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 total hip arthroplasty in the right hip for treatment of the enrollees chronic hip pain. Findings:  The physician reviewer found that Evidence based medical guidelines recommend total hip arthroplasty when all reasonable conservative measures have been exhausted and other reasonable surgical options have been seriously considered or implemented. Criteria includes exercise therapy (supervised physical therapy and/or home rehab exercises) and medications. Subjective findings should include limited range of motion, or nighttime joint pain, or no pain relief with conservative care. Objective findings should include over 50 years of age and body mass index less than 35. Imaging findings of osteoarthritis on standing x-rays or arthroscopy are required. Guidelines state that every effort should be made to avoid a hip replacement in younger patients. The National Institute for Health and Care Excellence recommend total hip arthroplasty and resurfacing arthroplasty as treatment options for patients with end stage arthritis of the hip who have failed nonsurgical management.  The American College of Rheumatology recommends total joint arthroplasty for patients with hip osteoarthritis following failed medical therapy. Medical therapy recommendations included exercise, weight loss for overweight patients, medication management, walking aids, and psychosocial interventions. This patient has a three year history of chronic right hip pain that interferes with activities of daily living and sleep. Clinical examination findings are consistent with impingement syndrome, including positive FADIR testing and radiographic findings of crossover sign. Right hip x-ray report documented a normal study with no significant bony or joint pathology. The orthopedic surgeon has reported findings consistent with moderate hip osteoarthritis. Conservative treatment was documented to include anti-inflammatory medications, platelet rich plasma injections, physical therapy, activity modification, and corticosteroid injections without sustained improvement. However, evidence based peer reviewed criteria have not been met at this time. There is a lack of evidence of severe osteoarthritis to support total hip arthroplasty in a patient under the age of 50. Additionally, there is no discussion of alternative surgical treatment options for this patient or evidence of a trial of reasonable use of an assistive device/walking aid(s). Final Result: The reviewer determined that the requested services are 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 orthopedic 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 the surgical procedure, reduction mammoplasty for treatment of her macromastia. Findings:  The physician reviewer found that review of the submitted documentation and relevant literature demonstrates the medical necessity of the requested surgery. According to the American Society of Plastic Surgeons (ASPS) guidelines Based on the results of Level I and II Evidence, reduction mammaplasty has been proven effective at reducing macromastia related symptoms and improving postoperative quality of life. In this case, the patient has multiple functional deficits supported by typical signs and symptoms associated with macromastia. She has back, and shoulder pain, as well as shoulder grooving from her bra straps. She has evidence of significant macromastia on examination detail. Her pain has failed conservative management with narcotics, activity modification and physical therapy. Her degree of resection planned is supportive of her clinical functional deficit. She would likely benefit significantly from breast reduction surgery. In sum, the patient has functional problems that are directly related to her significant macromastia. Final Result: The reviewers determined that the requested surgery 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 plastic surgery and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested Synvisc-One injections (48 mg/6 ml syringe for treatment of the enrollees medical condition. Findings: The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested services.  The evidence-based medical guidelines state that hyaluronic acid injections in the knee are recommended as a possible option for severe osteoarthritis for patients who have not responded adequately to recommended conservative treatments, to potentially delay total knee replacement.  There is insufficient evidence for other conditions, including patellofemoral arthritis, chondromalacia patella, patellofemoral syndrome, or osteochondritis dissecans.  This patient presents with right knee pain with reported difficulty weight-bearing and walking.  Right knee examination documented diffuse global tenderness with painful, but functional, range of motion.  She was status post right knee arthroscopic chondroplasty of the patellofemoral joint, removal of medial plica, and debridement of torn cartilage on the medial femoral condyle.  Updated radiographs showed minor degenerative osteoarthritis.  The current diagnosis is chondromalacia patella. There is a lack of compelling rationale to support the medical necessity of viscosupplementation in the setting of minor osteoarthritis/primarily patellofemoral osteoarthritis. Therefore, the requested Synvisc-One injections are not medically indicated for the treatment of this patient.Final Result: The reviewer determined that the requested services are 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 orthopedic 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

A 48-year-old female is requesting revisional gastric bypass surgery for treatment of her morbid obesity. Findings:  The physician reviewer found that this patient has morbid obesity. She had a previously attempted conversion from a LAGB to LRYGBP with complications that resulted in a gastro-gastric fistula with no real gastric bypass (as she is occluded to the roux limb). Therefore, the patient functionally has no weight loss procedure as the food that she eats enters her normal stomach and moves into the duodenum. The patient was recently reevaluated by a bariatric surgeon and underwent multidisciplinary evaluation. She was advised of the risks of surgery and is a reasonable candidate for surgical intervention. The previous complications were not due to lack of patient compliance, and although the patient is at risk of complications, she has been provided informed consent and would like to proceed. It is not possible to predict the amount of scar tissue in the gastroesophageal junction, however, based on the EGD and upper gastrointestinal (UGI) series, anatomically there should be enough stomach to create a pouch and therefore the procedure appears to be technically feasible. All told, this patient meets nationally accepted criteria for weight loss surgery and the proposed procedure is medically reasonable.
Appeal type: Medical Necessity
Decision: Upheld

