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

Nature of Statutory Criteria/Case Summary: A transgender enrollee has requested authorization and coverage for laser hair removal. Findings:  The physician reviewer found that the requested services are medically necessary in this clinical setting. The providers have documented that this patient has folliculitis as well as gender dysphoria.  Folliculitis is a condition that typically affects the male gender with curly hair and who shave too closely to the skin. For this condition, electrolysis/laser hair removal are an effective treatment option. Moreover, the medical literature supports hair removal lasers for treatment and management of folliculitis. In this patients case, laser hair removal is medically necessary for treatment of this patients recalcitrant folliculitis. With regard to whether the requested services are considered reconstructive in nature, recalcitrant folliculitis in a female is an abnormal body structure. Recalcitrant folliculitis is a condition that is congenital and generally occurs in people with curly hair. The highly curved hairs grow back into the skin and causes inflammation. The documentation from the treating providers note that this patient suffers from this condition. As such, the requested laser hair removal can provide more than a minimal improvement in the appearance of this patient and create as normal an appearance as possible. For these reasons, laser hair removal in this patients case is reconstructive in nature and not cosmetic. Final Result: The reviewer determined that the requested services are medically necessary and are reconstructive in nature 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: Upheld

A 27-year-old male enrollee has requested use of a continuous passive motion machine for treatment of his acute injury to the left knee, who is status post left knee arthroscopic surgery.  Findings:  The physician reviewer found the submitted documentation fails to demonstrate the medical necessity of the equipment at issue in this patients case.  There is a lack of support for the equipment at issue in this clinical setting.  The current medical literature does not demonstrate the necessity of the use of a continuous passive motion machine in this case.  As noted by Bible and colleagues, actual knee motion during continuous passive motion protocols are less than expected.  Per He and colleagues, there is a lack of evidence from randomized controlled trials to conclude that continuous passive motion machines reduce venous thromboembolism.  All told, the use of a continuous passive motion machine during a specified time frame was not medically indicated for the treatment of this patient.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested gene tests (MyRisk) for evaluation of the enrollee, who has a family history of breast cancer. Findings: Two physician reviewers found that this patients family history is suggestive of a breast/ovarian cancer syndrome.  BRCA1 mutation can increase the risk for breast, ovarian, cervical, uterine, pancreatic, gastric, and prostate cancers.  BRCA2 mutations can increase risk for breast, ovarian, gallbladder, bile duct, prostate, pancreatic, and gastric cancers.  In the event the BRCA tests were negative, there is still a possibility of hereditary predisposition from another gene defect.  In this case, the MyRisk panel was appropriate since the current clinical situation may be caused by several potential cancer-causing genes.  All told, gene testing was likely to have been of greater benefit than other methods of evaluating this patient.Final Result: Two 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: All three physician reviewers are board certified in internal medicine with sub-specialty certification in medical oncology 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: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for Afirma gene classifier testing performed.  Findings:  The physician reviewer found that  the Afirma gene classifier testing performed on the date in question was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The cytopathology of the 2.8 cm thyroid nodule was consistent with AUS. The risk of malignancy is 5-15% in these types of nodules . The American Thyroid Associations guidelines state that for nodules with AUS cytology, after consideration of worrisome clinical and sonographic features, investigations such as repeat [fine needle aspiration] 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. In this case, the benign result prevented the need of an additional biopsy or diagnostic surgery. This approach is supported by clinical studies and recommended for management and to avoid unnecessary procedures or diagnostic thyroidectomy). Therefore, the testing at issue has been established as likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Final Result:  All three (3) reviewers determined that the testing 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: Physician reviewers 1, 2 & 3 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: Upheld

