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

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for tolvaptan 30 mg tablets. Findings:  The physician reviewer found that Syndrome of inappropriate antidiuretic hormone secretion (SIADH) is challenging to treat, requiring a strict intake of fluids and generally leading to recurrent hospitalizations and significant morbidity and mortality due to severe hyponatremia. Thajudeen, and Salahudeen report that antidiuretic hormone (ADH) receptor antagonists, especially tolvaptan appear to be an effective treatment strategy for hyponatremia. In this case, the patient has profound hyponatremia, which may have life threatening consequences and result in repeated hospitalizations. Given that current medical literature supports the use of tolvaptan as effective in this clinical setting, the requested medication is medically indicated. Therefore, tolvaptan 30 mg tablets are medically necessary for the treatment of this patient.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 nephrology 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 30-year-old female enrollee requested genetic testing for methylenetetrahydrofolate (MTHFR) gene mutations, Factor V Leiden mutations, and Factor II (prothrombin) mutations for medical evaluation of her pregnancy in relation to her family history of premature delivery.   Findings:  Three physician reviewers found that although inherited thrombophilias are associated with increased risk of venous thromboembolism, the peer-reviewed medical literature does not support the genetic testing used to evaluate this patient for adverse pregnancy outcome. It remains controversial whether there is an association between inherited thrombophilias and uteroplacental thrombosis that can lead to adverse pregnancy outcomes (Scifres and Macones). Further, the American College of Obstetricians and Gynecologists (ACOG) suggest there is inadequate evidence to support the assessment of MTHFR polymorphisms in this clinical setting. All told, genetic testing was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.
Appeal type: Medical Necessity
Decision: Upheld

A 55-year-old female enrollee requested authorization and coverage of a gastric bypass with duodenal switch. The Health Plan denied the request indicating that the requested procedure is not medically necessary for treatment of the enrollees morbid obesity.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

An enrollee has requested authorization and coverage for Synvisc-One injection for both knees.Current medical literature pertaining to viscosupplementation reveals mixed results. Evidence from eight systematic reviews and six randomized controlled trials indicates that although viscosupplementation may relieve knee pain in some individuals with osteoarthritis, it is not known which individuals will benefit. Different studies have tried mixing hyaluronic acid with corticosteroids, platelet rich plasma, and other agents to make it more effective. The current evidence is limited, and guidelines from organizations such as the American Academy of Orthopedic Surgeons indicate that the evidence is not conclusive. As such, the Academy does not currently support viscosupplementation as standard treatment for osteoarthritis of the knees. In light of the foregoing, viscosupplementation can only be recommended in individuals with a history of lasting benefit from prior injections, and in carefully selected cases where everything else has been tried, and the options are limited. In this case, the patients options are limited. The patient has tried and failed other conservative treatments, including corticosteroid injections, with the alternative being bilateral total knee arthroplasties in the presence of mild to moderate osteoarthritis. Under these circumstances, the requested Synvisc-One injection for both knees is medically necessary to treat the patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested Harvoni for the treatment of his hepatitis C. Findings:  The physician reviewer found that according to the most recent joint guidelines issued by the American Association for the Study of Liver Diseases and the Infectious Diseases Society of America, 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, treatment-naive, non-cirrhotic, genotype 1a patients should be treated with Harvoni for eight to twelve weeks, or with Viekira Pak and ribavirin for twelve weeks. These guideline recommendations are based on multiple randomized clinical trials.  Although treatment is needed in this case, no medical rationale supported by current literature is provided to support the use of Harvoni over Viekira Pak in this patients case.  For these reasons, the requested treatment with Harvoni is not medically indicated for the treatment of this patient. 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 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