A 47-year-old female enrollee requested authorization and coverage of nerve decompression surgery. The Health Plan  denied the request indicating that the requested surgery is not medically necessary for treatment of the enrollees diabetic peripheral neuropathy.One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer upheld the Health Plans denial on the basis that the requested procedure is not medically necessary.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for bilateral iliac vein angiogram, left renal vein angiogram, IVUS, and possible angioplasty of any scarring in the iliac veins. Basile and colleagues report that pelvic congestion syndrome (PCS) is often an underdiagnosed cause of chronic pelvic pain that may occur either alone or in combination with vulvar varicosities and/or lower extremity venous insufficiency. In this case, the patient has undergone extensive workups including endoscopies and diagnostic laparoscopy. The records document symptoms that may represent a component of pelvic congestion or renal vein stenosis. Given that the patient has  exhausted other reasonable avenues, the requested services are medically indicated. Therefore, bilateral iliac vein angiogram, left renal vein angiogram, IVUS, and possible angioplasty of any scarring in the iliac veins are medically necessary for the evaluation of this patient.Final Result: The reviewer determined that the requested services are medically necessary for evaluation of the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in general surgery and in vascular 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: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for second neuropsychological examination. This patient was administered a battery of neurocognitive tests to evaluate cognition, memory, attention, and concentration. All of the tests administered to the patient are widely used and are considered to be valid and reliable measures of their focus. The tests have also been demonstrated to yield consistent results when administered by different providers. This patients personality profile, according to the Minnesota Multiphasic Personality Inventory (MMPI), indicates an unusually high number of symptoms endorsed in the areas of somatic, psychiatric, and cognitive functioning. This result suggests that the patient may be overly focused on these issues, which may further compound his distress and lead to further impairment. Testing also revealed evidence of severe depression and moderate anxiety. The neuropsychological testing included the Wechsler Adult Intelligence Scale Fourth Edition (WAIS-IV), which is the most common test of neuropsychological function. The Wechsler Memory Scale Fourth Edition (WMS-IV) is a widely used clinical instrument designed to assess domains of memory, including short-term, long-term, and working memory. Delis-Kaplan Executive Function System (DKEFS) is sensitive to frontal-lobe dysfunction and executive-function deficits associated with a variety of neurological, developmental, and psychiatric disorders. The Trail Making Test (TMT) is a measure of attention, processing speed, and mental flexibility. On review of this patients test results and reliability of the testing utilized, there is a lack of an indication for repeat neuropsychological testing. Given these findings, the requested second neuropsychological examination is not medically necessary for this patient. Final Result: The reviewer determined that the requested services are not medically necessary for evaluation of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer board certified in psychiatry and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

A 61-year-old female enrollee requested Orthovisc injections  for medical treatment of the enrollees bilateral knee pain.  Findings:  The physician reviewer found that review of the submitted documentation and relevant literature fails to demonstrate the medical necessity of the services. According to American Academy of Orthopedic Surgeons guidelines for the treatment of osteoarthritis of the knee, the authors do not recommend using hyaluronic acid for patients with symptomatic osteoarthritis of the knee due to a lack of efficacy within clinical trials. Additionally, the American College of Rheumatology indicates that due to the insufficient literature, they cannot make a recommendation for or against the use of intra-articular hyaluronates in treatment of patients with osteoarthritis of the knee. Furthermore, according to the Osteoarthritis Research Society International Guidelines for the nonsurgical management of knee osteoarthritis, the authors found that there were inconsistent conclusions among the available medical literature and that there is often conflicting results involving the use of hyaluronic acid injections regarding its safety and efficacy. Therefore, at this time the data is insufficient to support the use of hyaluronic injections for the treatment of osteoarthritis of the knee. Therefore, the services at issue were not medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Afrezza (insulin powder inhaler). Afrezza is a rapid-acting Technosphere insulin administered via a breath-powered oral inhaler to patients with diabetes requiring prandial insulin (Gala). Although Afrezza achieved the prespecified non-inferiority margin of 0.4% as compared to injections of rapid acting insulin in a recent trial, patients with type 1 diabetes who received Afrezza demonstrated less reduction in hemoglobin A1c levels. Based on the available documentation, there is a lack of support for use of Afrezza for this patient in lieu of injectable insulin, which is considered the standard of care in this clinical setting. For these reasons, the requested Afrezza (insulin powder inhaler) is not supported as medically necessary for treatment of this patients type 2 diabetes.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 internal medicine with sub-specialty certification in endocrinology, diabetes and metabolism 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 Otezla for treatment of her medical condition. Findings: The physician reviewer found that psoriasis is a chronic inflammatory skin disease affecting approximately 2% of the US population and 4.8% of people worldwide. Approximately 30-45% of those affected first experience symptoms during childhood or adolescence (Marji, et al). This skin disease typically presents with sharply demarcated, inflammatory, erythematous plaques with characteristic silver-white scaling due to epidermal hyperproliferation and parakeratosis secondary to the inflammation. Psoriasis has a high negative impact on the quality of life, especially in patients moderately or severely affected by the disease (Navarini and Trueb). About 20% of patients suffer from severe psoriasis, necessitating systemic drugs such as Acitretin, methotrexate, cyclosporin A or the newer biologic agents. This patient has severe plaque psoriasis that requires systemic treatment. Otezla is approved by the U.S. Food and Drug Administration (FDA) for treatments of such patients. All told, the requested Otezla is medically necessary for treatment of this 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: Upheld

