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

 Nature of Statutory Criteria/Case Summary:  An enrollee has requested Viekira Pak for treatment of his 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, regardless of fibrosis, should be treated except those with limited life expectancy due to non-liver-related comorbid conditions. Per the guidelines, treatment-naive genotype 1b patients are appropriate for treatment with a 12-week course of Viekira Pak. This recommendation is based on multiple high-quality clinical trials. In addition, the medication is U.S. Food and Drug Administration (FDA) approved for all patients with chronic hepatitis C genotype 1 regardless of fibrosis stage. AASLD/IDSA guidelines also cite data showing increased survival with earlier treatment. For these reasons, the requested treatment for Viekira Pak is supported as medically necessary for the treatment of this patients hepatitis C infection. Final Result: The reviewer determined that the requested medication is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.  Credentials/Qualifications: The reviewer is board certified in internal medicine with sub-specialty certification in gastroenterology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld

A 45-year-old male enrollee has requested for biofeedback therapy for treatment of his temporomandibular joint disorder (TMJ).   Findings:  Three physician reviewers found that biofeedback entails electronic recordings of physiological measures such as muscle tension (electromyographic or EMG biofeedback) or skin temperature (thermal biofeedback) that are relayed to the patient as visual or auditory signals for purposes of training control over these parameters. Although it is a relatively well known technique controversy still exists regarding biofeedback treatment for TMJ. Some studies have shown it to be completely beneficial in patients with myofascial pain disorder, while others have shown that it is only beneficial in patients who have only daytime para-functional habits. Other studies have shown no difference between biofeedback and splint therapy. Also biofeedback therapy is not utilized universally in the treatment of patients with TMJ/myofascial pain disorder.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for foot inserts (removable, molded to Pt model, UCB type, Berkeley Shell) for treatment of the enrollees diabetes and plantar fasciitis. Findings: The physician reviewer found that shoe inserts and modifications are considered medically necessary in limited circumstances. Inserts and other shoe modifications such as lifts, wedges, arch supports and other conditions are indicated if they are on a shoe that is an integral part of a leg brace and are medically necessary for the proper functioning of the brace. Prosthetic shoes are considered medically necessary if they are an integral part of prosthesis for individuals with partial foot amputation. Orthopedic footwear that does not meet the stated criteria is considered not medically necessary. Review of current guidelines from the Centers for Medicare and Medicaid Services (CMS) does not support the requested foot inserts (removable, molded to Pt model, UCB type, Berkeley Shell) as medically necessary for treatment of this patients plantar fasciitis. Final Result: The reviewer determined that the requested equipment 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 podiatry 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 52-year-old male enrollee has requested Kuvan for treatment of his tetrahydrobiopterin deficiency and phenylketonuria (PKU). Findings:  The physician reviewer found that in the relevant medical literature, about 2% of patients with phenylketonuria (PKU) have BH4 deficiency. When possible, treatment must begin as early as childhood and a diet low in phenylalanine is essential. In addition, L-Dopa, carbidopa, and serotonin are often supplemented. The addition of BH4 can lower serum levels of phenylalanine, but there is little evidence that the addition of BH4 improves neurologic status. As reported by Levy in his 2007 article, Kuvan has been approved by the Food and Drug Administration (FDA) for patients with PKU who show responsiveness to a BH4 load protocol. However, to date, there are no long-term studies demonstrating the safety or effectiveness of BH4 in this patients condition. As the patient is currently noted to be taking the appropriate dietary measures and supplements, the requested medication has not been established to be medically necessary in the management of this patients care at this time.
Appeal type: Medical Necessity
Decision: Overturned

A 27-year-old female enrollee requested authorization and coverage of the medication Vaniqa. The Health Plan denied the request indicating that the requested medication is not medically necessary for treatment of the enrollees facial hair.One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer overturned the Health Plans denial on the basis that the requested medication is medically necessary.
Appeal type: Experimental/Investigational
Decision: Overturned

