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

A 57-year-old male enrollee requested authorization and coverage of provigil for the treatment of attention deficit disorder.  The Health Plan denied the enrollees request indicating that the requested treatment is 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 medication is not medically necessary for treatment of the patients medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld

A 55-year-old female enrollee has requested use of a dynamic shoulder splint for the treatment of her shoulder stiffness and discomfort. Findings:  Three physician reviewers found that the scientific literature reveals inadequate peer-reviewed data to support the use of a dynamic shoulder splint to improve range of motion following proximal humerus fracture. If physical therapy is unsuccessful, surgical release is the preferred treatment in this setting. At this time, there is a lack of randomized, well-controlled, randomized studies demonstrating that the use of dynamic shoulder splinting results in an improved clinical outcome as compared to standard treatment.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a three-year-old female enrollee has requested the Vest Airway Clearance System (the Vest System) for the treatment of the enrollees cystic fibrosis. Findings:  The physician reviewer found that CPT was not performing the necessary job of mobilizing secretions, resulting in atelectasis and air trapping on chest CT scan. In addition, CPT was becoming impractical because of the patients resistance, making it difficult to perform optimally. The literature supports the use of the Vest System, and it is the community standard for those in whom CPT cannot be performed adequately. Use of the Vest System is therefore medically necessary and appropriate for this patient.
Appeal type: Medical Necessity
Decision: Upheld

The patient is a 52-year-old female with chronic hepatitis C (genotype 1a) and Stage 3 fibrosis who failed to achieve viral remission on pegylated interferon and ribavirin therapy. Her treating physician has recommended maintenance interferon therapy based upon the hypothesis that decreasing (but not eliminating) viral load over a prolonged period of time may benefit clinical outcomes of the patients disease. There are no compelling data that support the treating providers hypothesis outlined above. The proposed approach is experimental and controversial and awaits the results of completed controlled trials that will then be able to be critically evaluated. The results of analysis of such trials are necessary before interferon maintenance therapy for non-responders can be justified. There is no evidence regarding the safety or efficacy of the proposed therapy. Therefore, I have determined the requested therapy 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 enrollee is requesting authorization and coverage for Buttock Augmentation with a one-day hospital stay. The enrollee has gender dysphoria and has been on hormone therapy, consisting of estradiol, progesterone, and spironolactone. Her plastic surgeon indicates the enrollee has severe dysphoria and requires surgical intervention to treat it. The operation will drastically improve her quality of life. She has a significantly masculine body that prevents her from being fully accepted as a woman. The masculine qualities include a square torso, a lack of hips, and a lack of buttock projections. The enrollees estrogen treatment has not resulted in appropriate feminine fat distribution; therefore, surgical correction of the soft tissue is needed to address these body deformities. Her psychiatrist indicates she meets the full DSM V diagnostic criteria for gender identity disorder. There is no indication that her gender dysphoria is a symptom of any other mental disorder. Standards of care indicate that although surgery for assisting in body feminization, such as Buttock Augmentation, are generally labeled as purely aesthetic, the surgical procedures for an individual with severe gender dysphoria can be considered medically necessary, depending upon the unique clinical situation of the patients condition and life situation. Review of the record indicates the patient has been on long-term estrogen (hormone) therapy for the past eight years but has not achieved the appropriate feminine fat distribution. She has severe gender dysphoria and reports numerous situations where she has faced the threat of stigmatization and physical harm. This is impacting her psychological well-being. The medical literature indicates for certain patients, an intervention, such as, a reduction rhinoplasty, for example, can have a radical and permanent effect on a patients quality of life and is therefore, much more medically necessary than for a patient without gender dysphoria. In this case, Buttock Augmentation is requested for feminization. Considering the failure of long-term estrogen therapy in achieving this, as well as the patients severe gender dysphoria impacting the patients mental health, the Buttock Augmentation has the potential to radically and permanently positively impact this patients quality of life.Final Result: The reviewer determined that the requested service is medically necessary for the treatment of the enrollees medical condition. 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 similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Otezla 30 mg tablets, 60 tablets for 30 days. The submitted documentation supports the medical necessity of the requested medication. Psoriasis has a high negative impact on the quality of life, especially in patients moderately or severely affected by the disease. The long-term use of traditional systemic therapies is frequently unacceptable because of renal, hepatic, pulmonary toxicity and limited efficacy. Traditional systemic therapies for psoriasis, including methotrexate and cyclosporine, have a well-documented array of toxicities, particularly end-organ toxicities. Over the past several years, the use of anti-tumor necrosis factor biologic therapies for the treatment of moderate to severe psoriasis has been a major clinical and research focus. Despite several difficulties with documenting risks, some systemic treatments for psoriasis have been linked with an increased risk of selected cancers. In addition, patients treated with anti-tumor necrosis factor drugs may develop adverse events such as infections, acute infusion and injection reactions, autoimmunity and cardiovascular effects. It has been well-documented that therapies of psoriasis with injectable biologics increase the risk for malignancy and infection, mandating prior testing for tuberculosis. Apremilast (brand name Otezla), an oral PDE4 inhibitor, provides a novel therapeutic option for the treatment of patients with moderate to severe plaque psoriasis. Its effects on cyclic adenosine monophosphateregulated intracellular signaling, gene expression, and subsequent protein levels allow apremilast to modulate the immune responses that cause the inflammation associated with psoriasis. In this case, the patient has chronic plaque psoriasis that requires systemic treatment. The immunosuppressant and anti-tumor necrosis factor drugs recommended by the Health Plan can increase the risk for infection and malignancy. The medical evidence supports Otezla in this clinical setting. Therefore, Otezla 30mg, 60 tablets for 30 days, is medically necessary for treatment of the patients medical condition.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 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