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for gene expression profiling for evaluation of the enrollees cutaneous melanoma. Findings:  The 3 physician reviewers found that the National Comprehensive Cancer Network (NCCN) guidelines indicate that genetic testing such as the DecisionDx-Melanoma should not be used outside of a clinical trial setting. The use of this type of testing is not considered the standard of care in the treatment of the patient melanoma. Thus, its usage is not expected to impact the treatment or outcome of the patients melanoma. All told, gene expression profiling provided was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Final Result: The 3 reviewers determined that the testing at issue was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: Physician reviewer number one 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.Physician reviewer number two 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.Physician reviewer number three 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 50-year-old female enrollee has requested bilateral revision augmentation mammoplasty (implants), bilateral mastopexy (breast lift) and bilateral breast capsulectomy for treatment of her bilateral breast capsular contracture.  Findings:  The physician reviewer found that bilateral mastopexy (breast lift) is not medically necessary for the patients condition. Mastopexy for grade II ptosis is not medically indicated unless the removed skin is affected by conditions such as intertrigo or hidradenitis.  There is no documentation in the reviewed materials of any current skin condition that would be treated by mastopexy.  In this patients case, right breast capsulectomy is not medically necessary and left breast capsulectomy is medically necessary.  Surgery for visible but non-painful capsular contracture (grade III) or palpable but not visible or painful capsules (grade II) is not medically indicated.  If there is painful symptomatic grade IV capsular contracture and/or rupture of a silicone gel implant, removal of implant with capsulectomy would be medically indicated.  Removal of the capsule and implant with or without placement of a new implant should alleviate the pain and will prevent migration of the gel to adjacent areas where it could cause additional medical problems.  However, replacement of these implants with new breast implants is not medically indicated.  Since this patient has saline implants, age appropriate grade II ptosis and possible grade IV capsular contracture only on the left, only capsulectomy on the left is medically indicated.  In this case, the pain of grade IV capsular contracture is considered a functional impairment and capsulectomy surgery improves function by relieving the pain.  Per the submitted documentation, the patients condition does not constitute an abnormal structure of the body which would require bilateral revision augmentation mammoplasty (implants), bilateral mastopexy (breast lift) and right breast capsulectomy.  All told, the requested left breast capsulectomy is medically necessary.  However, the requested bilateral revision augmentation mammoplasty (implants), bilateral mastopexy (breast lift) and right breast capsulectomy are not medically indicated and are not reconstructive in nature.
Appeal type: Medical Necessity
Decision: Overturned

A 27-year-old male enrollee has requested the OmniPod External Insulin Pump and monthly supplies for the treatment of his type I diabetes. Findings:  The physician reviewer found that the OmniPod pump at issue has a single insertion system requiring only the use of one hand/arm and thus improves the effectiveness of the equipment for patients such as this patient who have limited use of an upper extremity.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a two-year-old female enrollee has requested  coverage for speech therapy for treatment of the enrollees autism. Findings:  The physician reviewer found that in general, patients with autistic spectrum disorders (ASD) experience similar deficits in terms of speech, language and social interaction. ASD is a complex neurological disorder of unknown etiology. There is a long history of approaches used to intervene and facilitate development of adequate communication and interpersonal skills in young patients with ASD. Typically, interventions in multiple areas provided using a team approach consisting of speech therapy, occupational therapy, and behavioral therapy are employed for maximum functional improvement. As noted by Volkmar and colleagues, fundamental to the diagnosis of ASD are deficits in speech and language. The authors indicated that, Most children with ASD will benefit from therapies designed to improve their ability to communicate and engage in social interactions, which is necessary as deficits in the use of language for social purposes are universally seen in this population. As these delays may impede social adaptation and acceptance, the authors concluded that, Research has shown that intervention makes a difference, and that early intervention focused on communication and social skills can significantly improve the outlook for individuals on the spectrum. This patient exhibits deficits in expressive and receptive language as well as socialization as a result of her neurologic disorder. The sooner and more aggressively her deficits are targeted, the better chance she has of developing adequate skills to function in the community. Accordingly, I have concluded that the requested therapy is medically necessary for treatment of the patients medical condition. The Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Overturned

A 55-year-old male enrollee has requested a combination of Victoza 1.8mg/0.1 pen injection/Janumet 50-500mg for treatment of his diabetes. Findings: The physician reviewer found that Victoza is a glucagon-like peptide 1 receptor agonist. Dipeptidyl peptidase-4 inhibitors such as Janumet slow the metabolism of glucagon-like peptide 1. Thus, in theory, the use of these medications both would raise glucagon-like peptide 1 levels. However, the use of the combination of Victoza and Janumet has not been adequately studied. There is a lack of medical studies demonstrating the safety of the combination of these two classes of medications. The current medical evidence does not support the use of the requested combination. In this patients case, either Janumet or Victoza is medically indicated and appropriate. However, the requested combination of Victoza 1.8mg/0.1 pen injection/Janumet 50-500mg is not medically indicated for the treatment of this patient. Thus, a portion of the requested medications is medically indicated for this patient.
Appeal type: Medical Necessity
Decision: Upheld

A 32-year-old female enrollee has requested for an abdominoplasty, panniculectomy and suction assisted lipectomy for treatment of her excess skin condition Findings:  The physician reviewer found that there is a lack of photographic evidence of intertrigo, rashes, or hyperpigmentation of the lower abdominal areas. Furthermore, the submitted medical records do not support a six-month or longer history of diagnosis of intertrigo, dermatitis or skin necrosis problems with treatment and failure of conservative therapies.
Appeal type: Medical Necessity
Decision: Upheld

