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

An enrollee has requested authorization and coverage for bilateral mastectomy revision treatment plan as proposed by out of network surgeon, including one surgery, removal of extra skin, nipple re-grafting, and single incision from behind each armpit connected to the center of the enrollees chest. The Health Plan has denied this request indicating that the requested services are not medically necessary for treatment of the enrollee who had undergone a chest reconstruction. Findings:  Based on the documentation provided, the patients original gender-conforming surgery produced a significantly abnormal result. The records indicate the patient continues to have significant excess skin, contour deformity and abnormal nipple positions. His condition should be considered a complication of the original male chest reconstruction that was performed.  As such, reasonable measures to correct this are medically necessary. The photographs show evidence of an abnormal male appearance of the chest consistent with previous examinations. There is significant soft tissue redundancy bilaterally and significant contour deformity of the left lateral chest. The nipple positions are asymmetric and not in a normal position for a male. The medical documentation and review of the photographs support a significantly abnormal result that would not be expected from chest surgery.  The two plastic surgeons offered different surgical plans for treatment of this patients abnormal chest presentation.  However, the in-Plan surgeon did not address the asymmetric and abnormal nipple positions, which significantly contributes to this patients chest deformity.  The surgical plan proposed by an out of network surgeon is consistent with the treatment of the deformity present in this patient according to the examination and photographs. Therefore, the documentation provided supports the medical necessity for bilateral mastectomy revision treatment plan as proposed by an out of network surgeon, including one surgery, removal of extra skin, nipple re-grafting, and single incision from behind each armpit connected to the center of the patients chest.Final Result: The reviewer has determined that the requested services are medically necessary for the 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: Experimental/Investigational
Decision: Overturned

A 55-year-old female enrollee has requested a bilateral breast magnetic resonance imaging (MRI) for evaluation of her suspicious left axillary mass and right upper quadrant breast thickening. Findings:  Two physician reviewers found that the indications for breast MRI have been clearly defined by the American Cancer Society and specific guidelines have been established. Some of these indications include patients with a defined high risk of developing breast cancer, with new diagnosis of breast cancer, for evaluation of extent of disease, and assessment of disease after treatment. In a recent article from Moy and colleagues, the authors suggest that MRI is of little added benefit when both mammography and ultrasound are negative and should be reserved for high-risk patients. However, when mammography and ultrasound fail to fully evaluate a finding, breast MRI to be a useful complementary study to conventional breast imaging modalities. In this case, previous biopsies have already been performed with negative results. However, the clinical literature suggests that negative findings on mammogram and ultrasound may not rule out clinical findings in the breast. As such, although a mammogram, ultrasound and biopsy may be negative, MRI is warranted in this situation to further evaluate this patient for suspicious findings.
Appeal type: Medical Necessity
Decision: Upheld

A 44-year-old female requested authorization and coverage of the removal of fatty deposits near the medial canthi of her eyelid.  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: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary:  An enrollee has requested digital breast tomosynthesis for evaluation of her medical condition.  Two physician reviewers found that in this patients case, the superior efficacy of the services at issue has not been established.  There is a lack of peer-reviewed literature that supports the use of digital breast tomosynthesis compared to currently available techniques in this clinical setting.  Although breast tomosynthesis may be a promising technique, its superior clinical efficacy has not been substantiated in the peer-reviewed literature.  Therefore, digital breast tomosynthesis was not likely to have been superior over other methods of evaluation.  Final Result: Two reviewers determined that the services at issue were 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: 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

