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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for a group 3 power wheelchair. The requested group 3 power wheelchair is not medically necessary. The documentation indicates that the patient has a mobility deficit. However, the documentation does not reveal that the patients mobility deficit cannot adequately be address with use of an appropriately fitted manual wheelchair. The durable medical equipment (DME) evaluation revealed that a group 3 power wheelchair is not appropriate for the patient. The DME evaluation noted that a manual wheelchair with tilt in space, rehabilitation seating with positioning components, and pressure relieving cushion, is appropriate for the patient to complete mobility related activities of daily living (MRADLs) in the home. The documentation does not demonstrate that a group 3 power wheelchair is medically necessary for this patient. 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 physical medicine and rehabilitation with sub-specialty certification in neuromuscular medicine and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

A 64-year-old female enrollee has requested  for Diovan HCT 160 mg for treatment of her hypertension. Findings:  The physician reviewer found that this patient has responded to higher doses of Diovan. While the patient did not respond to Diovan 80 mg, the requested higher dose of the medication has been effective in treating this patients hypertension. She has tried and failed Toprol XL. As long as the patient is responding to this medication, it should be continued.
Appeal type: Medical Necessity
Decision: Upheld

The patient is a 39-year-old female with a body mass index (BMI) of 32.7. She has a family history of diabetes mellitus and experiences shortness of breath. She has requested authorization for gastric bypass surgery. There is no evidence she has undergone a formal psychological evaluation to determine whether she is an appropriate candidate for weight loss surgery. The Health Plan has denied authorization for gastric bypass surgery on the basis that it is not medically necessary for treatment of the patients obesity.With a BMI of 32.7 and no significant comorbidities, the patient does not meet nationally accepted medical necessity criteria for consideration of weight loss surgery. Furthermore, in light of this patients BMI, there is potential that further attempts at conservative weight loss will be successful. Furthermore, as the patient has the potential for further weight loss through conservative means, the risks of weight loss surgery outweigh the potential benefits of the procedure. Therefore, I have determined that 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: Upheld

A 47-year-old male enrollee requested authorization and coverage of a non-glare coating of his eyeglass lenses. The Health Plan denied the request indicating that the requested eyeglass coating is not medically necessary for treatment of the enrollees headaches.One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer upheld the Health Plans denial on the basis that the requested eyeglass coating is not medically necessary.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary:  An enrollee has requested breast tomosynthesis for evaluation of her medical condition. Two physician reviewers found that breast tomosynthesis was likely to be more beneficial for evaluation of the patients medical condition than available standard modalities. The peer reviewed literature cited above supports the use of breast tomosynthesis over conventional mammogram due to improved cancer detection rate. According to Skaane and colleagues, The use of mammography plus tomosynthesis in a screening environment resulted in a significantly higher cancer detection rate and enabled the detection of more invasive cancers. In addition, Caumo and colleagues examined center-specific effect of integrated 2D/3D mammography based on the screening with tomosynthesis or standard mammography (STORM) trial. The authors concluded the following Integrated 2D/3D-mammography significantly increased cancer detection for both screening services; potential reduction in false positive recalls (FPR) is likely to differ between centres with those experiencing relatively higher FPR most likely to benefit from 2D/3D-mammography screening. For the reasons provided, the breast tomosynthesis was likely to be more beneficial for evaluation of this patient than standard modalities.  Final Result:  Two 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: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for Afirma Gene Expression Classifier for evaluation of the enrollees thyroid nodule. Findings:  Three physician reviewers found that the cytopathology was consistent with follicular lesion of undetermined significance (FLUS). The size of the solitary nodule was 1.8 cm. The Bethesda System recommends a second fine needle aspiration (FNA) when the cytopathology is consistent with FLUS. The newest 2015 American Thyroid Associations guidelines state: For nodules with AUS/FLUS cytology, after consideration of worrisome clinical and sonographic features, investigations such as repeat FNA or molecular testing may be used to supplement malignancy risk assessment in lieu of proceeding directly with a strategy of either surveillance or diagnostic surgery. Informed patient preference and feasibility should be considered in clinical decision-making. FNA with molecular testing is considered standard of care following this cytopathology diagnosis rather than repeat biopsy or diagnostic surgery. The risk of malignancy on FLUS lesions is 5-15%. If the genetic test is suspicious, the risk of malignancy increases to 40%. However, the risk of malignancy decreases to less than 6% with benign findings by genetic testing. Therefore, the test is beneficial for the medical decision making without an additional procedure. Proceeding directly to the genetic testing helped this patient and the provider with medical decision making. If the result was benign continued observation would have been appropriate, which was the case with this patient. However, with a suspicious result, the recommendation would have been to perform thyroidectomy with no additional delay due to the increased risk for cancer.  All told, proceeding with genetic testing was appropriate and in line with current standards. Final Result: Three reviewers determined that the testing 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: All three physician reviewers are board certified in internal medicine with sub-specialty certification in endocrinology, diabetes and metabolism and are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