A 33-year-old female enrollee has requested for nasal surgery for treatment of her deviated septum. Findings:  The physician reviewer found that the defects described in the operative report include deviation of the septum and hypertrophy of the turbinates. These conditions cause functional impairment and needed to be corrected with septal and turbinate surgery. The remaining defects are cosmetic in nature; the rhinoplasty part of the surgery was largely concerned with correcting these defects.
Appeal type: Medical Necessity
Decision: Upheld

A 21-year-old male enrollee has requested residential treatment for treatment of the enrollees alcohol dependence, opioid dependence, cocaine dependence and sedative or anxiolytic dependence. Findings:  The physician reviewer found that the patient appeared to show insight into his substance use and was motivated for recovery. There were no significant withdrawal symptoms during the time period in question. There is no history of suicidal ideation or other behaviors or psychiatric conditions which required containment on a 24-hour basis. The patient had sober supports, and there is no evidence of a significant medical comorbidity. The patient had been in treatment on an outpatient basis, but that was several months prior to his admission to this program. As of the first date of service at issue, the American Psychiatric Association practice guidelines for residential treatment level of care were not met and the medically necessary level of care for this patient was intensive outpatient treatment. Based upon current, evidence-based, practice standards, residential treatment provided during the period at issue was not medically indicated for this patient.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for oxycodone-acetaminophen (Percocet) 10-325.  Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested medication.  The records document a long history of chronic back pain.  This patient self-escalated his opiate medication and is in violation of his agreement.  The current medical evidence does not support the requested medication in this setting.  Clinical practice guidelines support tapering opiates when the agreement has been violated. 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 anesthesiology with sub-specialty certification in pain 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: An enrollee has requested authorization and coverage for two weeks prescription of tramadol hydrochloride (HCL) 50 mg tablet per month. Findings:  The physician reviewer found that in the documentation available for review, the stepwise World Health Organization (WHO) ladder for pain relief is considered a reasonable approach to pain control in the palliative and the non-palliative settings. In this patients case, not all non-opioid treatment options have been utilized. The medical literature suggests that clinicians should consider alternative options to opioids as well as to wean patients to lower doses of opioids or even off opioids for treatment of pain. Furthermore, no objective treatment goals for pain and function are noted for the requested medication. The Centers for Disease Control and Prevention states that when starting opioid therapy, clinicians should prescribe the lowest effective dosage. In addition, multiple minimal requirements for opioid prescribing have not been performed and the need to use them as the primary medication treatment strategy for pain has not been established in this patients case. For all these reasons, the requested medication, two weeks prescription of tramadol HCL 50 mg tablet per month, is not medically necessary for treatment of this patient. Final Result: The reviewer determined that the requested medication is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in anesthesiology with sub-specialty certification in pain 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: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for positron emission tomography with computerized tomography for attenuation (PET/CT).National Comprehensive Cancer Network (NCCN) guidelines for both pancreatic and extrahepatic biliary carcinoma advocate the use of conventional CT of the chest and CT or MRI of the abdomen and pelvis every 8 weeks to assess treatment success/failure in these two types of malignancies unless conventional or prior PET/CT imaging has been equivocal. In such unusual cases, PET/CT imaging has proven to be of use as a problem solver.In this case, while conventional imaging techniques may be used to assess the degree of metastatic disease, the original PET/CT scanning reported an ill-defined area of increased metabolic activity in the region of the pancreatic head abutting the second duodenum, which could represent the primary tumor. Despite the patients decreasing CA19-9 tumor marker, it would be important to assess the metabolic nature and size of what is probably the primary tumor, not just the metastatic disease. Since treatment decisions hinge on a quantitative improvement in the appearance and physiology of the likely primary tumor, positron emission tomography with computerized tomography for attenuation (PET/CT) would be justified and necessary, at this mid-chemotherapy point in treatment, as the best imaging option. Accordingly, the requested positron emission tomography with computerized tomography for attenuation (PET/CT) is medically necessary to treat 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 diagnostic radiology 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 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. This applies regardless of fibrosis stage or viral load. Per guidelines, treatment-naive non-cirrhotic genotype 1b patients should be treated with Harvoni for 12 weeks, or with Viekira Pak without ribavirin for 12 weeks. These guideline recommendations are based on multiple randomized clinical trials.  