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

The patient is a 64-year-old morbidly obese female with a history of diabetes, hypertension, and juvenile asthma. She has requested authorization and coverage for a panniculectomy. The Health Plan has denied the patients request on the basis that a panniculectomy is not medically necessary for treatment of the patients medical condition.Without evidence of skin breakdown or intractable skin rash, this patients request for panniculectomy is cosmetic in nature. Her morbid obesity would be more appropriately addressed with gastric bypass surgery than with panniculectomy. Panniculectomy as a stand-alone procedure would not improve any of the patients stated medical conditions. Therefore, I have determined the requested procedure is not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned

The patient is a 52-year-old man with a five-year history of chronic inflammatory demyelinating polyneuropathy (CIDP), treated successfully with intravenous immunoglobulin (IVIG) therapy. When IVIG treatment is delayed he becomes unable to ambulate independently. He was reported to have polymyositis and a history of melanoma. He is under the care of a neuromuscular specialist. The submitted records indicate the patients status worsened after IVIG was discontinued so he has resumed the therapy.At issue is whether IVIG therapy is medically necessary for treatment of the patients medical condition.The patient has been diagnosed with CIDP by a neuromuscular specialist. He has been successfully treated with IVIG for almost five years, which has allowed him to continue working. The medical literature supports the use of IVIG as first-line therapy for CIDP. This view is also widely held by members of the neurological community. Since IVIG is viewed as the standard of care in this clinical setting and no alterative therapy has been proposed, the patients previous and continued use of IVIG therapy is medically appropriate and indicated. Therefore, I have determined the therapy at issue was/is medically necessary for treatment of the patients medical condition. The Health Plans denial should be overturned.
Appeal type: Experimental/Investigational
Decision: Overturned

A 56-year-old female enrollee has requested Avastin for the treatment of her ovarian cancer. Findings:  Three physician reviewers found that it is reasonable to consider alternative biologic therapy such as Avastin to salvage this patients disease. Her current combination of Avastin with oral Cytoxan therapy has been tolerated with documented white blood count of 3,400. Any further cytotoxic regimen would likely result in significant risk of febrile neutropenia.  Therefore, Avastin is expected to be more beneficial than continuation of standard chemotherapy.
Appeal type: Medical Necessity
Decision: Upheld

The parent of a 17-year-old male enrollee has requested for residential treatment services for treatment of his behavioral health condition. Findings:  The physician reviewer found that there were no signs of oppositional defiant behavior and the patient was compliant with treatment. He had no negative acting-out behaviors at that time. The patient was described as a role model to peers, and it was noted that he was committed to sobriety.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for positron emission tomography (PET) scan (CPT codes 78815, 78451, and HCPCS codes A9552, A9526, A9502). Based on the records for review, this patient has biopsy proven sarcoidosis. The patients cardiac magnetic resonance imaging (MRI) did not show cardiac involvement. However, MRI was performed in 2015, and the patient has since developed cardiac symptoms including palpitations and presyncope. In addition, she has intermittent arrhythmias on monitoring and conduction disease on electrocardiography, which can be manifestations of cardiac sarcoidosis. Cardiac involvement has been demonstrated in up to 25% of patients with systemic sarcoidosis. Moreover, the patients treatment plan would likely change and be intensified should the PET scan confirm cardiac involvement. For these reasons, the requested PET scan (CPT codes 78815, 78451, and HCPCS codes A9552, A9526, A9502) is medically necessary for evaluation of this patient. Final Result: The reviewer determined that the requested services are medically necessary for evaluation 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 certification in cardiovascular 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

Findings:  The physician reviewer found that an enrollee has requested authorization and coverage for Prolia. The submitted documentation does not support the medical necessity of the requested medication. Biophosphonates are considered first-line treatment for osteoporosis in most women. Prolia is relatively safe, but there is no long-term safety data at this time, as opposed to bisphosphates, which have been used for years. Prolia has the risks of hypocalcemia, osteonecrosis of the jaw, atypical femur fractures, and serious infections. Denosumab is an alternative to IV zoledronic acid for women at high risk for fracture, difficulty with the dosing requirements of oral bisphosphonates, and who prefer to avoid intravenous bisphosphonates due to side effects, or who have chronic kidney disease.In this case, the patient has a history of normal kidney function and no pending dental issues. The records fail to demonstrate any gastrointestinal symptoms or inability to take oral bisphosphonates. There is no history of contraindication to bisphosphonates or chronic kidney disease. Given the patients history, the current guidelines would recommend oral bisphosphonates. Reclast or zoledronic acid is preferred if oral bisphosphonates cannot be tolerated. Prolia would not be recommended as an alternative in her case. The records fail to demonstrate any contraindication to oral bisphosphonates or IV bisphosphonates. Under these circumstances, Prolia is not medically necessary for treatment of the patients medical condition.Final Result: The reviewer determined that the requested medication is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is board certified in internal medicine, with subspecialty certification in rheumatology, and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