A 32-year-old female enrollee has requested inpatient mental health treatment for treatment of her major depressive disorder, recurrent, severe, and post-traumatic stress disorder. Findings:  The physician reviewer found the submitted documentation demonstrates the medical necessity of a portion of the services at issue.  In this patients case, acute hospitalization was initially indicated.  However, the documentation provided does not substantiate the medical necessity for treatment at the acute level of care after the date indicated.  Throughout the hospital course, the patient had a varying presentation consistent with chronic intrapsychic conflict and unrefined coping skills.  On the date indicated, she reported suicidal ideation to the therapy intern during individual session, and later that day articulated her inability to perform activities of daily living.  The following date, she refused group therapy.  The patient was tolerating her medications without side effect and sleeping well.  Suicidal ideation was denied, and there was no change to the diagnosis.  Per the physician notes, the patient denied suicidality.  In sum, there was no evidence of an acute psychiatric or medical syndrome, grave disability or imminent threat to self or others.  There was no endorsement of suicidality.  She had not demonstrated behavioral dysregulation or engaged in self-injurious behavior.  The patient continued to need specialty care for her enduring symptomatologies and chronic emotional dysregulation.  However, a less restrictive treatment setting would have been medically appropriate.  All told, inpatient mental health treatment was medically necessary but not thereafter.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the Cologuard test. Findings:  Two of the three physician reviewers found that there is support for the services at issue in this patients case. Cologuard testing has been approved by the U.S. Food and Drug Administration (FDA) to test for colon cancer. This testing can detect most (but not all) adenomas if they have high-grade dysplasia. In this case, the patient was due for colorectal cancer screening, had average risk for colorectal cancer, and did not have a family history of personal history that would place her at elevated risk for colorectal cancer. In sum, Cologuard test was likely to have been more efficacious than other methods of evaluating this patient.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 and 3 are board certified in internal medicine with sub-specialty certification in gastroenterology and are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient is diagnosed with gender identity disorder. She began hormone therapy in 2016. On 3/6/19, the patient was noted to have thick male pattern facial hair growth. The facial hair was noted to exacerbate her gender dysphoria. At issue in this case is whether hair removal of the face is medically necessary for the treatment of this patients medical condition. Facial hair is a major feature of masculine development. In a transgender woman, the presence of masculine facial hair can lead to significant distress. Most transgender women indicated that their face was most imperative to have changed (Ginsberg, et al.). Of women's facial procedures, hair removal is predominant. In this case, the patient was diagnosed with gender identity disorder and experiences distress relating to her masculine facial hair. The patient was noted to have thick hair on her face, and her provider recommended hair removal with electrolysis. Therefore, hair removal of the face is medically necessary for this patient. Final Result: The reviewer determined that the requested service 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 psychiatry with subspecialty certification in child and adolescent 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: Upheld

A 47-year-old male enrollee requested authorization and coverage of Disk-Cure treatment. The Health Plan denied the request indicating that the requested therapy is not medically necessary for treatment of the enrollees back pain.One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer upheld the Health Plans denial on the basis that the requested therapy is not medically necessary.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for 40 hours per week of applied behavioral analysis (ABA) therapy, 13 hours per week of supervision, four hours per week of group parent training and four hours per week of individual parent training for treatment of the enrollees autism spectrum disorder. Findings:  The physician reviewer found that ABA is medically indicated for children with autism spectrum disorders. In this case, the patient has received a high level of ABA services since 2015. However, he has not yet met any of his behavioral goals and continues to have a high level of maladaptive behaviors. There is a lack of evidence provided that shows he has made enough progress to allow for a reduction in ABA hours. In addition, the patients maladaptive behaviors including aggression, non-compliance and vocal protest which require a high level of ABA services. Furthermore, 18 hours per month of supervision is clinically indicated.  Also, four hours per month of group parent training and four hours per month of individual parent training is indicated. Therefore, 40 hours per week of ABA therapy, 18 hours per month of supervision, four hours per month of group parent training and four hours per month of individual parent training are medically necessary in this clinical setting. Final Result: The reviewer determined that a portion of the requested services are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be partially overturned. Credentials/Qualifications: The reviewer is board certified in pediatrics with sub-specialty certification in developmental-behavioral pediatrics 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 41-year-old male enrollee has requested Nuvigil 150mg, 1 per day for treatment of his medical condition. Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested medication.  Nuvigil is a psychostimulant drug which has been approved by the U.S. Food and Drug Administration for the treatment of shift work sleep disorder and excessive daytime sleepiness associated with obstructive sleep apnea.  In this patients case, the medical records lack documentation of physical and diagnostic testing indicative of sleep disorder or sleepiness associated with obstructive sleep apnea.  The medical records note sedation associated with opioids and the patient reported minimal benefit with opioid therapy.  In this clinical setting, it is more appropriate to wean opioid therapy rather than adding a psychostimulant to blunt the effects of the opioids.  The medical records lack documentation of conservative measures to control opioid sedation or sleep apnea.  Epstein and colleagues noted that the presence or absence and severity of sleep apnea must be determined before initiating treatment.  The current medical evidence does not support the requested medication in this clinical setting.  All told, the requested Nuvigil 150mg, 1 per day is not medically indicated for the treatment of this patient.
Appeal type: Urgent Care
Decision: Overturned

