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

Standard Review :The parent of a transgender male enrollee has requested authorization and coverage for bilateral mastectomy and nipple/areola reconstruction. The Health Plan has denied this request indicating that the requested services are not medically necessary and are not reconstructive in nature for treatment of the enrollees gender dysphoria.  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. Nature of Statutory Criteria/Case Summary: The documentation provided supports the requested services in this clinical setting. Based on the documentation provided, the patient has gender identity disorder and is transitioning to the male gender. This patient has female breasts that would not likely resolve with continued hormonal therapy. While the Health Plan criteria provides that the patient should be 18 prior to undergoing surgical intervention, chronological age is not as important as the level of pubertal development. In this patients case, his breasts appear to be consistent with a teenage female. Hormone therapy will unlikely resolve this patients breast enlargement.  Since the condition will not resolve even with hormone therapy, surgical intervention to treat this patients dysphoria is medically reasonable and appropriate.  All told, this patient has evidence of abnormal breasts for a male and his medical condition will not likely improve with continued hormonal therapy. Therefore, bilateral mastectomy and nipple/areola reconstruction are medically necessary for treatment of this patients gender dysphoria. With regard to whether the requested services are considered reconstructive in nature, the submitted documentation reveals that the patients breasts constitute an abnormal structure of a male body. Based on the patients gender dysphoria and identification as a male, a normal appearance of the breasts for a male is the ultimate goal. As such, the abnormal breasts is considered a developmental abnormality in a male. The plan of the surgery is to create a more normal appearance for a male chest. The requested services would create a relatively normal appearing male chest and would offer more than a minimal improvement in the appearance. In sum, bilateral mastectomy and nipple/areola reconstruction are reconstructive in nature. Final Result: The reviewer determined that he requested services are medically necessary and are reconstructive in nature for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.
Appeal type: Experimental/Investigational
Decision: Overturned

A 42-year-old male enrollee requested continuous glucose monitoring (CGM) system (including insulin pump (E0784); disposable sensor CGM system (A9276); external transmitter, CGM system (A9277); and external receiver, CGM system (A9278)) for medical treatment of his type 1 diabetes.  Findings:  Two physician reviewers found that the requested services are likely to be more effective for this patient than other available options. The patient has long-standing type 1 diabetes with a less than optimal HbA1c level of 9.7 and unstable blood glucose levels with large glycemic fluctuations and wide fluctuations in preprandial blood sugars. As this system is likely to benefit the patients health, the requested services are likely to be more beneficial than other available therapies for this particular patient.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary:  An enrollee has requested partial hospitalization program level of care services and intensive outpatient services for treatment of her behavioral health conditions.  Findings:  The physician reviewer found that modern psychiatric practice aims to place patients in the least restrictive treatment setting.  In general and if feasible, community intervention settings offer optimization of treatment gains.  However, transient placement in more restrictive settings is often clinically appropriate.  In this case, the patient was extraordinarily ill upon presentation.  In the absence of an intensive course of treatment, a poor outcome was expected.  Additionally, from the community standard perspective, it is common to utilize partial hospital and intensive outpatient programs in step-wise fashion upon discharge from acute hospitalizations, and treatment stays under these circumstances most often exceed 72-hours.  Based on the physician and therapy notes, this patient was engaged in active treatment but had not consolidated the therapeutic treatment gains necessary to succeed in a less restrictive setting.  The disputed services were at least in part for purposes of diagnostic assessment and shaping of future clinical interventions.  The patient did not possess the clinical stability or harmonized support network to succeed in the outpatient setting.  The services in dispute were reasonably expected to improve her condition and prevent a more serious episode of illness.  Thus, partial hospitalization program level of care services and intensive outpatient services from were medically indicated for the treatment of this patient.  Final Result: The reviewer determined that the services at issue were medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.  Credentials/Qualifications: The reviewer is board certified in psychiatry 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