A 21-year-old female enrollee has requested Remicade 400mg every four weeks for treatment of her ankylosing spondylitis.  Findings:  The physician reviewer found that based on review of the available records, there is a lack of objective evidence that the cause of the patients pain is ankylosing spondylitis. Per the physical examination documented in several progress notes, the patient presents with muscle spasm in the cervical and lumbar spine. However, there are no x-ray reports or laboratory studies such as erythrocyte sedimentation rate (ESR) for review. In addition, this patient has a diagnosis of fibromyalgia and is on multiple pain medications for that condition. Further, there is a paucity of data in the medical literature supporting the requested dose of Remicade for the diagnosis of ankylosing spondylitis and Remicade is not a pain medication. All told, the requested medication is not medically necessary for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for weekly acupuncture. Findings:  The physician reviewer found that the submitted documentation supports the medical necessity of a portion of the requested services.  This patient has a history of a chronic lumbar condition which flares up.  The patient  reported symptomatic and functional improvement following prior acupuncture care.  The records indicate that the ongoing acupuncture treatment is addressing the patients medical condition, with evidence of objective functional improvement.  Therefore, the continuation of acupuncture treatment is medically necessary. As the symptoms and function were significantly improved with the prior five sessions, an additional five sessions are medically appropriate to help the patient transition to an independent exercise program.  Due to the chronicity of this injury, the use of passive care should be limited, as the benefits obtained with it will be limited as well.  Self-management strategies, such as an independent exercise program, self-imposed restrictions, and proper biomechanics, are supported by the literature to stimulate self-reliance.  All told, a portion of the requested services (five sessions of weekly acupuncture) is medically indicated for the treatment of this patient. Final Result: The reviewer determined that a portion of the requested services is 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 oriental 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: The patient has requested authorization and coverage for Mavyret 100 mg/40 mg, three tablets daily, for eight weeks for treatment of the enrollees chronic hepatitis C virus (HCV) genotype 1a. 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 should be treated except those with limited life expectancy due to non-liver-related conditions. The guidelines recommend that all patients should be treated, regardless of fibrosis stage. The guidelines recommend that non-cirrhotic treatment naive genotype 1a patients should be treated with Mavyret for eight weeks. These recommendations are based on multiple randomized clinical trials, and the medication is U.S. Food and Drug Administration (FDA) approved for all patients with chronic hepatitis C genotype 1 regardless of fibrosis stage. The ENDURANCE-1 trial showed that only eight weeks of treatment is needed. The AASLD/IDSA guidelines cite data showing reduced survival with delayed treatment. For these reasons, the requested treatment with Mavyret 100 mg/40 mg, three tablets daily, for eight weeks 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 male enrollee requested bronchial thermoplasty for medical treatment of his severe persistent asthma.   Findings:  Two physician reviewers found that this patients records do not support an indication for bronchial thermoplasty. He is on an aggressive regimen of bronchodilators, has his allergic and sinus disease, and has no intercurrent smoking history to raise the possibility of chronic obstructive pulmonary disease (COPD). Further, his sinus disease is being treated medically and surgically and he has no evident reflux. The patient has not undergone a trial of Xolair for his elevated IgE, which is more likely to provide this patient with an improved health outcome than the requested bronchial thermoplasty.
Appeal type: Experimental/Investigational
Decision: Upheld

A 30-year-old female has requested Botox injections for treatment of her migraine headaches.  Findings:  Two physician reviewers found that the patient has documented migraine headaches that occur approximately 12-15 times a month with duration of up to 112 days. In the past, the patient has had headaches while taking Adderall, Imitrex, and Norco. There is no documentation that the patient has tried or failed any preventative therapies including antidepressants, antihypertensive medications or antiepileptics. In the past, the patient has had a trial of Botox with reported relief of her symptoms. Her provider has requested the continued use of this therapy. The literature provided documents the utility of several of the migraine prevention therapies. Although Botox can be useful in migraine headaches, it should not be selected without a proper trial of more standard preventative therapies such as antidepressant, antihypertensive, or antiepileptic medications. There is no documentation that this patient has tried any of these standard headache medications. Without documented trial and failure of these potentially effective therapies, the continued use and exposure to Botox cannot be justified and would not be considered standard of care.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary:  An enrollee has requested immune cell function assay testing for evaluation of his medical condition.  Findings:  Three physician reviewers found that the testing in dispute is a measure T-cell function and has been shown to have correlation with the degree of immunosuppression in a patient and associated rejection or infection.  It is used in conjunction with drug level monitoring to guide immunosuppressive therapy decisions.  There is sufficient support for the services at issue in this clinical setting.  Immune cell function assay testing has becoming a standard of patient monitoring and has been used as an adjunct to monitoring the overall immunosuppressive state of the transplant patient.  All told, immune cell function assay testing was likely to have been superior over other methods of evaluating this patient.  Final Result: Three 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:  One reviewer is board certified in surgery and is actively practicing.  Two reviewers are board certified in surgery with sub-specialty certification in surgical critical care 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: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for the residential treatment center (RTC) services for treatment of the enrollees polysubstance abuse. Findings:  The physician reviewer found that the records indicate that this patients post-acute withdrawal symptoms were mild in nature. He was not a danger to himself or others. He was cooperate and not hostile or aggressive towards others. His activities of daily living (ADLs) were not impaired. He was engaged in the program. There were no emotional, behavioral, or cognitive factors requiring RTC level of care services. His medical conditions were chronic and could have been safely and adequately managed in an outpatient setting, as could the medication changes that occurred. His relapse risk was rated as moderate by staff. Although his wife was not supportive, his brothers and mother participated. The patient was seeking a sober living environment. He had not had treatment at a lower level of care in the previous year. His treatment and recovery could have continued at an ambulatory lower level of care in conjunction with community based services such as Alcoholics Anonymous (AA). 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