A 35-year-old male has requested coverage for past emergency services provided.  Findings:  The physician reviewer found that the patient presented to the emergency room complaining of left upper canine tooth pain for one week. The patient reported having bitten into a hard piece of bread one week prior and experienced pain in the canine tooth since that time. The patient denied any other trauma, fever, chills or facial swelling. His vital signs and physical examination were unremarkable. While in the emergency room, the patient received an injection of pain medication and was ultimately diagnosed with a possible dental fracture.  The patient was prescribed narcotic pain pills and was instructed to follow up with a dentist. At issue in this case is whether a prudent layperson in the patients circumstances would have sought immediate medical attention on the date at issue. California law defines an emergency medical condition as a medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain) such that the absence of immediate medical attention could reasonably be expected to result in any of the following: (1) Placing the patients health in serious jeopardy; (2) Serious impairment to bodily functions; (3) Serious dysfunction of any bodily organ or part.This case meets prudent layperson criteria for an emergency medical condition as the dental pain experienced by the patient was of sufficient severity, namely significant pain, such that an absence of immediate medical attention would likely result in continued uncontrolled pain and significant discomfort. A prudent layperson in this patients circumstances would have sought immediate medical attention for purposes of pain control. Therefore, it was medically reasonable and appropriate that the patient sought care for evaluation and treatment of his dental pain and possible dental fracture.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a three-year-old male enrollee has requested intravenous immunoglobulin therapy for a period of two years for treatment of the enrollees hypogammaglobulinemia and antibody deficiency.  Findings:  The physician reviewer found that this patient has a documented immune deficiency disorder.  As noted by the patients provider, standard recommendations by leading experts recommend at least a two-year trial of immunoglobulin in this clinical scenario. This patient has received intravenous immunoglobulin therapy, with beneficial results reported. Subcutaneous infusion is considered standard of care for young children with this clinical presentation. Although the Health Plan has only authorized intravenous immunoglobulin therapy for a period of 26 weeks, the current medical evidence supports intravenous immunoglobulin therapy for a two-year period. All told, the requested intravenous immunoglobulin therapy for a period of two years is medically indicated for this patient.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a 16-year-old male has requested human growth hormone Nutropin AQ 20mg/2ml. for treatment of his idiopathic short stature.  Findings:  The physician reviewer found that this patients height is more than 2.25 standard deviations below normal.  He has a history of unexplained short stature and poor growth velocity that was responsive to growth hormone therapy.  Serial bone age radiographs have demonstrated significant delay in skeletal maturation.  The growth chart shows an improvement in growth velocity with growth hormone therapy administration, with a fall-off in growth velocity upon discontinuation of growth hormone therapy.  Most recently, he has demonstrated poor growth velocity of 2 cm. per year despite pubertal progression. With a normal weight-to-height ratio, malnutrition and malabsorption are not likely etiologies for his growth failure.   This patient meets generally accepted criteria for growth hormone therapy for idiopathic short stature. According to Lawson Wilkins Pediatric Endocrinology Society guidelines, a trial of growth hormone therapy should be approved for children with otherwise unexplained short stature who pass growth hormone stimulation tests but who exhibit certain criteria.  These criteria include height more than 2.25 standard deviations below the mean for age or more than 2 standard deviations below the mid-parental height percentile, growth velocity less than the 25th percentile for bone age, bone age more than 2 standard deviations below the mean for age, low serum IGF-1 and/or IGFBP-3, and other clinical features suggestive of growth hormone deficiency. This patient meets most of the above criteria.  Thus, the requested human growth hormone Nutropin AQ 20mg/2ml is medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for estriol micronized powder 100% and prospective authorization and coverage for continued refills for treatment of the enrollee, who is status post total hysterectomy. Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the medication at issue. This patient has requested reimbursement and prospective authorization and coverage for a compounded hormone face cream with estriol.  It appears she is also taking estrogen and progesterone in some other form, as well as testosterone.  She says she believes the compounded hormone is safer for her, and that she does not want to take animal-based hormones.  The medical evidence does not support the medication at issue in this clinical setting.  There is a lack of evidence that compounded bioidentical hormones are safer or more efficacious than standard U.S. Food and Drug Administration (FDA) approved and tested options.  Due to issues related to compounding, dosing is frequently inconsistent.  This may actually increase the risk of such treatments.  All told, estriol micronized powder 100% and continued refills was not and is not medically indicated for the treatment of this patient. Final Result: The reviewer determined that the medication at issue was not and 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 obstetrics and gynecology 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.