The parent of a 17-year-old male enrollee has requested Botox injections for the treatment of the enrollees chronic headaches. Findings:  Two physician reviewers found that chronic headache is one of the most challenging pain syndromes, and this patient has had an unusual set of clinical circumstances. His symptoms seem most clearly to be associated with elevations in intracranial pressure, and correction of that problem has alleviated his headaches on a number of occasions, albeit temporarily. The fact that he has improved following VP shunting and shunt revision is not consistent with a migraine component. Further, the fact that he did not have any (even transient) control with any of the triptans is also unusual. While there is conflicting evidence regarding the efficacy of Botox in the treatment of chronic migraine, there does seem to be a subset of patients who respond in the studies to date. However, the efficacy of Botox has not been shown in the treatment of chronic daily headaches or in medication overuse headaches. In addition, there are no studies that have been done demonstrating efficacy of Botox in headaches associated with elevated intracranial pressure or in patients with a history of head trauma or Arnold-Chiari malformation. Therefore, the use of Botox in this setting would be investigational, and not likely to be more beneficial to the patient than other standard treatments.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Gammagard. The records provided for review document that this patient has total immunoglobulin G (IgG) and subclasses 1 and 2 deficiency. The patient has experienced a multitude of sinus and lung infections. Treatment has included several courses of antibiotics and sinus surgeries without substantial improvement. The patients provider has recommended treatment with immunoglobulin therapy. Current data supports the safety and efficacy of immunoglobulin therapy in this clinical setting. Researchers reported immunoglobulin therapy has a positive impact on the frequency of sinusitis and pulmonary infections in patients with common variable immunodeficiency (CVID) and specific antibody deficiency. Given this support, the requested Gammagard is medically necessary for 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 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.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for the RT300 FES Therapy System. Given the debilitating nature of this patients spinal cord injury (SCI), the requested functional electrical stimulator (FES) has the potential to improve her function and quality of life. Luo and colleagues noted that, Due to the physical impairment and mental distress associated with SCI, patients often report reduced participation in physical activities and deteriorating aerobic fitness. The authors noted that, FES-assisted training has been shown to positively impact the cardiovascular functions of SCI patients, primarily by increasing exercise and peak ventilation. Marquez-Chin and Popovic commented that, functional electrical stimulation has evolved into an important therapeutic intervention that clinicians can use to help individuals who have had a stroke, or a spinal cord injury regain their ability to stand, walk, reach, and grasp. All told, the requested the RT300 FES Therapy System is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Findings:  Two of the three physician reviewers found the requested the RT300 FES Therapy System is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the requested device is 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: Physician reviewer 1 is board certified in physical medicine and rehabilitation and is actively practicing. Physician reviewer 2 is board certified in anesthesiology with subspecialty certification in pain management and is actively practicing. Physician reviewer 3 is board certified in physical medicine and rehabilitation with subspecialty certification in pain management 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 female enrollee requested Harvoni for medical treatment of her hepatitis C virus.   Findings:  Two physician reviewers found that based on the documentation submitted for review, the requested medication is not medically necessary for treatment of the patients HCV. The patient presents with minimal to no fibrosis on liver biopsy. She is asymptomatic with no glomerular disease or extrahepatic manifestation of hepatitis C. In this clinical setting, the patient may be followed periodically with non-invasive fibrosis measurements. Therefore, Harvoni is not medically necessary for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested reimbursement and prospective authorization and coverage for inpatient hospitalization for treatment of the enrollees behavioral health conditions.  Findings:  The physician reviewer found that the patient has a history of two prior hospitalizations for impulsive suicidal behaviors. She had recently received partial hospitalization program services. The patient continued to have delusions and was internally preoccupied. The inpatient team was actively titrating her clozapine dose, and the patient continued to disrobe on the unit. During the dates of service in dispute, the patient was unable to attend to her activities of daily living. She had not showered in two days, and she was not grooming her hair or brushing her teeth. She continued to be delusional. The patient continued to isolate. Although the patients parents are supportive, it is unlikely that she would cooperate with partial hospitalization attendance and weekly blood draws for complete blood count monitoring. All told, inpatient hospitalization was and is medically necessary for the treatment of this patient. Final Result: The reviewer determined that the services at issue were and are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in psychiatry with expertise in child and adolescent psychiatry and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested Harvoni for treatment of her hepatitis C.   Findings:  The physician reviewer 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 should be treated except those with limited life expectancy due to non-liver-related conditions.  This applies regardless of fibrosis stage or viral load.  For treatment-naive patients with genotype 4, the guidelines recommend treatment with daily Harvoni for 12 weeks.  This recommendation is based on high-quality clinical trial data.  All told, the requested treatment with Harvoni is supported as medically necessary for the treatment of this patients hepatitis C infection.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

A 30-year-old male enrollee requested authorization and coverage of a bilateral mastectomy with ultrasound and suction-assisted lipectomy. The Health Plan denied the request indicating that the procedure is cosmetic in nature and 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 procedure is cosmetic in nature and not medically necessary.
Appeal type: Medical Necessity
Decision: Upheld

