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

The patient is an 82-year-old female who sustained a right hip fracture in February 2004 and a left hip fracture in April 2004. The patient was admitted to a skilled nursing facility (SNF) in May 2004. She began physical and occupational therapy in that same month. She progressed steadily with therapy. Physical and occupational therapy were discontinued in June 2004. The patient was discharged from the SNF later that same month. At issue is whether continued skilled nursing facility services were medically necessary as of June 2004.  Based on the records provided, the patient had not reached a plateau as of June 2004. She could not safely be discharged to home as of that date. The clinical evidence demonstrates that as of June 2004 the patient was progressing with therapy and there was an expectation she would continue to progress with additional therapy. The patient did not reach a plateau or near plateau until mid-June 2004. As such, the SNF services the patient received were medically appropriate and indicated through mid-June 2004.Based upon the information set forth above, I have determined the services at issue were medically necessary for treatment of the patients medical condition through mid-June 2004. Therefore, the Health Plans denial should be partially overturned.
Appeal type: Medical Necessity
Decision: Upheld

A 41-year-old male enrollee has requested CPT codes 76102, 70250, 77077, and 92520 for treatment of his obstructive sleep apnea.  Findings:  The physician reviewer found that the patient has been diagnosed with obstructive sleep apnea and was being worked up for a mandibular repositioning device. The provider indicated that the patient did not have any history of temporomandibular disorder. The CPT codes in dispute, 76102, 70250, 77077, and 92520, are not accepted as part of a standard work up for a patient being fitted with a mandibular repositioning device. The need for this level of imaging is not supported within the scientific literature under these circumstances. The records indicate the patient had an adequate work up without the CPT codes at issue.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for BRCA gene test for evaluation of her risk for cancer. Findings:  The physician reviewer found that according to the National Comprehensive Cancer Network (NCCN) Guidelines, BRCA 1 and BRCA2 testing should be considered in individuals without a personal history of cancer when there is a first- or second-degree blood relative (same side of family) who themselves meet the BRCA 1 and BRCA2 testing criteria, or a third-degree blood relative who has breast cancer and/or ovarian carcinoma and who has two or more close blood relatives with breast cancer (at least one with breast cancer at age 50 or younger) and/or ovarian carcinoma. In this case, the patients family history, while not classic for BRCA mutations, does meet the NCCN criteria. The patients maternal grandmother, who is a second degree blood relative, has a history of breast cancer diagnosed at 50 years of age. The patients mother developed ovarian cancer, and it appears the ovarian cancer developed from metastasis from the colon, but primary peritoneal cancers cannot be ruled out from the data presented. Final Result: The reviewer determined that the requested testing is 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: The reviewer is board certified in internal medicine with sub-specialty certification in medical oncology 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: An enrollee has requested reimbursement for residential treatment center services. Findings:  The physician reviewer found that the residential treatment center services provided were not medically necessary for treatment of the patients medical condition. According to the documentation submitted for review, as of the date of service in question, the patient was not in withdrawals, and was not at risk for imminent withdrawals. There was no suicidal, homicidal, or psychotic ideation, and no self-harm behavior. There were no emotional, behavioral, cognitive, or impulsive symptoms that would warrant this level of care. He was medically and psychiatrically stable. His medication assisted treatment was not attempted until later, at which time it was declined. He was motivated and appeared to be working the program. Although he continued to struggle with his emotions, over the course of treatment he became an accepting and participating member of the milieu.  By the date of service in question he could have been stepped down to an ambulatory level of care to work further on relapse prevention and developing coping skills in order to ward off the relapse risks he faced. As such as of the date of service in question, 24-hour supervision at residential level of care was not medically necessary for treatment of the patients medical condition. Final Result: The reviewer determined that the services at issue were not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in psychiatry with sub-specialty certification in addiction 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 parent of an enrollee has requested substance abuse residential services for treatment of the enrollees behavioral health condition. Findings: The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity for the services at issue. In a first noted psychiatric the reviewer found that the patient continued to have insomnia and depression, no new psychiatric medication changes were made, and she denied any suicidal or homicidal ideations. There was no evidence of psychosis noted. She continued to have poor insight and judgment. In a subsequent psychiatric evaluation two days following the first, it was noted that she had a good week, she was not having any issues with sleep and her medication seemed to be helping her cope with her stressors. She denied any suicidal or homicidal ideations again. The medications appeared to be helping her. There was no evidence of suicidal or homicidal ideation, no evidence of psychosis, and both insight and judgment were deemed fair. In the psychiatric evaluation dated three weeks later, similar symptoms and planning were shown.  All told, the documentation provided does not demonstrate that the patient required the structured 24-hour setting of a residential treatment center after the second noted psychiatric evaluation.  The patient could reasonably have been treated at a lower level of care in an outpatient care. Therefore, for these reasons, the services following the second noted psychiatric evaluation were not medically necessary for treatment of this patient.Final Result: The reviewer determined that the services at issue were not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is board certified in psychiatry and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the digital breast tomosynthesis for evaluation of the enrollees breast cancer examination. Findings:  Two physician reviewers found that digital breast tomosynthesis  is a technique that was developed as a problem solving adjunct to routine mammography. However, in this case there were no problems to be resolved. The patient did not have dense breasts, she did not have a mass, there were no palpable lumps, and she did not have suspicious calcifications. In this clinical setting, a routine mammogram would have been sufficient. Tomosynthesis has not been shown to provide significant increased value in patients who do not have dense tissue that could obscure an abnormality, especially when there has been no change when compared to multiple prior mammograms over 12 years. Accordingly, the digital breast tomosynthesis performed 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 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: All three 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

