compression device (HCPCS E0483) is medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested device 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 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: Upheld

Nature of Statutory Criteria/Case Summary: The patients parent has requested authorization and coverage for brand name medication, Zovirax cream. Findings: Researchers conclude that for episodic treatment of herpes labialis, oral antiviral agents are superior to topical antiviral therapy. The authors noted that while topical agents, such as acyclovir, can also be used for episodic treatment, these topical agents are not effective in the prevention of recurrent herpes labialis. Given the current medical literature, the requested medication is not medically indicated. Therefore, brand name medication, Zovirax cream is not medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested medication is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is board certified in internal medicine with sub-specialty certification in infectious disease 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 has requested authorization and coverage for a high-frequency chest wall oscillation device. Reports recommend mucus clearance as the mainstay of therapy in bronchiectasis. Researchers listed several mucus clearance strategies such as flutter or Acapella devices, in combination with active breathing techniques, or a regimen of nebulized hypertonic saline solution. In this case, given the patients lack of mucus production, mucus impaction, and diffuse bronchiectasis, there is insufficient evidence to support a high-frequency chest wall oscillation device as medically necessary over other treatment options. Therefore, a high-frequency chest wall oscillation device is not medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested device 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 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: Upheld

The representative of a 45-year-old male enrollee has requested continued acute rehabilitation services for treatment of the enrollees medical condition status post intracranial hemorrhage and cognitive deficits.  Findings:  The physician reviewer found that the patient had a stroke last year and was severely impaired. The severity of stroke is a powerful predictor of stroke outcome (Massucci, et al). Stroke outcome at three months is unchanged based on the intensity of rehabilitation (Grenthe Olsson and Sunnerhagen). On the said date, the inter-disciplinary team conference noted no change in functional status and communication skills. He changed 5% in transfer and positioning but remained 85% dependent. He improved to 75% assistance with placing aftershave. These are minimal changes after three months of acute rehabilitation. After these changes there were no further gains. At this time, post-stroke no significant change in functional status can be expected from a reasonable medical perspective for continued stay in an acute rehabilitation hospital. Thus, the requested acute inpatient skilled services are not medically necessary to maintain or restore functional status.
Appeal type: Medical Necessity
Decision: Upheld

A 49-year-old female enrollee has requested acupuncture for the treatment of her medical condition. Findings:  The physician reviewer found that Acupuncture is understood as an alternative complimentary medical technique of treatment. Its underlying rationale is based on the premise that the essential energy called Qi flows through the body along invisible lines called meridians. Stimulating points along these lines either with pressure or needle intervention corrects the flow of Qi to optimize health and impact pain. While literature support is somewhat lacking, there is evidence to suggest there can be significant benefit from conservative, non-operative modalities such as acupuncture. However, in the case of this specific patient, she reported that acupuncture had provided only minimal relief of her neck and knee pain and migraines headaches. There is inadequate documentation in this case to demonstrate the patient had significant response to acupuncture to support the necessity of the past or future treatment.
Appeal type: Experimental/Investigational
Decision: Upheld

A 59-year-old female enrollee requested authorization and coverage for hereditary nonpolyposis colon cancer (HNPCC) testing.  The health plan has denied this request indicating that the requested testing is considered experimental for treatment of the enrollees cancer.Three physician reviewers performed an experimental/investigational Independent Medical Review.  All three-physician reviewers concluded that the requested testing is not likely to be more beneficial for treatment of the medical condition than any available standard therapy.  The health plans denial was upheld.
Appeal type: Medical Necessity
Decision: Upheld

The patient is a 38-year-old female with dyspepsia and heartburn. She has been taking antacids for relief of her symptoms. The submitted records reveal no objective clinical evidence of weight loss, dysphagia, abdominal pain or anemia. On 6/22/02, the patients provider indicated the patients family history was negative for colon cancer or other gastrointestinal malignancies. The patients physical exam was negative. The patient has requested reimbursement for an endoscopy and colonoscopy that were performed in June 2002. The Health Plan has denied the patients request on the basis that the procedures at issue were not medically necessary.The Health Plans denial should be upheld. The submitted evidence does not demonstrate that the procedures at issue were medically indicated. There is no documentation of symptomatology that would warrant an endoscopy. In addition, there is no evidence that the patient received a trial of any H2 blockers or proton pump inhibitors prior to the endoscopy at issue. Furthermore, at the time the patient underwent the endoscopy and colonoscopy there was no objective evidence of any of the accepted clinical indications for the procedures at issue. Therefore, I have determined that the procedures at issue were not medically necessary for evaluation of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld

The parent of a 9-year-old female enrollee has requested blood tests, comprehensive stool analysis tests and urine porphyrins tests for evaluation of the enrollees medical condition. Findings:  The physician reviewer found that the submitted documentation and relevant literature fails to demonstrate the medical necessity of the requested testing. Bloating, cramping, gas, bulky stools are symptoms that frequently accompany fat malabsorption. Some of the causes of fat malabsorption include: biliary atresia, celiac disease and other food intolerances, certain medications, certain types of cancer, cholestasis, chronic liver disease, Crohns disease, radiation treatments, parasitic infection and Whipples disease. In this patients case, appropriate screening evaluation was conducted and no clinically significant findings were identified. Upon review of the patients medical records, her providers took appropriate steps to screen for malabsorption conditions. Lab work and physical exam proved unrevealing. As such, clinical indications for the requested testing have not been established. Based on the medical literature cited above and the documentation submitted for review, the requested testing is not medically necessary for evaluation of the patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld

