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

A 38-year-old female enrollee has requested authorization and coverage for a computed tomography coronary angiography for evaluation of her heart abnormalities.  Findings:  Two physician reviewers found that coronary CTA is a mature and accurate technology that is capable of imaging the coronary arteries and other cardiac structures in a completely non-invasive manner. No other non-invasive technology is capable of performing this feat with the clarity, speed and accuracy of the CTA. In addition, CTA has now been shown to have lower doses of radiation than other commonly used cardiac tests such as thallium and technetium nuclear stress tests, invasive coronary angiography and percutaneous coronary angioplasty. CTA has been shown to provide not only excellent clinical performance potential but also relevant and incremental prognostic information.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary:An enrollee has requested reimbursement for gene testing (fetal sex and fetal chromosomal microdeletions genomic sequence analysis, circulating cell-free fetal DNA in maternal blood) for their medical condition of pregnancy.  Findings:  The physician reviewer found that Three physician reviewers found that the current medical evidence supports cell-free DNA testing as a screening option for women at increased risk of fetal aneuploidy. This population was defined as women 35 years or older, fetuses with ultrasonographic findings indicative of an increased risk of aneuploidy, women with a history of trisomy-affected offspring, a parent carrying a balanced Robertsonian translocation with an increased risk of trisomy 13 or trisomy 21, and women with positive first-trimester or second-trimester screening test results. Given this patients case, the aneuploidy risk warranted cell-free DNA testing for aneuploidy. However, testing for sex chromosomes and microdeletion syndromes was not indicated. Given the rarity of these conditions, the detection rate is significantly lower than for trisomy 21 and 18. The American College of Obstetricians and Gynecologists does not support routine screening for microdeletions. Therefore, the superior efficacy of gene testing (fetal sex and fetal chromosomal microdeletions genomic sequence analysis, circulating cell-free fetal DNA in maternal blood) has not been established. Final Result: The reviewers determined that the services at issue were not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: Physician reviewers 1, 2 and 3 are board certified in obstetrics and gynecology 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: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary:  An enrollee requested whole genome sequencing (WGS) for evaluation of his progressive fatigue, respiratory and swallowing dysfunction, muscle soreness, mild weakness, cramping and twitching.  Findings:  Three physician reviewers found that according to the documentation submitted for review, the patient has a complex history likely due to an underlying genetic explanation. However, there is a lack of published literature that demonstrates that WGS has a significantly better detection rate than whole exome sequencing (WES) in this clinical setting. Moreover, there is a lack of research that compares the likelihood of finding a clinically significant variant on WGS compared with WES. Many studies lump WES and WGS together, referring to them as WES/WGS since both provide the same kind of data. However, there is a lack of data demonstrating that WGS specifically would be more beneficial. Therefore, the requested services are not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Final Result: Three reviewers determined that the requested services are not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: Two reviewers are board certified in pediatrics with sub-specialty certification in clinical genetics and are actively practicing. One reviewer is board certified in clinical genetics and clinical biochemical genetics and is actively practicing.  All three reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested authorization and coverage for 30 hours per week of direct applied behavioral analysis (ABA) therapy, 16 hours per month of supervision and four hours per month of parent training. Findings:  The physician reviewer found that one study reported that autistic children who respond to ABA therapy will show marked improvements in behavior after two years of therapy. In this case, the progress report shows multiple areas of improvement, the Vineland Adaptive Behavior Scales demonstrate that he is functioning between the 1st and 5th percentiles in language, living skills, and socialization despite over five years of intensive ABA therapy. The requested amount of ABA hours that include 30 hours per week of direct therapy, 16 hours per month of supervision and four hours per month of parent training will not likely improve his medical condition.  Final Result: The reviewer determined that the requested services are not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in pediatrics with sub-specialty qualification in child neurology 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 ultraviolet light therapy for the treatment of the enrollees acne. Findings:  Three physician reviewers found that the interventions performed on many occasions on this patient are not the standard of care. There is no indication that the patient was treated with Accutane therapy or that such treatment was contraindicated. Accutane therapy was indicated for this patients condition and would likely have benefitted the patients condition more than the actinotherapy and the other treatments provided.