Nature of Statutory Criteria/Case Summary:   The parent of an enrollee has requested for human growth hormone Nutropin AQ for the treatment of the enrollees medical condition. Findings:  The physician reviewer found that the requested medication has not been established as medically necessary for treatment of the patients medical condition. The patient presents with short stature, ADHD and Crohns disease. Inflammatory bowel disease, particularly Crohns disease, can cause growth failure and reduced adult final height; the etiology is multifactorial and includes poor nutrition, chronic inflammation, and medications used to treat the disease. In addition, ADHD is implicated in constitutional delay of growth, and medication to treat ADHD may further suppress appetite. Currently, the risk/benefit ratio of growth hormone therapy in the setting of Crohns disease is not known to be definitively in favor of therapy, and growth hormone treatment in this setting is considered controversial. Furthermore, in this patients case, epiphyses are nearly fused, and the addition of growth hormone at this point in time is unlikely to result in any improvement in the patients final adult height. 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 pediatric endocrinology 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 53-year-old male enrollee has requested CyberKnife radiosurgery for treatment of his metastatic lung cancer. Findings:  Two physician reviewers found that the patient presented with stage IV non-small lung cancer. His initial work up included a PET-CT which showed bilateral pulmonary metastatic disease and diffuse osseous metastatic disease. In the presence of active extracranial systemic disease, it is more reasonable to treat this patient with conventional whole brain radiation. CyberKnife radiosurgery cannot be recommended in this instance.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary:An enrollee has requested breast augmentation for treatment of the enrollees gender dysphoria. The surgical concept of treating breasts from male-to-female transgender is well-established and documented within the medical literature. According to Weigert and colleagues, Breast augmentation in male-to-female transsexuals is part of gender reassignment surgery. Hormonal feminization might not be sufficient to induce mammogenesis, so many patients seek surgery for their chests to resemble the female gender. However, the medical necessity of breast augmentation for transgender females with gender dysphoria is a case specific determination. In this patients case, based on the overall level of documentation and review of the submitted photographs, the patient has evidence of female breast development. Photographs depict breast development that is consistent with a relatively normal adult female appearance for a female, although on the smaller side. There is a well-developed inframammary fold and projected breasts. Augmentation mammoplasty, in this patient, would be to enhance the volume and appearance of a relatively normal structure. Therefore, this procedure would be consistent with cosmetic surgery. This patient has been treated with hormone therapy and the submitted photographs document the presence of visible breast tissue. As such, the patient does not present with an abnormal structure of the body.Findings:The physician reviewer found that the requested procedure is not medically necessary for treatment of the patients medical condition and is not reconstructive in nature. Therefore, the Health Plans denial should be upheld.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

Nature of Statutory Criteria/Case Summary:  An enrollee has requested Harvoni for 12 weeks or 8 weeks of Harvoni in the alternative for treatment of her chronic hepatitis C virus genotype 1.  Findings:  Three 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. Given this support, the requested 12 week course of Harvoni is medically necessary for treatment of this patients hepatitis C virus.  Final Result: Three 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. 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: Experimental/Investigational
Decision: Overturned

