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

A 54-year-old female enrollee has requested a second bilateral breast reduction revision for treatment of her status post revision of breast reduction with chest wall contouring.   Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested services.  The medical records document obesity, and this is associated with higher complication rates.  In this clinical setting, the optimal approach is weight loss prior to breast surgery.  In this patients case, the current complaints are not related to macromastia.  There are no documented functional complaints.  Given the patients prior medical and surgical history, the submitted photographs demonstrate the expected results in this setting.  Thus, this patients condition does not constitute an abnormal structure of the body.  All told, a second bilateral breast reduction revision is not reconstructive in nature and is not medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld

A 30-year-old female enrollee has requested weekly ultrasounds and non-stress tests for evaluation of her hypothyroidism treated with levothyroxine while pregnant.  Findings:  The physician reviewer found that maternal and fetal thyroid abnormalities are related as thyroid function is dependent on adequate iodide intake, and its deficiency early in pregnancy can cause both maternal and fetal hypothyroidism. In addition, maternal TSH-receptor-blocking antibodies can cross the placenta and cause fetal thyroid dysfunction. However, the more common antithyroid peroxidase and antithyroglobulin antibodies have little or no effect on fetal thyroid function even though they too cross the placenta. Similarly, maternal Hashimoto thyroiditis is not typically associated with fetal thyroid dysfunction. In fact, the prevalence of fetal hypothyroidism in women with Hashimoto thyroiditis is estimated to be only 1 in 180,000 neonates. There is no evidence in this patients case that she has autoimmune hypothyroidism. As this patient is on thyroid therapy, she should have her serum TSH repeated every 4-6 weeks during the first 20 weeks, at 24-28 weeks, and at 32-34 weeks gestation. An increase in thyroid requirements is seen in about 20-30% of patients in the second half of pregnancy. Immediately after delivery, the patient should return to her pre-pregnancy dosage. All told, there is no support for serial ultrasound examinations and non-stress tests for the indication of hypothyroidism in pregnancy. Therefore, the requested services are not medically necessary for evaluation and treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for a hair transplant. The World Professional Association for Transgender Health (WPATH) notes, Non-genital surgical procedures are routinely performed.these surgical interventions are often of greater practical significance in the patients daily life than reconstruction of the genitals. Adjusting the hairline is an essential part of facial feminization surgery. Scientists noted that hair transplant is an essential part of facial feminization surgery and reported, After the forehead, the hairline pattern is the second most important feature of gender identification within the upper third of the face. The combined evaluation of these two features should be a basic premise of facial feminization surgery. The medical evidence supports the requested services for the treatment of this patient with gender dysphoria. Therefore, a hair transplant is medically necessary for the 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 and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested Harvoni for treatment of her hepatitis C virus.  Findings:  The physician reviewer found that according to 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. This applies regardless of fibrosis stage or viral load. Per the guidelines, genotype 1a patients who have failed PEG-interferon/ribavirin should be treated with Harvoni for 12 weeks. These guideline 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 (Afdhal, et al). The patient is ineligible for the alternative for genotype 1a (Viekira Pak with ribavirin) due to prior anemia with ribavirin  anemia can be induced or exacerbated by ribavirin as shown in a trial of ribavirin monotherapy (Dusheiko, et al). AASLD/IDSA guidelines cite data showing reduced survival with delayed treatment (Jezequel, et al). For these reasons, the requested treatment with Harvoni 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: Medical Necessity
Decision: Upheld

A male enrollee requested the prescription drug Prolia 60 mg for treatment of his osteoporosis with compression fracture at T8 with back pain.  Findings:  The physician reviewer found that Prolia is indicated for the treatment of postmenopausal women with osteoporosis at high risk for fracture or patients who have failed or are intolerant to other available osteoporosis therapy. Although the patient may benefit from Prolia treatment, he does not meet the criteria for this medication at the present time, as he has not failed bisphosphonate treatment. Based on the documentation submitted for review and the peer-reviewed literature cited above, the requested medication is not medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld

A 50-year-old female enrollee has requested for Botox injections for treatment of her chronic pain.    Findings:  The physician reviewer found that Botox is not of proven efficacy in case-controlled, peer-reviewed literature in the treatment of chronic back pain or myofascial pain. Furthermore, a response to trigger point injection is not known or proven to be a reliable predictor of a positive response to Botox injections. Because of the lack of evidence supporting the use of Botox in this setting, the medically necessity of Botox for this patient has not been established.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: an enrollee has requested authorization and coverage for a computed tomography (CT) scan of the left foot. Findings:  The physician reviewer found that the gold standard in the diagnosis of gout is demonstrating uric acid crystals in the joint fluid or in tophi. Bony alterations occur only years into the illness and even then, only 45% of patients have radiographic findings. Further confusing the issue is that hyperuricemia can occur in patients who do not have gout. Early diagnosis is important, as uric acid lowering medications can play a role in preventing functional impairment. Over the years, various modalities have been developed to more accurately diagnose gout Historically, radiographs have been the mainstay of imaging, but only demonstrate chronic (irreversible) changes.  More recently, CT, magnetic resonance imaging (MRI), and ultrasound have been used. CT is the best modality to demonstrate bony changes, while MRI is better for soft tissues. Ultrasound has some advantages as well, but is highly operator dependent and has a small field of view. Dual energy CT scanning has shown to be promising in differentiating the various crystals. While there are some problems with specificity, at the very least, if one can diagnose crystalline disease, one can exclude simple osteoarthritis.  Final Result: The reviewers 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 physician reviewer is board certified in diagnostic radiology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

The patient is a 59-year-old female with a history of chronic pelvic pain.  Her perivaginal pain has been evaluated and treated extensively. Both conservative therapies such as medications and physical therapy and interventional procedures such as surgical release of the pudendal nerves and Botox injections have proven to be unsuccessful.  The patient continues with pain and paresthesias in the clitoris, urethra, vagina, perineum and rectum.  She has been under the care of a pain management specialist and radiofrequency ablation of the pudendal nerve with hyaluronidase and steroid injections has been recommended.  The patients request for authorization of the recommended procedures was denied by the Health Plan citing a lack of medical necessity.The patient has a well-established diagnosis of chronic pelvic pain.  She has undergone multiple therapies and continues to have significant pain.  Radiofrequency ablation of the pudendal nerves is a viable option for pain control given her history of previous therapeutic interventions.  The procedure involves the use of heat to obtain neurolysis.  The benefits of this procedure include accurate target monitoring, limited need for anesthesia, precise probe placement, low incidence of mortality/morbidity, and rapid post-procedure recovery.  The procedure is accompanied by the use of a mixture of local anesthetic, steroid and hyaluronidase to maximize epidurolysis at the involved nerve site.  The patients provider has exhausted all other therapies at this point.  Therefore, I have determined the requested procedures are medically necessary for treatment of the patients medical condition. The Health Plans denial should be overturned.
Appeal type: Urgent Care
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for medical services rendered in an urgent care.Findings: The physician reviewer found that the services at issue were not necessary for treatment of an emergency medical condition. No emergent condition was identified and no emergent treatment was provided. In this case, the patient presented to urgent care with symptoms that were not acute. The patients rash had been present for one month. The patients symptoms were not severe. There is no documentation of any difficulty breathing or swallowing. Given that the patients symptoms were not sudden or severe, the patients symptoms do not meet criteria for an emergency medical condition. As such, the services provided do not meet criteria for emergency medical services.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 emergency 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 reimbursement for whole breast ultrasound. The records provided for review document that this patient underwent routine mammography studies and was found to have an area of architectural distortion in the setting of heterogeneously dense breast tissue. Due to these findings, the patient underwent evaluation with tomosynthesis examinations followed by whole breast ultrasound. Multiple modalities have been used to resolve the problem of the heterogeneously dense breast. Most recently, tomosynthesis has been demonstrated to yield additional data helpful in this diagnostic setting. When there are concerns following tomosynthesis, options include follow-up mammography, magnetic resonance imaging (MRI), and ultrasound. There are several peer-reviewed medical literature articles that support the use of whole breast ultrasound as an adjunct to mammography. Berg and colleagues found that whole breast ultrasound provided an increased detection rate of occult breast cancer when added to routine mammography. MRI of the breast has been shown to have a high level of sensitivity, but a relatively low level of specificity. For this patient, the whole breast ultrasound was performed concurrent with the additional left breast mammographic images, which is consistent with the recommendations in the medical literature. For these reasons, the whole breast ultrasound screening was medically necessary for treatment of this patient.  Final Result: The reviewer determined that the services at issue were 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 diagnostic radiology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