An enrollee has requested reimbursement and prospective authorization and coverage for continued acute inpatient hospitalization and residential treatment center services upon discharge from this acute inpatient stay.   Findings:  The physician reviewer found that the patient was hospitalized for a month.  The patient was unable to sustain any therapeutic momentum from the admission.  The patient had previously failed outpatient services, intensive outpatient programming and partial hospitalization.  Regarding a specific episode of care, the patient was difficult to manage from the outset despite the highly-specialized setting of an acute inpatient psychiatric unit.  Upon presentation, the patient was agitated, paranoid and manic.  The records noted that the patient was hypomanic, paranoid, delusional, labile, agitated and suspicious.  This patient has a severe and chronic mental illness associated with poor clinical outcomes, significant comorbidity, erratic behaviors and elevated suicide rates.  Due to the patient's adherence to treatment, lack of insight and protracted illness burden with substance use, the patient poses a significant threat to himself and the community if inadequately treated from the psychiatric perspective.  Based on the medical record, the episode of illness that prompted the admission had not resolved by a specific date while a less restrictive treatment setting would have been inadequate and unsafe at the time.  The patient would have more than likely been promptly re-admitted if discharged.  Further, considering the unsupportive and strained parental dynamic at home coupled with a formidable symptom complex that has not responded to an array of prior treatment interventions, step-down to the residential level of care to further consolidate the treatment gains related to his addictions and acute-on-chronic mental illness would be safe, appropriate and consistent with good medical practice.  Final Result: The reviewers 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 physician 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: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary:   An enrollee has requested an office consultation with a plastic surgeon for treatment of her medical condition.  Findings:  The physician reviewer found that the submitted documentation supports the medical necessity of the requested services.  This patient has well-documented signs and symptoms of significant macromastia that has failed reasonable conservative management.  She is noted to have failed conservative management of multiple bras, acupuncture, massage therapy, physical therapy and medical management of her chronic rashes.  Multiple medical professionals support a referral for possible breast reduction.  The patient has a well-defined functional deficit of chronic pain and chronic rashes that are likely directly related to her macromastia.  All told, the requested office consultation with a plastic surgeon is medically indicated 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 plastic surgery and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

The patient is a 31-year-old woman with a BMI of 42.6 and a history of degenerative joint disease and asthma. The patient has undergone a psychological evaluation and is considered an appropriate candidate for weight loss surgery. The Health Plan indicates the patient does not meet Health Plan criteria for authorization of gastric bypass surgery.With a BMI of over 40 the patient meets nationally accepted criteria for consideration of weight loss surgery. Further, it is unlikely that the patient will be able to lose weight and maintain the weight loss through non-surgical means. There is no scientific evidence demonstrating that structured diet or exercise plans have been successful in the treatment of the obese. In fact, the Swedish obesity study identifies that even though there may be reduction or resolution of some symptoms with diet and exercise, surgery has the longest and best long-term outcome for the obese. Furthermore, the patient has undergone an appropriate psychological evaluation and is considered an appropriate candidate for weight loss surgery.Based upon the information set forth above, I have determined that the requested procedure is 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 patient has requested authorization and coverage for continuous glucose monitor (CGM) device. The records provided for review document that this patient has a history of type 2 diabetes, hypertension, and anemia. The provider noted that the patient has vertigo, which interferes with her ability to check her blood glucose levels at regular intervals. Moreover, the patient is noted to have occasional erratic blood glucose levels. The U.S. Food and Drug Administration (FDA) approved CGM devices to record blood sugar levels at repeated intervals throughout the day and night in patients with diabetes (Olczuk and Priefer). CGM devices have been demonstrated to be clinically valuable due to the accuracy and convenience in the management of patients with type 2 diabetes. In addition, CGM devices can promote glycemic and weight control, help reduce the risk of hypoglycemia and hyperglycemia, and improve relevant lifestyle behaviors. CGM devices have become useful tools for real-time monitoring of blood glucose and for assessing the impact of treatment and lifestyle on daily changes in blood glucose levels (Zheng, et al.). Given this support, the requested CGM device is medically necessary for treatment of this patient. Final Result: The reviewer determined that the requested equipment 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 subspecialty certification in endocrinology, diabetes, and metabolism 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 parent of a three-year-old male enrollee has requested speech therapy for the treatment of the enrollees speech problems. Findings:  The physician reviewer found that the medical records do not indicate that the patients expressive delay is related to an injury, illness or other medical condition. Rather, this appears to be a developmental speech delay. At age 312 it is not clear whether the problem is simply a delay or an actual speech impairment. In either case, the deficits are educational in nature, and as such, speech therapy is not medically indicated.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for Qsymia that was purchased and prospective authorization and coverage for Qsymia. The Health Plan has denied this request and reported that the medication at issue was not and is not medically necessary for the treatment of this patient. At issue in this case is whether Qsymia purchased and prospective Qsymia was and/or is medically necessary for the treatment of the patients medical condition. Patients with BMI greater than or equal to 25 can have obesity-related complications treatable by weight loss therap. Patients who have a history of being unable to successfully lose and maintain weight and who meet label indications are candidates for weight loss medications. Qsymia is a medication approved by the U.S. Food and Drug Administration (FDA) to treat and manage obesity. In this case, the patients history of obesity and efforts in managing the disease illustrate the need to manage her obesity as a chronic disease. The patient reported that Qsymia has been beneficial. She has tried other medications and treatments for obesity. The medical evidence supports the medication at issue in this clinical setting. Therefore, the Qsymia that was purchased and prospective Qsymia was and is medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested medication was and 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 endocrinology, diabetes and metabolism 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