A 42-year-old female enrollee has requested endovenous surgery for the treatment of her varicose veins. Findings:  Two physician reviewers found that the FDA approved endovenous RFA for treatment of perforating veins in 2006. While long-term, well-controlled, randomized studies of the procedure are still lacking, the patients provider has recommended the procedure based on the specific location of the patients venous incompetence after a failed trial of conservative therapy. Given that elimination of the true source of the reflux offers the best chance of successful treatment, the proposed procedure is likely to result in a superior clinical outcome for this patient.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for lumbar fusion surgery for treatment of the enrollees back pain. Findings: The physician reviewer found the request for L4-5 lumbar fusion surgery has not been established as medically necessary for treatment of the patients medical condition. The use of posterolateral fusion after failed disc arthroplasty has not been shown to be effective. There is a lack of medical literature supporting posterior-alone revisions of lumbar disc arthroplasty without removing the prosthesis. Alahmadi and Deutsch performed a review of revision surgery for patients with lumbar artificial discs who failed to achieve satisfactory lower back pain control despite the optimal appearance of prosthesis visible on the imaging. The results were not favorable. None of the five patients in the study had significant improvements in their back pain after the fusion. The only patient who had initially significant improvements after the disc replacement, had poor pain control after the fusion. Given the lack of support in the peer-reviewed literature, the requested surgery is not medically necessary for treatment of the patients medical condition. Final Result: The reviewer determined that the requested surgery 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 neurological 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 authorization and coverage for bilateral breast mastectomy with nipple/areola reconstruction for treatment of the enrollees gender dysphoria and are not reconstructive in nature. Findings:  The physician reviewer found that There is support in the medical literature for the services at issue in this clinical setting. This patient has documented gender dysphoria and is in transition to becoming a male. In determining medical necessity, the patients age should not be the sole determining factor. In this patients case, the records note evidence of abnormal breasts for a male despite the use of hormonal therapy and this medical condition would not likely resolve with continued hormonal therapy. The photographs support the patient has significantly female appearing breasts. Since this patients condition has not resolved despite an adequate course of hormone therapy, surgical intervention to treat this patients gender dysphoria is medically indicated. Therefore, bilateral breast mastectomy with nipple/areola reconstruction are medically necessary for treatment of this patients gender dysphoria.With regard to whether the requested services are reconstructive in nature, the submitted documentation as well as the photographs reveal that the patients breast development constitutes an abnormal structure for a male who has failed hormonal therapy. The patients breast development constitutes an abnormal structure of the body. The appearance of the patients breasts should be more consistent with adult male breasts. The abnormal structure of the body is caused by a developmental abnormality, specifically, the patients gender dysphoria. The plan of the surgery is to create a more normal appearance for a male and to create a relatively normal appearing male chest.  Additionally, the surgery would offer more than a minimal improvement in the appearance to the best extent possible. In summary, bilateral breast mastectomy with nipple/areola reconstruction are reconstructive in nature. 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: Experimental/Investigational
Decision: Upheld

A 61-year-old male enrollee has requested a whole body CT scan for an evaluation of the enrollee, who has been diagnosed with Parkinsons disease. Findings:  Three physician reviewers found that the submitted documentation indicates that the examination was ordered for screening purposes. The American College of Radiology does not recommend whole body CT scans in this clinical situation. Further, the radiation from a CT scan may be associated with a small increase in the possibility of developing cancer later in a persons life.  At this time, the benefits of whole body CT scans for screening purposes have not been demonstrated.  In this patients case, the whole body CT screening performed was not likely to be superior over all other methods of evaluation.
Appeal type: Medical Necessity
Decision: Overturned

A 48-year-old female enrollee has requested epidural steroid injections for treatment of her back pain.  Findings:  The physician reviewer found that epidural steroid injections are medically necessary for the treatment of this patients chronic back and leg pain.  The patient has tried and failed to receive relief with anti-inflammatory and opioid medications.  She has participated in physical therapy and a home exercise program. The patient had significant reduction in her pain lasting about three months at a time following previous epidural steroid injections.  Vad and colleagues performed a prospective randomized study on transforaminal epidural steroid injections in lumbosacral radiculopathy. The study concluded that fluoroscopically-guided transforaminal epidural injections serve as an important tool in the non-surgical management of lumbosacral radiculopathy secondary to a herniated nucleus pulposus.  Botwin and colleagues performed a prospective cohort study to identify the short-term and long-term therapeutic benefit to fluoroscopically-guided lumbar transforaminal epidural steroid injections in patients with radicular leg pain from degenerative lumbar stenosis. They found that fluoroscopically-guided transforaminal epidural steroid injections may help reduce unilateral radicular pain and improve standing and walking tolerance in patients with lumbar degenerative spinal stenosis.  Rosenberg and colleagues performed a prospective study to determine the effectiveness of transforaminal epidural steroid injections. They found that epidural steroid injections might offer significant pain reduction for up to one year after initiation of treatment in patients with discogenic pain and possibly in patients with spinal stenosis.  All told, the requested epidural steroid injections are medically necessary in this patients case.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary:   An enrollee has requested breast tomosynthesis for evaluation of her medical condition.  Findings:  Three physician reviewers found that 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, by separating the various layers of breast tissue, one can better detect abnormalities. Accordingly, digital breast tomosynthesis was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.  Final Result: Three reviewers determined that the diagnostic procedure 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 reviewers are board certified in diagnostic radiology 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: Medical Necessity
Decision: Overturned