A 51-year-old male enrollee has requested laminectomy at L4 and release of neural roots, osteotomy of intercorporeal graft at L4-5 and fixation with transpedicular screws from L2 to L5 for the treatment of his low back pain. Findings:  The physician reviewer found that this patient has midline and unilateral buttock pain and no radicular pain. He has had a normal examination. MRI did not reveal significant stenosis, degeneration or foramen compromise. Dynamic studies showed no instability. Thus, the requested procedures are not medically indicated. There are no indications for the surgery.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary:  An enrollee has requested in home physical therapy services 2-3 times per week for treatment of her medical condition status post back surgery.  Findings:  The physician reviewer found that there is a lack of recent health care provider notes to support the medical necessity of the requested in home physical therapy services. Specifically, there are no clearly documented diagnoses, rationales, or goals of the requested physical therapy, which should be part of any physical therapy treatment plan. Based on the currently available documentation, the medical necessity of the requested in home physical therapy services 2-3 times per week has not been established. Final Result: The reviewer determined that the requested therapy 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 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 77-year-old male enrollee has requested neuromuscular electrical stimulation for treatment of his medical condition status post right internal capsular stroke with left hemiparesis.  Findings:  The physician reviewer found that a review of the medical literature indicates that recovery of stroke occurs fastest in the first three months. Hsu and colleagues reported on the use of neuromuscular electrical stimulation (NMES) for patients with acute strokes. The authors concluded that there is some increased improvement in wrist and hand patient assessments in patients treated with NMES along with regular inpatient rehabilitation when compared with patients who only received regular inpatient rehabilitation. This study however was small and only studied 66 patients. Furthermore, there is no significant difference in the motor activity log including the amount of use and quality of movement at two-month follow-up.Per documentation, this patient received NMES therapy and experienced improved strength. The treating provider acknowledged in the records that the patients improvement may be secondary to natural neuro-recovery. Thus, while literature suggests there may be a role in NMES in improving certain wrist and hand parameters in patients after stroke, there is inadequate evidence that such parameters translate into functions.
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. There is support in the medical literature for the use of breast tomosynthesis compared to 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. As such, the use of breast tomosynthesis was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.  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: Medical Necessity
Decision: Overturned

A 55-year-old female enrollee requested authorization and coverage of a positron emission tomography (PET) scan. The Health Plan denied the request indicating that the requested PET scan is not medically necessary for evaluation of the enrollees medical condition status post diagnosis of breast cancer.One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer overturned the Health Plans denial on the basis that the requested PET scan is medically necessary.
Appeal type: Medical Necessity
Decision: Upheld

A 38-year-old female enrollee has requested a magnetic resonance imaging (MRI) of the lower back for evaluation of her lower back pain. Findings:  The physician reviewer found that the submitted documentation and relevant literature fails to demonstrate the medical necessity of the requested diagnostic study. The patient presents with low back pain, reported to have begun in the year indicated. She was reported to have been treated with physical therapy and continued to note increasing low back pain, which was worsened with lateral side bending and twisting.  She was noted on physical exam to have no abnormal findings except for some tenderness over the lumbar paraspinous musculature. According to Chou and colleagues (2011), Diagnostic imaging is indicated for patients with low back pain only if they have severe progressive neurologic deficits or signs or symptoms that suggest a serious or specific underlying condition. Given that the patient has no specific findings on physical examination suggesting a neural compression and has previously undergone a computed tomography (CT) of the abdomen, which was negative for any findings, the requested MRI of the lower back is not clinically indicated. In addition, there were no recent physical exam findings suggesting that the patient has developed neurological deficits at this time to indicate the need for an MRI. Based on the medical literature cited above and the documentation submitted for review, the requested diagnostic study is not medically necessary for evaluation of the patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned

A 42-year-old male enrollee requested authorization and coverage of a gastric bypass with duodenal switch. The Health Plan denied the request indicating that the requested procedure is not medically necessary for treatment of the enrollees morbid obesity.One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer overturned the Health Plans denial on the basis that the requested procedure is medically necessary.
Appeal type: Experimental/Investigational
Decision: Overturned

A 51-year-old female enrollee requested digital breast tomosynthesis for medical evaluation of the enrollees breasts.  Findings:  Two physician reviewers found that there is sufficient support for digital breast tomosynthesis in this clinical setting.  Initial and ongoing studies have shown a significant decrease in the recall rate from screening mammography and a detection of small cancers not readily apparent on traditional full field digital mammography.  Thus, the technique is now commonly used as an adjunct to standard digital screening mammograms.  All told, digital breast tomosynthesis was likely to have been more effective than other modalities for the evaluation of this patient.