Nature of Statutory Criteria/Case Summary: An enrollee has requested Sovaldi and ribavirin for treatment of his hepatitis C virus.  Findings:  The physician reviewer found that the proposed treatment is medically necessary and is considered the standard of care for the treatment of the patients with hepatitis C virus (HCV) genotype 2. Per the American Association for the Study of Liver Diseases/Infectious Disease Society of America (AASLD/IDSA) guidelines, all patients with chronic active HCV are eligible for treatment and should be treated with U.S. Food and Drug Administration (FDA) approved antiviral therapy regardless of fibrosis score. Successful hepatitis C treatment results in sustained virologic response (SVR), which is tantamount to virologic cure, and as such, is expected to benefit nearly all chronically infected persons. The evidence supports treatment in all HCV-infected persons, except those with limited life expectancy (less than 12 months) due to non-liver-related comorbid conditions. The goal of treatment of HCV-infected persons is to reduce mortality and liver-related health adverse consequences, including end-stage liver disease and hepatocellular carcinoma, by the achievement of virologic cure. The proposed combination therapy with Sovaldi and ribavirin has been approved by the FDA based upon a large trial involving genotype 2 and 3 patients. This regimen has also been endorsed by the AASLD/IDSA in their recent guidelines for the treatment of HCV patients. The initial phase three studies (FISSION, FUSION and POSITRON) demonstrated that the Sovaldi regimen was well-tolerated, safe and efficacious. As such, Sovaldi and ribavirin for 12 weeks is medically necessary for treatment of the patients medical condition. Final Result: The reviewer determined that the requested medications 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 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: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for OxyContin 15 mg ER tablets, once every 12 hours. The Centers for Disease Control and Prevention (CDC) guidelines state that, Nonpharmacologic therapy and nonopioid pharmacologic therapy are preferred for chronic pain. Clinicians should consider opioid therapy only if expected benefits for both pain and function are anticipated to outweigh risks to the patient. Similarly, the Federation of State Medical Boards guidelines noted that, Continuation, modification or termination of opioid therapy for pain is contingent on the clinicians evaluation of (1) evidence of the patients progress toward treatment objectives and (2) the absence of substantial risks or adverse events, such as signs of substance use disorder and/or diversion. In this case, the patient has chronic pain involving the lower back, and neck with involvement of the left side of her body, which the provider attributes to Lyme disease as demonstrated on antibody testing. The patients pain is rated as 10/10 and there is documentation of at least 30% pain relief with her current opioid regimen. The providers notes state that the patient has not demonstrated any aberrant or drug seeking behavior, and that the medications are managing the pain and allowing for the performance of activities of daily living. There is no documentation of any irregularities in the CURES report or inconsistent urine drug screens. The patient has tried and failed several different classes of medications including both opioid and non-opioid classes. The provider noted that the patients current regiment including OxyContin 15 mg every 12 hours is effective. Given these findings, the requested OxyContin 15 mg ER tablets, once every 12 hours is medically necessary for 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 anesthesiology with subspecialty certification in pain management 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: Overturned

A 32-year-old female enrollee requested implantation of subcutaneous implantable cardioverter defibrillator (ICD) for medical treatment her medical condition.  Findings:  Three physician reviewers found that the requested services are likely to be more effective than other treatment options.  This patient is at high-risk due to long QT syndrome and family history of sudden death.  There is sufficient support for the requested services in this clinical setting.  Subcutaneous ICD has been shown to be efficacious in treatment of ventricular arrhythmias, especially in patients who do not require pacing, as compared to transvenous ICD and do not involve transvenous or intra-cardiac leads.  In sum, the requested implantation of subcutaneous ICD is likely to be superior over other available options.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/ Case Summary:  The enrollees parent requested authorization and coverage for optometric vision therapy. The enrollee has refractive amblyopia in both eyes. She has anterior visual midline shift syndrome (VMSS) and requires yoked prism in her lenses to center the VMSS.  These lenses are a form of vision therapy and will change as her visual system improves and becomes more integrated.  The optometrist has recommended neuro-optometric vision therapy, designed to increase the visual sub skills necessary for proper educational intervention.  The individualized vision therapy program will emphasize binocular work to improve eye-teaming efficiency and depth perception; visual-motor tasks to improve body awareness and control, visual direction of gross and fine motor skills, eye-hand coordination; inter-sensory integration skills through visual-auditory-verbal matching; and reintegration of spatial-visual processing and its relationship to the proprioceptive base of support. The enrollees diagnoses are esotropia, amblyopia, and high myopia.  Review of the literature indicates standard treatments for these conditions include eye muscle surgery; with or without occlusion/cycloplegic therapy, and spectacle correction.  A literature search failed to generate any studies comparing standard treatments to vision therapy. There are various non-standardized testing results to indicate dysfunction in the enrollees visual pursuit.  Literature does not support the efficacy of eye exercises, behavioral vision therapy, or special tinted filters or lenses for improving educational performance in these pediatric neurocognitive conditions.  These approaches lack scientific evidence of efficacy and are not endorsed. Convergence insufficiency as the only diagnosis for which vision therapy has been proven beneficial in randomized clinical trials. Convergence insufficiency has been associated with reading impairment and poor academic performance. However, these associations do not prove a causal relationship between these conditions.  Additionally, there is no evidence the enrollee has convergence insufficiency. Final Result: Three of the three reviewers determined that the requested services are not likely to be more beneficial than any available standard therapy for treatment of the enrollees medical condition. Credentials/Qualifications: Three reviewers are board certified in Ophthalmology and are actively practicing.  All three reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary:An enrollee has requested reimbursement for advanced lipoprotein testing for evaluation of the enrollees hypercholesterolemia. Findings:  The physician reviewer found that the physician reviewer found that this patient presented with increased coronary risk. In this circumstance, guidelines for the management of cardiac risk and dyslipidemia have been established, are periodically updated by expert committees and are endorsed by several national organizations. These guidelines currently do not recommend routine performance of specialized tests in the context of assessing coronary risk including lipoprotein-associated phospholipase A2, sub-classifications of low-density lipoprotein, high-density lipoprotein subclasses, myeloperoxidase, lipoprotein (a), C-reactive protein, high sensitivity C-reactive protein, insulin, fibrinogen, genetic testing and homocysteine. Treatment change or addition based on the results of screening with these specialized tests has not been shown to improve cardiac outcome incremental to that achievable by treatment based on standard risk factor profiling and basic lipid analysis. Even though results of some of these specialized tests may be abnormal and considered independent risk markers for coronary disease, there is a lack of controlled trials that demonstrate outcome benefits by treating routinely obtained abnormal results. All told, advanced lipoprotein testing was not likely to have been of greater benefit than other methods of evaluating this patient.   Final Result: All three reviewers determined that the services at issue were 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 internal medicine with sub-specialty certification in cardiovascular disease 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 internal medicine with sub-specialty certification in cardiovascular disease 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 internal medicine with sub-specialty certification in cardiovascular disease 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 proton beam radiation therapy for treatment of his medical condition.  Findings:  Three physician reviewers found that proton beam radiation therapy is not likely to be more beneficial than standard therapy consisting of conventional fractionated photon therapy.  For a subtotally resected grade 1 meningioma, the medical evidence supports fractionated external beam radiation with photons to a total dose of 45 to 54 Gy, or consideration of stereotactic radiosurgery if deemed safe.  In this dose range, the potential benefit of proton therapy due to its Bragg Peak and sharper dose fall off is not likely to be clinically relevant.  Thus, the requested proton beam radiation therapy is not likely to be of greater benefit than other treatment alternatives.  Final Result: Three reviewers determined that the requested services are not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: All three reviewers are board certified in radiation oncology 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