However, in this case, Viekira Pak is contraindicated due to use of clopidogrel (a strong CYP2C8 enzyme inhibitor) which can result in cardiac arrhythmias due to QT interval prolongation.  Harvoni has no such drug interaction.  For these reasons, the requested treatment with Harvoni is 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 physician 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: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the digital breast tomosynthesis performed. Findings:  The physician reviewer found that in this case, the digital breast tomosynthesis performed on the dated of dispute was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. previous month's study was a baseline mammogram, and it was noted that she had heterogeneously dense breasts. In addition, there were questionable areas of distortion in each breast and she was recalled for additional imaging. It is specifically those patients who have dense breasts and areas of architectural distortion that can benefit most from tomosynthesis. The ability to separate out the overlapping structures enables the possibility of demonstrating an otherwise occult tumor. For the reasons provided, the services at issue were 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 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: Physician reviewers 1, 2 & 3 are board certified in diagnostic radiology and are actively practicing. The reviewer s 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 64-year-old female enrollee has requested magnetic resonance spectroscopy (MRS) for evaluation of her brain mass.   Findings:  Three physician reviewers found that the lesion does not have the contrast-enhanced MRI characteristics of a tumor, and the lesion is currently less pronounced, not larger as would be expected for a tumor, compared to the scan obtained three years ago. Nevertheless, the gold standard for radiographic diagnosis of a suspected brain tumor is a contrast-enhanced MRI, which this patient has undergone. A MRS, which assesses metabolites within tumors and normal tissues, is optimally used to differentiate viable tumor from radiation necrosis following radiation treatment. In this case, the patient has not had radiation so an attempt to differentiate the two is unnecessary.While there are a large number of studies that confirm the technical feasibility of an MRS, there are very few that actually evaluate its diagnostic accuracy and whether it can positively affect diagnostic thinking and therapeutic decision making. Those that do address these issues are generally flawed or of poor quality. Hollingworth and colleagues conducted a systematic review of the literature and found that of the 22 studies that measured the diagnostic performance of a MRS, only one provided encouraging findings that MRS can make a significant contribution to diagnosis for patients with indeterminate brain lesions. Hollingworth and colleagues concluded that additional, well-designed, prospective studies aiming to replicate this head-to-head comparison are needed to provide more definitive evidence for the utility of a MRS. There is insufficient evidence that a MRS would be more beneficial for diagnosis of this patients suspected, but highly unlikely, tumor than available standard diagnostic tools (in this case, a contrast-enhanced MRI).
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for substance abuse rehabilitation services at a dual diagnosis facility that provides onsite IV fluids to assist with severe vomiting caused by cyclical vomiting syndrome. The progress notes indicate this patient was admitted with a history of substance use and mood disorder that included depression and anxiety. Applying the American Society of Addiction Medicine (ASAM) criteria for level of placement, the requested services are medically necessary. For dimension 1, the patient presents with acute intoxication and withdrawal potential. She has demonstrated significant withdrawal symptoms including delirium, abnormal lab values, and tachycardia. For dimension 2, the patient has biomedical conditions and complications. She has several medical problems as indicated by her cyclical vomiting, seizure disorder, and migraines. Further, for dimension 3, the patient continues to have emotional problems that contribute to her lack of sobriety. For dimension 4, the patient has exhibited minimal readiness to change considering her continued substance abuse. For dimension 5, the patient is at high risk for relapse as indicated by her history of numerous prior substance treatment trials and attempts, with inability to maintain sobriety. For dimension 6, recovery and living environment, the patient meets these criteria based on her lack of stable housing. All told, the requested substance abuse rehabilitation services at a dual diagnosis facility that provides onsite IV fluids to assist with severe vomiting caused by cyclical vomiting syndrome are supported as medically necessary for treatment of this 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 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.