A 44-year-old male enrollee requested authorization and coverage of a sleep study for the treatment of a history of sleep disturbance.  The health plan denied the enrollees request indicating that the requested study 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 service is not medically necessary.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/ Case Summary: The enrollee has requested authorization and coverage for acupuncture. The enrollee has chronic low back pain without sciatica. The provider indicated the referral was concerning the enrollees left side low back pain originating in the left piriformis area and radiating down the enrollees entire left leg. Magnetic resonance imaging (MRI) of the left spine showed evidence of bilateral recess stenosis at L4-5 due to facet hypertrophy and a left L4-5 nerve encroachment due to a bulging disc. There was also evidence of hyperlordosis indicating muscle involvement. The enrollees condition causes her pain 24 hours a day and is a physical burden. She has been to physical therapy and chiropractic treatment but the pain does not subside. Current peer reviewed literature and evidence based guidelines support the use of acupuncture for chronic low back pain. According to one study, many current guidelines recommend acupuncture in specific circumstances for back pain or headache. Acupuncture is effective for the treatment of chronic musculoskeletal, headache, and osteoarthritis pain. Treatment effects of acupuncture persist over time and cannot be explained solely in terms of placebo effects. Referral for a course of acupuncture treatment is a reasonable option for a patient with chronic pain. Systematic reviews show that acupuncture, used either in isolation or as an adjunct to conventional therapy, provides short-term improvements in pain and function for chronic low back pain.Final Result: The reviewer determined that the requested service is medically necessary for the treatment of the enrollees medical condition.Credentials/Qualifications: The reviewer is board certified in acupuncture 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: Upheld

A 53-year-old female enrollee has requested skilled nursing facility (SNF) services for the treatment of her compression fracture. Findings:  The physician reviewer found that the level of function achieved with PT and OT indicates the enrollee no longer required inpatient rehabilitation. Her rehabilitation needs could be addressed at a lower level of care. She had no daily skilled nursing needs.
Appeal type: Experimental/Investigational
Decision: Upheld

Physician 1: This patient is a 52-year-old female with degenerative disc disease and a broad-based herniation at L3-4. She has significant radiculopathy, and conservative treatment has not improved her pain.  The patient is requesting percutaneous discectomy, and the Health Plan has denied authorization due to the experimental/investigational nature of the procedure.There is no literature to support the likelihood that percutaneous discectomy would be more effective than the standard microdiscectomy procedure. With a broad-based disc bulge, which was demonstrated in the MRI, the percutaneous procedure is not the best approach. Percutaneous discectomy would not be consistent with the standard of care in this clinical situation; the complication rate is higher and outcomes are no better than the standard procedure.  Therefore, I have determined that the requested procedure is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Plans denial should be upheld.Physician 2: This patient is a 52-year-old woman with a disc protrusion at L3-4 resulting in back pain and radiculopathy. Conservative treatment has improved the pain level somewhat, but has not resolved the radiculopathy in the right lower extremity.  The patient prefers the less invasive percutaneous discectomy over the standard microdiscectomy procedure, and has requested authorization from the Health Plan.  The Health Plan has denied this request on the basis that percutaneous discectomy is considered investigational.Despite early reports touting the benefits of percutaneous discectomy, substantiation of the overall efficacy of the procedure remains elusive. Numerous studies have shown the long-term results of this method are quite poor. The patient is likely to achieve better results with standard treatment modalities. Therefore, I have determined that the requested procedure is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Plans denial should be upheld.Physician 3: This patient is a 52-year-old woman with low back pain and pain radiating to the right thigh due to a right-sided foraminal disc protrusion at L3-4.  She has not found symptomatic relief in conservative treatment approaches and is now requesting approval for percutaneous disc discectomy at L3-4.  The requested procedure is deemed to be experimental/investigation by the Health Plan, and authorization and coverage was denied.Percutaneous discectomy is a novel and potentially effective treatment for low back pain and radiculopathy due to disc herniation. However, the long-term efficacy has not been proven in the peer-reviewed literature.  The procedure is still considered investigational, and it is not likely to be more effective than standard microsurgical and open surgical treatment of the patients disc herniation.  The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld

A 45-year-old male enrollee has requested for a continuous passive motion (CPM) device for post-operative rehabilitation.  Findings: The physician reviewer found that there are no well-controlled clinical studies establishing the long-term benefits of CPM use beyond the period of hospitalization following ACL reconstruction or even following knee replacement. Many of the touted benefits are theoretical. Objective evidence that CPM results in improved clinical outcomes is lacking at this time.