A 58-year-old male enrollee has requested for an upright magnetic resonance imaging (MRI) for evaluation of her shoulder pain.  Findings:  Two physician reviewers found that upright MR units are a type of open MR that has been approved by the Food and Drug Administration (FDA) as a medically accepted means of providing MRI for patients with severe claustrophobia. In addition, MRI is the exam of choice to evaluate internal derangement of the shoulder joint. This patient has shoulder difficulties that need advanced imaging however due to severe claustrophobia he has been unable to undergo a traditional open MRI study. As upright MR units are medically approved devices and this severely claustrophobic patient is in medical need of MRI of both shoulders, the requested upright MRI is likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary:   The parent of an enrollee has requested shoe inserts for the treatment of the enrollees medical condition.  Findings:  The physician reviewer found that the submitted documentation supports the medical necessity of the requested equipment.  Flatfoot can be divided into two general categories, flexible and rigid.  In flexible flatfoot, the collapsed arch is present only when the patient bears weight.  In rigid flatfoot, the arch is fixed in position regardless of weight-bearing status.  According to the literature, symptomatic flatfoot requires treatment. Options include activity modification, proper shoes and orthoses, stretching and strengthening exercises, and nonsteroidal anti-inflammatory medications.  Surgery may be considered if all other treatment options fail.  This patient has been using orthotics for a significant period of time, with improvement in pain and facilitation of activities.  The literature supports the utility of orthoses in this patient population, particularly regarding prevention of surgical intervention.  All told, the requested shoe inserts are medically indicated for the treatment of this patient.   Final Result: The reviewer determined that the requested equipment 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 pediatrics with sub-specialty certification in pediatric 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 parent of a 20-year-old female enrollee has requested for the treatment of the enrollees Prader-Willi syndrome (PWS). Findings:  The physician reviewer found that the patient may have GH deficiency based upon the IGF-1 level provided and the short stature despite GH therapy in the past. The value of GH therapy in adults is that treatment does improve lean body mass and fractional body fat without glucose impairment. However, GH therapy will not diminish appetite, and GH therapy in this instance is not medically indicated.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested Sovaldi and Daklinza for treatment of his 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.  Patients with cirrhosis are high priority for treatment.  This patient is ineligible for ribavirin due to his wifes pregnancy.  The U.S. Food and Drug Administration (FDA) approved prescribing information for ribavirin states that it is contraindicated in the male partners of women who are pregnant, and that extreme care must be taken to avoid pregnancy during therapy and for six months after completion of treatment.  Due to the severity of liver disease, the risk of decompensation of cirrhosis, and the high priority of cirrhotic patients for treatment, delay in treatment is against current guidelines.  The guidelines only recommend one therapy for cirrhotic treatment-naive, ribavirin-ineligible genotype 2 patients: Sovaldi/Daklinza for 16 weeks. For these reasons, Sovaldi and Daklinza are medically necessary for the treatment of this patients hepatitis C infection.  Final Result: The reviewer determined that the requested medications 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 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 37-year-old female enrollee requested authorization and coverage of a total abdominal hysterectomy. The Health Plan denied the request indicating that the requested procedure is not medically necessary for treatment of the enrollees uterine fibroid.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 not medically necessary.