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Acthar Gel 80 u/mL subcutaneous injection twice a week for six months. Acthar Gel is U.S. Food and Drug Administration (FDA) approved for the treatment of nephrotic syndrome (NS). While Acthar Gel has not been widely studied in IgA nephropathy, there is evidence that it may be beneficial in some patients. Researchers found that Acthar gel may meet an important treatment needed in patients with treatment-resistant NS in response to first-line therapies, patients unable to tolerate first-line therapies, and in patients with advanced disease. This patient has over three grams of proteinuria and renal biopsy diagnosis supports the presence of glomerulonephritis. Given these findings, the requested Acthar Gel 80 u/mL subcutaneous injection twice a week for six months is medically necessary for 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 subspecialty 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 62-year-old female has requested LINX surgery for treatment of her gastroesophageal reflux disease.  Findings:  Three physician reviewers found that per the medical records, the patient has experienced gastroesophageal reflux disease symptoms for approximately 20 years.  She has been tried on a number of acid reducing therapies, including proton pump inhibitors.  The patients main symptoms include nocturnal coughing, voice hoarseness, an acid sensation in the chest, and early morning dysphagia.  An upper endoscopy with biopsy and placement of a Bravo pH monitoring device confirmed acid reflux primarily in the upright position.  The current medical evidence does not support the requested procedure in this case.  There is a lack of long-term data supporting the LINX procedure in this clinical setting.  Acid reflux is a chronic condition.  The durability of the LINX procedure has not been established.  In this clinical setting, the requested procedure is not likely to be of greater benefit than traditional fundoplication or maximization of medical therapy.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for residential treatment center services for treatment of the enrollees behavioral health condition. Findings:  The physician reviewer found that the residential treatment center services are medically necessary for treatment of the patients medical condition. Bipolar disorder represents a severe mental disease that has poor outcomes and an exceedingly elevated suicide rate. The risk of suicide is even higher for previous attempters and substance users. Thus, this patient is at-risk for a poor clinical outcome. Based on the documentation provided, she has not found the optimal psychotropic medication regimen. Residential placement is indicated to allow the patient to consolidate treatment gains and develop coping skills to manage her anger. The treatment team had yet to hear back from previous providers for collateral information and aftercare planning. The patient was angry and experiencing aggressive ideation with thoughts of self-harm. She did not like her university and had no firm plan in place for the summer or following semester. A family session was planned. With the strained parent-child dynamics, a hasty discharge to home would have likely been unsuccessful, and likely resulted in prompt readmission. Considering the relevant history and peer-reviewed literature, residential treatment is safe, appropriate and consistent with good practice and reasonably expected to improve the patients condition and prevent a more serious episode of illness in this case. Therefore, the requested services are medically necessary for treatment of the patients behavioral health 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 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.