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for facial feminization surgeries including reduction of forehead, contouring and setback of anterior frontal sinus; brow reduction. Gender dysphoria refers to distress that is caused by a discrepancy between a persons gender identity and that persons sex assigned at birth. This often results in depression and anxiety. Treatment for gender dysphoria aims to minimize dysphoria and help patients attain their sought-after gender role. Research notes that facial feminization procedures are not cosmetic, but rather serve a primarily reconstructive purpose in transgender women whose overall physical appearance otherwise prevents them from being perceived as female. The study aggregates opinions from multiple organizations including the American Medical Association, American Association of Family Physicians, Endocrine Society, American Psychiatric Association, American Psychological Association, American College of Obstetricians and Gynecologists, and the American Public Health Association. The authors note that the medical procedures attendant to sex reassignment are not cosmetic or elective or for the mere convenience of the patient. These reconstructive procedures are not optional in any meaningful sense, but are understood to be medically necessary for the treatment of the diagnosed condition. A publication notes that gender reassignment is the only treatment for gender dysphoria that has shown significant benefits in numerous research trials and meta-analyses over the past half century. A study concludes that Transwomen have diminished mental health-related quality of life compared with the general female population. However, surgical treatments (e.g. FFS [facial feminization surgery], GRS [gender reassignment surgery] or both) are associated with improved mental health-related quality of life  Further a study notes that this surgery does not aim to rejuvenate the face but rather it helps transgender women in passing as a female and integrating into everyday society. In conclusion, the submitted documentation demonstrates the patient experiences significant anxiety and distress secondary to her male facial features. There is sufficient scientific literature demonstrating that facial feminization surgery is effective in relieving gender dysphoria in patients such as this patient. Therefore, the requested services are medically necessary for treatment of the patients medical condition.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 psychiatry with expertise in treatment of gender dysphoria 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 documentation does not support that the requested gait trainer is medically necessary for this patients medical condition. The current medical literature does not include adequate data demonstrating improved health outcomes with use of gait trainers in this clinical setting. There is a lack of research in adults with cerebral palsy on the effects of   functional mobility. Additionally, a review of the records provided for review reveals the patient has impaired upper and lower extremity coordination. In addition, the records do not report that the patients alignment of the lower extremity is such that the foot and ankle can tolerate a standing or upright position as well as independent reciprocal movement. All told, the requested Meywalk gait trainer is not supported as medically necessary for treatment of this patients cerebral palsy and dystonia.  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 physical medicine and rehabilitation with sub-specialty certification in neuromuscular 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 patient has requested authorization and coverage for varicocelectomy. Findings:  The physician reviewer found that first-line treatment options include medications such as antibiotics, anti-inflammatory agents, antidepressants, and neuroleptics. In addition, modalities including acupuncture, pelvic floor physical therapy, and psychotherapy may be beneficial. Minor nerve blocks, transcutaneous electrical stimulation and pulsed radiofrequency have also been utilized with some degree of efficacy. Once conservative options are exhausted surgical procedures may be considered as a last resort. The records provided for review document that this patient has testicular pain that has been present for a few months and at least partially responded to conservative therapy. There is a lack of support for diagnosis of varicocele. Treatment with varicocelectomy is not a clinically appropriate and generally accepted standard for management of this patients medical condition. Therefore, the requested varicocelectomy is not 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 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: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for digital breast tomosynthesis performed for the evaluation of the enrollees medical condition. Findings:  Three physician reviewers found that the patient had a two month history of right breast pain. She underwent a diagnostic mammogram consisting of a combination two dimensional and three dimensional tomosynthesis examination. There were no prior images for comparison.  In addition to the mammogram, she had a targeted sonogram of her right breast. 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.  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 (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.  In this particular patient, the presence of breast pain is not, in itself, a reasonable indication for tomosynthesis.  Breast pain, or mastodynia, is an unusual presentation of breast cancer. However, the patients breasts have been described as being heterogeneously dense. It is specifically those patients who have dense breasts that can benefit most from breast tomosynthesis. The ability to separate out the overlapping structures enables the possibility of demonstrating an otherwise occult tumor. In sum, digital breast tomosynthesis performed was likely to have been of greater benefit than other methods 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: Upheld