A 45-year-old male enrollee requested authorization and coverage of continued rehabilitation therapy for the treatment of residual facial paralysis.  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 services are not medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned

An 18-year-old male enrollee requested growth hormone (GH) therapy (Norditropin) for medical treatment of his GH deficiency.   Findings:  The physician reviewer found that the patients medical records substantiate the diagnosis of GH deficiency. The patient has been treated with human GH (Norditropin) since the diagnosis of growth hormone deficiency, with good results. The treatment is in progress and has not been determined to be completed. The patient has continued to grow at a rate of 2.5 cm per year. It is indicated in the literature that treatment may be withdrawn when this rate falls below 2.5 cm per year. Thus, continued treatment is medically necessary not just because of the final height goal, but also for the benefits related to metabolic health and psychosocial implications of appropriate growth for age (Drake, et al; Rogol). Consistent with these findings, the requested GH therapy (Norditropin) is supported as medically necessary for treatment of this patients GH deficiency.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for bilateral mammoplasty. Findings:  The physician reviewer found that World Professional Association for Transgender Health (WPATH) Standards of Care (SOC) acknowledges that in the treatment of the male-to-female patient, surgical procedures in the treatment of gender dysphoria may include breast/chest surgery: augmentation mammoplasty (implants/lipofilling) (Coleman, et al.). The WPATH also states that augmentation mammoplasty is  understood to be medically necessary for the treatment of the diagnosed condition. For this patient, the providers have documented that the patient is committed to feminine transformation as evidenced by hormone therapy and gender confirmation surgery. The patient meets the WPATH criteria for gender dysphoria and indication for mammoplasty based upon clinical documentation of persistent gender dysphoria. Moreover, the requested mammoplasty is in accordance with the generally accepted standards of mental health and substance use disorder care, clinically appropriate in terms of type, frequency, extent, site, and duration, and not primarily for the convenience of the patient or provider. Given these findings, the requested bilateral mammoplasty  is medically necessary for treatment of this patient. 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 with expertise in transgender health 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 parent of an enrollee has requested authorization and coverage for treatment once per week with a psychiatrist or psychologist who specializes in selective mutism. As noted by researchers, selective mutism has been defined as an anxiety disorder in the diagnostic and statistical manual of mental disorders (DSM-5). Cognitive behavioral therapy (CBT) is the recommended approach for children with selective mutism, which is offered by trained mental health providers such as psychiatrists or therapists trained in this technique. Follow-up studies at one and five years demonstrated significant improvement in patients with selective mutism, with 70% of children in complete remission at the five-year mark. The use of CBT by a psychiatrist or therapist in selective mutism is considered the standard of care. Accordingly, the requested treatment once per week with a psychiatrist or psychologist who specializes in selective mutism is 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 pediatrics with sub-specialty certifications in neurodevelopmental behavioral pediatrics and genetics 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

The patient is a 39-year-old female with episodic migraine headaches, which on occasion have been associated with unilateral weakness. She has been using DHE 45 1mg subcutaneously for treatment of her migraines. There is no aura associated with the headaches and the medication has generally been successful.  The patients request for authorization of DHE 45 was denied based upon the Health Plans determination that it is not medically necessary for treatment of her migraine headaches.A review of the medical record submitted indicates the consulting neurologist has made a diagnosis of hemiplegic migraine. DHE-45 is contraindicated in patients with hemiplegic migraine. There are other available therapies that are likely to be effective for treatment of this patients migraines. Therefore, I have determined the requested medication is not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.