A 33-year-old female enrollee has requested Neurontin 300mg, Ambien 10mg, Lamictal 150mg, prazosin 1mg, clonazepam .5mg, alprazolam .5mg, fluoxetine 20mg and bupropion 15mg  for the enrollees bipolar disorder, obsessive-compulsive disorder and panic disorder.  Findings:  The physician reviewer found that per the submitted documentation, medication changes were made frequently, and there is no documentation regarding degree of compliance.  This patient has been diagnosed with bipolar disorder, and Lamictal is an evidence-based treatment for this condition according to the American Psychiatric Association practice guidelines. The patient seems to have been fairly stable throughout her treatment with her current provider, and she appears to have been on this medication the entire time. The concurrent use of two antidepressants for bipolar depression is not indicated per the American Psychiatric Association guidelines, and the history given by the patient suggests that she has failed both fluoxetine and bupropion in the past. Hence, the documentation fails to justify the use of these medications. In this patients case, clonazepam was not and is not medically indicated. She has been on this medication for a long time, and there is no evidence that the provider has attempted to titrate the dose or discontinue this medication. Ambien has also been added with no indication that the patients response has been monitored, and with insufficient documentation to justify its use. Neurontin has no indication for sleep according to FDA guidelines or current literature. The record documents a complaint of frequent nightmares. This is a sound rationale for use of prazosin in this case. The prescription of alprazolam is supported by the indication of situational anxiety for which this medication is indicated.All told, Neurontin 300mg received on the said date was not medically indicated, and continued use of Neurontin 300mg is not medically indicated. Ambien 10mg provided on the said date was not medically necessary, and the submitted documentation fails to establish the medical necessity of continued use of Ambien 10mg. In this patients case, clonazepam .5mg received on the said date was not medically indicated, and continued use of clonazepam .5mg is not medically necessary. Fluoxetine 20mg provided during the said timeframe was not medically necessary, and continued use of fluoxetine 20mg is not medically indicated.  In this patients case, bupropion 15mg received from this time period was not medically indicated, and continued use of bupropion 15mg is not medically indicated.  However, the medical documentation demonstrates the medical necessity of Lamictal 150mg provided on the date in question, and continued use of Lamictal 150mg is medically indicated.  Additionally, prazosin 1mg received on the said date and continued use of prazosin 1mg was and is medically necessary.  Also, the medical records demonstrate the medical necessity of alprazolam .5mg provided on the date in question, and continued use of alprazolam .5mg is also medically indicated.
Appeal type: Medical Necessity
Decision: Overturned

A 37-year-old male enrollee has requested acute inpatient psychiatric services for treatment of his behavioral health condition. Findings:  The physician reviewer found that according to the medical records provided, the patient remains psychotic and cognitively impaired by his mental illness. He has not been adherent with medications. He has been delinquent in both maintaining his activities of daily living and consuming an appropriate diet. While he has not reported suicidality or homicidal ideation, based on past behaviors and current signs and symptoms, the patient poses a significant safety risk to himself and the community. Although the patient has been resistive to treatment and has poor insight, the disputed services remain medically necessary for active treatment and to prevent a more serious condition. In sum, considering the case in its entirety within the context of current practice guidelines and relevant peer-reviewed literature, continued acute inpatient psychiatric services are medically necessary for this patient.
Appeal type: Experimental/Investigational
Decision: Upheld

A 46-year-old female enrollee has requested lumbar/sacral facet joint injections/destruction (radiofrequency neurolysis) for treatment of her lower back pain.   Findings:  Three physician reviewers found that review of the submitted documentation indicates the patient underwent radiofrequency neurotomy on the left side in the past with good results. She also underwent right-sided L5 dorsal ramus and S1, S2, and S3 lateral branch blocks with transient relief, however, the duration has not been shown. This was a single block relief and false-positive results cannot be ruled out. The requested procedure should be performed only after the results are positive with dual blocks, however, these blocks should first be administered with a sacroiliac joint injection, followed by dorsal ramus and lateral branch blocks. In this patients case, only one block was performed. Further duration and intensity of the relief also has not been described (Manchikanti et al and Falco et al). Given the lack of controlled diagnostic blocks, and the lack of documentation of appropriate improvement after a diagnostic block, the requested procedure is not likely to be more beneficial for the patient than any standard therapy.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested Harvoni for treatment of her hepatitis C virus 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 AASLD and IDSA guidelines noted that all patients should be treated, regardless of fibrosis stage and treatment-naive genotype 1a patients should be treated with Harvoni or with Viekira Pak with ribavirin for 12 weeks. These guideline recommendations are based on multiple randomized clinical trials, and the medications are U.S. Food and Drug Administration (FDA) approved for patients with chronic hepatitis C genotype 1 (Kowdley, et al; Afdhal, et al; Feld, et al; Poordad, et al). No medical contraindication to Viekira Pak with ribavirin is reported in this case. The AASLD and IDSA guidelines do not recommend Harvoni over Viekira Pak with ribavirin, even in light of potential ribavirin side effects. For these reasons, treatment is indicated in this case, but the requested treatment with Harvoni is not supported as medically necessary over Viekira Pak with ribavirin for the treatment of this patients hepatitis C infection.  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 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.