A 35-year-old female enrollee requested authorization and coverage for an abdominoplasty.  The health plan has denied this request indicating that the requested procedure is considered cosmetic for treatment of the enrollees dependent abdominal flap.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 considered cosmetic and is not medically necessary.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a female enrollee requested residential behavioral health services for medical treatment of the enrollees depression, anxiety, and substance abuse. Findings:  The physician reviewer found that progress notes during the treatment period show that the patient was unstable, anxious and depressed. The treatment notes indicate that she is still having a significant problem dealing with stress in an appropriate manner, and being with her family is a major precipitant of that stress. Had she been discharged, she would not have had the coping ability to deal with her anxiety and depression and most likely would have resorted again to using substances for this purpose. Accordingly, residential behavioral health services were medically necessary for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage of Harvoni for treatment of the enrollees hepatitis C virus. Findings:  The physician reviewer found that according to the most recent joint guidelines issued by the American Association for the Study of Liver Diseases (AASLD) and the Infectious Diseases Society of America (IDSA), 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, and advanced fibrosis is not required for treatment. Per guidelines, treatment naive genotype 1 patients should be treated with Harvoni. Patients with viral load of less than 6,000,000 IU/mL can be treated. These guideline recommendations are based on multiple randomized clinical trials. The Health Plans preferred medication, Zepatier, has already been requested and denied.  AASLD/IDSA guidelines cite data showing reduced survival with delayed treatment. For these reasons, treatment of hepatitis C is needed in this patients case. All told, 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 regimen 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: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the remote heart monitor. The use of different types of ambulatory cardiac monitoring for arrhythmias has evolved over the past 10-15 years. Researchers reported that current guidelines suggest that short duration monitors (24 or 48 hour Holter) or symptom-activated external loop recorders are available. Newer systems with mobile outpatient telemetry for longer periods of time have developed more recently and are recommended for infrequent symptoms or when there is investigation of the cause of cryptogenic stroke and suspected atrial fibrillation. Researchers also reported that the Heart Rhythm Society describes that the choice of monitor needs to be matched to the individual patients symptom frequency. Use of the MCOT is usually reserved for cases of infrequent symptoms or when the shorter duration monitors are negative or inconclusive. For these reasons, the remote heart monitor provided was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Findings:  Three physician reviewers found the remote heart monitor provided was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Final Result: The reviewers determined that the remote heart monitor provided was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Credentials/Qualifications: Physician reviewers 1, 2 and 3 are board certified in internal medicine with sub-specialty certification in cardiovascular disease 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 Skyrizi 150 mg syringe (1 mL/84 days). The U.S. Food and Drug Administration (FDA) has approved Skyrizi for the treatment of patients with moderate-to-severe psoriasis and is highly efficacious. Researchers evaluated the safety and efficacy of Skyrizi in comparison to ustekinumab and placebo. The authors concluded that Skyrizi showed superior efficacy to both placebo and ustekinumab in the treatment of moderate-to-severe plaque psoriasis. The records provided for review document that this patient has extensive enough disease to warrant consideration of biologic therapy with a BSA of approximately 10%. There are no step therapy requirements per the American Academy of Dermatology (AAD) and National Psoriasis Foundation (NPF) psoriasis treatment guidelines. Given this support, the requested Skyrizi 150 mg syringe (1 mL/84 days) 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 dermatology with subspecialty certification in dermatopathology 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 43-year-old male enrollee has requested laser treatment for treatment of his pseudofolliculitis nuchae.  Findings:  The physician reviewer found that there is no documentation as to the patient having already failed first-line therapies, which include topical steroids, topical retinoid creams or topical or oral antibiotics.  The patient was treated with intralesional corticosteroids without improvement. However, combination therapy is generally needed.  Additionally, refraining from cutting the hair short, or shaving the scalp, is useful for preventing the condition from flaring.  The submitted documentation does not demonstrate that these first-line therapies have been tried.  Additionally, there is no medical documentation as to the severity of the condition.  All told, the requested laser treatment is not medically necessary for this patient.