An enrollee has requested reimbursement for monitored anesthesia care (MAC) provided for a colonoscopy. The submitted documentation supports that the services at issue were medically necessary. Studies have indicated that monitored anesthesia care is indicated if the patient has a prior history of intolerance to colonoscopy under conscious sedation. In this case, the patient has a pertinent past medical history that is significant for both GERD and rectal cancer. In addition, the patient has previously undergone four colonoscopies. The records indicate that the patient did not tolerate colonoscopy under moderate sedation. Further, the diagnosis of GERD places the patient at increased risk of aspiration and/or a pulmonary complication during the colonoscopy. Therefore, the patient meets the medical criteria for the use of monitored anesthesia care during the colonoscopy. Accordingly, the monitored anesthesia care (MAC) provided was medically necessary for the patients medical condition.
Appeal type: Urgent Care
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for emergency medical services. Findings:  The physician reviewer found that the medical services provided were not necessary for treatment of an emergency medical condition. The patient was diagnosed with descending aortic intramural hematoma. The follow up chest CT scan performed was not indicated for an emergency medical condition. The patient had already been diagnosed one month earlier and the follow up chest CT scan was performed to monitor that condition. There is no documentation to support new or recurrent chest pain to suggest an acute or potentially emergent medical condition.  Final Result: The reviewer determined that the patient did not receive emergency medical services on the date of service at issue. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in internal medicine with sub-specialty 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: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the FoundationOne gene test. Based on the available documentation, this patient has demonstrated resistance to therapy. FoundationOne is a molecular assay that explores the mutations of an individual patients cancer cells. The goal of the assay is to identify a specific mutation or target which could guide the provider as to which chemotherapeutic agent would be useful. However, there is a paucity of evidence that the FoundationOne assay adds to decision-making ability or yields a result that is both reliable and clinically beneficial. There are non-randomized studies exploring the value of molecular profiling, but the results have not been convincing as to the efficacy of such an approach to treatment. In addition, a randomized trial did not demonstrate a significant clinical benefit from choosing therapy based on molecular targets versus by the providers clinical judgment. Currently, the data suggests that finding a mutation does not support treatment directed at that target to produce a clinically meaningful response. All told, the FoundationOne gene test was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. One reviewer found that the FoundationOne gene test was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Final Result: Two of the three reviewers determined that the testing at issue was 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 and is actively practicing. One Reviewer is board certified in and is actively practicing. One Reviewer is board certified in 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 patient has requested reimbursement for residential treatment center (RTC) services provided Findings:  The physician reviewer found that the records indicate that this patient was not a danger to himself or others, he was not aggressive or violent, he was not self-harming, and he was not gravely disabled. He was medically and psychiatrically stable to the extent that he did not require treatment in a 24-hour facility. There were no emotional, behavioral, or cognitive to warrant the RTC level of care. There was no evidence of a high degree of impulsivity, psychosis, agitation, depression, mania, hallucinations, or any other significant symptom that would interfere with his care. He demonstrated ongoing depression and anxiety, but these conditions did not require residential treatment. He was accepting of the principles of treatment, was motivated, and involving himself in his recovery. No new problems had arisen. He was cooperative and participating in his treatment plan. He was medication compliant, and no medication changes had been made since admission. He had a stable home environment with supportive parents. He no longer met the medical necessity guidelines for RTC level of care and could have been successfully treated at an ambulatory level of care with concomitant sober living. Thus, the RTC services provided were not medically necessary for treatment of this 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 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 platelet rich plasma (PRP) injections for treatment of her medical condition.  Findings:  Two physician reviewers found that based on the available documentation, it was not likely to be more beneficial for this patient to have had PRP injections for diagnosis of lateral epicondylosis than treatment with any available therapy. The platelets are cytoplasmic fragments from megacaryocytes. These bioactive proteins include substances active in forming fibrin scaffolds and introducing angioplastic factors into the tissue fields. PRP is harvested from the patients own centrifuged blood from the buffy coat of the centrifugate. PRP is used in a number of clinical situations including decubitus care, non-union fractures, and following total knee replacement and spinal fusions. However, the efficacy of PRP has not yet been established for use in this clinical setting. In the article by Sheth and colleagues, the authors found a lack of consistency in outcome measures across all studies. Montalvan and colleagues conducted a double blind placebo controlled randomized trial with evaluation at six months and found that two ultrasound guided PRP injections for epicondylitis were not more efficacious than saline injections at six month follow-up. All told, there is a lack of current peer-reviewed medical literature supporting the utility of PRP injections as likely to have been more beneficial for treatment of the patients medical condition than any available standard therapy.  Final Result: Two reviewers determined that the services at issue were 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 orthopedic surgery 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.