A 62-year-old female enrollee has requested for Malarone 100mg for treatment of her condition. Findings:  The physician reviewer found that there was no documentation provided requiring specific medical therapy with Malarone. The review of standard therapy for malaria prophylaxis (prophylaxis of Plasmodium falciparum malaria in areas where chloroquine resistance has been reported) indicates doxycycline is a recommended first-line treatment. The dose for prophylaxis is 100mg per day starting one day prior to travel. It is used daily while in endemic areas and continued for a period of four weeks after travel to the endemic area. The patient has no documented contraindications to doxycycline therapy.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for incontinence supplies (adult diapers, disposable bed linens, feminine wash, and adult wipes) for treatment of the enrollees mixed urinary incontinence. Findings:  The physician reviewer found that based on the current medical literature and this patients diagnosis, the requested adult diapers are medically necessary. The patient has mixed urinary incontinence which is a medical problem with physical and social implications. The use of protective diapers is a safe, effective and generally acceptable standard of care for management of patients with urinary incontinence. However, the use of bed sheets/linen and feminine wash is not considered a standard of care for management of urinary incontinence. The proper use of appropriate protective diapers should improve the need to frequently change the patients bed linens. In addition, an over-the-counter body wash can be used to wash the patient and use of a specific feminine wash or adult wipes are not medically necessary. Thus, the requested adult diapers are supported as medically necessary while the disposable bed linens, feminine wash, and adult wipes are not medically necessary for treatment of this patients medical condition. Final Result: The reviewer determined that a portion of the requested equipment 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 urology 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

Findings:  The physician reviewer found that The patient has requested authorization and coverage for Euflexxa injection series (three injections to each knee). Evidence from systematic reviews and randomized controlled trials indicate that although viscosupplementation may relieve knee pain in some patients with osteoarthritis, data has not established which patients will benefit. Guidelines from the American Academy of Orthopedic Surgeons (AAOS) indicate that the data on safety and efficacy of viscosupplementation remain inconclusive. As such, the AAOS does not currently recommend viscosupplementation as routine treatment for osteoarthritis of the knees. Viscosupplementation is reserved for patients with a history of lasting benefit from prior injections and in cases where the remaining options are limited. In this case, the patient has a history of severe tricompartmental osteoarthritis. The records document that this patient has excruciating knee pain and is not able to perform activities of daily living. The patient has been treated with and failed to substantially improve despite treatment with non-steroidal anti-inflammatory drugs (NSAIDs) and corticosteroids. Treatment with Synvisc-One caused an allergic reaction. The patient does not wish to have total knee arthroplasties at this time. The provider has recommended viscosupplementation with Euflexxa injection series of both knees. Consistent with the recommendations in the medical literature, the requested Euflexxa injection series (three injections to each knee) 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.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested reimbursement for residential psychiatric disorder treatment services provided for treatment of the enrollees depression, polysubstance abuse, and attention deficit hyperactivity disorder (ADHD). Findings: The physician reviewer found that the records demonstrate that the residential psychiatric disorder treatment services provided were medically necessary for treatment of this patients medical condition. Throughout the course of this admission, the patient exhibited both auditory and visual hallucinations that were not optimized by treatment despite reasonable efforts to do so. Also, the patient endorsed significant symptoms including flashbacks and extreme anxiety. During the course of treatment, the patient demonstrated self-injurious behaviors and appeared to have decompensate during a home visit. Given these findings, the patient could not have been safely been treated in a less intensive level of care. Accordingly, the services at issue were medically necessary. Final Result: The reviewer determined that services at issue were medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in psychiatry with sub-specialty certification in child and adolescent psychiatry and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld

A 56-year-old male enrollee, who was found to have a 1.5cm by 2.3cm mass in the mid pole of the left kidney, has requested authorization for CT and ultrasound-guided radiofrequency ablation (RFA).Findings:  Two physician reviewers found that RFA is not supported as an established cancer surgery. No improvement in health outcomes following such a procedure has been established, nor has this approach received general acceptance in the medical community. The standard of care for a renal mass suspicious for renal cell carcinoma is partial or complete nephrectomy.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Orthovisc injection series in both knees. Findings: Per the medical literature, although viscosupplementation may relieve knee pain in some individuals with osteoarthritis, it is not known as to which individuals will benefit. The current evidence is limited, and guidelines from organizations such as the American Academy of Orthopedic Surgeons indicate that the evidence is not conclusive. In light of the foregoing, viscosupplementation can only be recommended in individuals with a history of lasting benefit from prior injections, and in carefully selected cases where everything else has been tried, and the options are limited. In this case, the patient reports persistent severe pain despite rest, activity restrictions, icing, and NSAIDs, with the alternative being a total knee arthroplasty. Given the patients limited options and based on the current medical literature, the requested services are medically indicated. Therefore, Orthovisc injection series in both knees 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 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.