A 31-year-old female enrollee has requested Latisse for treatment of her dry eyes. Findings:  The physician reviewer found that the submitted documentation and relevant literature fails to demonstrate the medical necessity of the requested medication. Latisse eye drops have shown to be effective in promoting eyelash growth in patients having madarosis (lack of eyelashes) as a result of certain ocular diseases. It is also recognized that the eyelashes perform a function in keeping debris from contaminating the tear film and ocular surface. However, this patient was instructed to use artificial tears to combat her dry eye problem. If the tear supplementation was effective, it should have limited the amount of debris that might contaminate the tear film. If artificial tears were not effective, use of Restasis might have been recommended. The medical literature does not support the use of Latisse in this clinical setting.  For the reasons set forth above, Latisse is not medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Findings:  The physician reviewer found that  The patient has requested authorization and coverage for electrolysis on the extremities and buttocks. The World Professional Association for Transgender Health (WPATH) states that hair removal is a treatment for gender dysphoria, noting, In addition (or as an alternative) to the psychological and medical treatment options described above, other options can be considered to help alleviate gender dysphoria, for example  hair removal through electrolysis, laser treatment, or waxing. In a study on hair removal and psychological well-being in transfeminine adults, Bradford and colleagues concluded, Results of this study suggest that hair removal is associated with both decreased distress but also increased subjective well-being (e.g. higher positive affect). Given that correcting male-pattern body hair with hair removal treats gender dysphoria, the requested services are medically indicated. Therefore, electrolysis on the extremities and buttocks is medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested service is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.
Appeal type: Experimental/Investigational
Decision: Overturned

A 66-year-old female enrollee requested facet nerve bilateral ablation for medical treatment of her lumbar facet arthropathy.  Findings:  Two physician reviewers found that in this patients case, the services are likely to be of greater benefit than other treatment alternatives.  The current medical evidence supports the services at issue in this clinical setting.  The documentation submitted for review indicated that medial branch diagnostic blocks were performed and resulted in 80% relief lasting temporarily.  This patients pain pattern, imaging studies and significant benefit from medial branch blocks support the diagnosis of facet joint mediated pain.  Therefore, facet nerve bilateral ablation is likely to be of greater benefit than other available options.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Otezla 30 mg. Findings:  The physician reviewer found that the requested medication is medically necessary for treatment of the enrollees medical condition. Therefore, the Health Plans denial should be overturned.The submitted documentation supports the medical necessity of the requested medication. This enrollee has tried and failed therapy with methotrexate. Otezla is non-immunosuppressive and has been approved by the U.S. Food and Drug Administration (FDA) for the treatment of psoriasis and psoriatic arthritis. In this enrollees case, the requested medication is being used for its FDA-approved indication. The enrollee is wheelchair-bound and has a history of fistulas in the past, making him at higher risk of infection. Since the biologics are immunosuppressive, the use of Otezla is favored over the Health Plans preferred agents. The medical evidence supports the requested medication in this clinical setting. Therefore, Otezla 30 mg is medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested medication is medically necessary for treatment of the enrollees medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in dermatology 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

Nature of Statutory Criteria/Case Summary:   An enrollee has requested proton beam therapy for treatment of her medical condition. Findings: Three physician reviewers found that the submitted documentation fails to demonstrate the superior efficacy of the requested services.  Currently, there is insufficient clinical data to discern whether treatment with proton beam radiation offers a clinical benefit compared to conventional photon radiation.  The data regarding central nervous system tumors treated with proton beam radiation therapy is limited to retrospective series, with a lack of evidence of long-term clinical outcome compared to conventional intensity modulated radiation therapy.  There is insufficient published clinical outcome evidence of proton beam radiation therapy for ependymoma from well-controlled studies in peer-reviewed medical literature.  Thus, the requested proton beam radiation is not likely to be of greater benefit than other treatment options. Final Result: Three reviewers determined that the requested services are not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld.  Credentials/Qualifications:   All three reviewers are board certified in radiation oncology and are actively practicing. All three reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

A 46-year-old female enrollee has requested artificial disc replacement at C3-C4 and fusion at C4-C5 for treatment of her degenerative disc disease.  Findings:  The physician reviewer found the submitted documentation fails to establish the medical necessity of the requested services. This patient, from a cardiac standpoint, is clinically stable and her feeding disorder has been resolved as she is eating by mouth. Thus, the requested LVN level of care services are for supervision services and do not meet medical necessity criteria for skilled nursing services, especially given that the patient is not ventilator or tracheostomy dependent and does not require intravenous therapies (Elias et al). Based upon the documentation submitted for review and the peer-reviewed literature cited above, the medical necessity of the requested continued private duty licensed vocational nurse (LVN) level of care has not been established in this clinical setting.