The parent of a 17-year-old male enrollee has requested Botox injections for the treatment of the enrollees headaches. Findings:  Three physician reviewers found that this patient is likely suffering from chronic migraine with associated myofascial pain. The literature shows that Botox is appropriate therapy for chronic migraine with associated myofascial pain for patients who have failed preventive therapies. This patient had tried migraine preventives before Botox without success, and has had previous success with Botox. Thus, Botox was likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for bilateral sacral lateral branch block (bipolar radiofrequency ablation for treatment of the enrollees pain. Findings:  Two physician reviewers found that the current medical evidence does not support the requested services in this clinical setting. Radiofrequency ablation of the lateral sacral branches to treat sacroiliac joint pain is not an established treatment in this case because the reported efficacy varies widely as does the technique used.  The American Society of Interventional Pain Physicians clinical practice guidelines found this approach to only have limited evidence in support of the procedure. Similarly, Aydin and colleagues found that while the technique was promising, there is a need for prospective randomized controlled studies. Final Result: Two reviewers determined that the requested treatment is 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 anesthesiology with sub-specialty certification in pain medicine 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

A 63-year-old female enrollee requested authorization and coverage of the medication Zithromax. The Health Plan denied the request indicating that the requested medication is considered experimental for treatment of the enrollees chronic obstructive pulmonary disease (COPD).Three physician reviewers performed an experimental/investigational Independent Medical Review. Two of the three physician reviewers concluded that the requested therapy is not likely to be more beneficial for the treatment of the enrollee's medical condition than any available standard therapy. One of the three physician reviewers concluded that the requested therapy is not likely to be more beneficial for the treatment of the enrollee's medical condition than any available standard therapy. Because two of the three physician reviewers concluded that the requested therapy is not likely to be more beneficial for the treatment of the enrollee's medical condition than any available standard therapy, the Health Plans denial has been upheld.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary:  An enrollee has requested a gene analysis blood test for treatment of her medical condition. Findings:  Three physician reviewers found that the testing was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. There is a lack of peer-reviewed literature that demonstrates better outcomes of treatment or a clinically relevant change in planned treatment in a patient with known Factor V Leiden deficiency who is not pregnant and currently has no deep venous thrombosis or other hematological problems. For the reasons provided, the services at issue were 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 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:   One reviewer is board certified in vascular and interventional radiology and is actively practicing. One reviewer is board certified in clinical genetics and is actively practicing.  One reviewer is board certified in internal medicine with sub-specialty certification in medical oncology 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

The patient is a two-year-old female who has a history of profound bilateral congenital sensorineural hearing loss diagnosed at 15 months of age by Auditory Brainstem Response testing. A three-month trial of power hearing aids was of little benefit. Audiologic testing revealed responses/threshold between 100dB and no response for the right ear and between 95dB and no response for the left ear. Binaural aided testing with the power hearing aids revealed thresholds between 50-70dB. CT scan imaging of the temporal bones revealed anatomy suitable for cochlear implantation. The recommendation of the cochlear implant team is for simultaneous bilateral implants. The Health Plan has denied coverage for the proposed procedure on the basis that it is not medically necessary for treatment of the patients condition.The patient is certainly a candidate who meets medical indications/necessity for unilateral cochlear implantation. At issue is whether bilateral cochlear implants are medically necessary. The submitted literature has been thoroughly reviewed. The peer-reviewed literature available on bilateral cochlear implantation in profoundly deafened children is small and inconclusive. Pertinent literature includes Litovskys study in 2004 (the Gantz study in 2002 included only adults) in which only 3 of the 20 subjects were prelingually deaf children. The rest were adults. The three children had sequential, not simultaneous, bilateral cochlear implants and the improvement in sound localization and speech perception was slight. Subsequently, Litovsky has looked at an additional 13 children, again all of whom received sequential not simultaneous bilateral cochlear implants (Ear & Hear 2006). The results suggest that many but not all of the children performed better on measures of sound localization on acuity. The authors concluded that these results must be interpreted with caution because benefits on any other task as well as the long-term benefits of bilateral cochlear implants are yet to be fully understood. Peters, et. al., presented a study at the American Otolaryngological Society in May 2006 demonstrating improved speech perception scores in noise in a cohort of 30 children. However, all children received sequential rather than simultaneous bilateral cochlear implants and the age range was 3-13 years. Thus, there is no significant peer-reviewed literature that supports the purported benefits of simultaneous bilateral cochlear implantation in a two-year-old patient. In fact, Dr. Litovsky admonishes that the factors that might contribute to such benefits must be carefully evaluated in large populations of children using a variety of measures. The number of children evaluated thus far has been small and the variety of measures are few. Given the lack of evidence supporting simultaneous bilateral cochlear implantation at this time, I have determined the requested procedure is not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.