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

The parent of a 17-year-old female enrollee has requested surgical removal of keloid scars from the ear for the treatment of the enrollees keloid scars. Findings:  The physician reviewer found that a keloid is a scar, and scars are normal occurrences. It would only be considered abnormal with photographic documentation of a very large size, or documented symptoms of pain interfering with function, sleep, loss of range of motion/mobility or recurrent infections in the keloid. In this patients case, the submitted documentation does not demonstrate that the keloid is an abnormal structure of the body. The medical records do not demonstrate that the requested surgery will be performed to improve function. Given the lack of photographs, there is no evidence that the requested surgery will offer more than a minimal improvement in the appearance of the patient. As such, the requested surgery is not reconstructive in nature as defined by Californias reconstructive surgery statute. With regard to the medical necessity of the proposed procedure, the presence of a keloid scar in and of itself does not make removal medically necessary. In the absence of medical chart documentation of impaired function (for example, blockage of the ear canal or impaired range of motion) and/or significant symptomatology, removal of a keloid scar is not necessary from a medical standpoint. Thus, there is inadequate evidence demonstrating that the requested procedure is medically necessary in this particular case.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/ Case Summary:  The enrollee is requesting authorization and coverage for monitored anesthesia care (MAC) during an upcoming colonoscopy procedure. The enrollee has a past medical history of drug rash eosinophilia systemic syndrome, lupus and arthritis, chronic stomach pain, chronic bloating, and difficulty swallowing. The enrollee was evaluated for bloating and pain. The provider advised a colonoscopy. The medical records describe a enrollee report of an anesthesia history of problems with anesthesia; therefore, the provider recommended monitored anesthesia care (MAC) for the procedure. This enrollee does not meet professional society criteria for monitored anesthesia care (MAC). The medications used for the colonoscopy do not cause the type of problems the enrollee reported in her history. The medical records do not support the enrollees history of difficult airway to support the need for monitored anesthesia care (MAC).Final Result: The reviewer determined that the requested service is not medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The physician 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 similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Mavyret 100 mg/40 mg three times per day for eight weeks. The Health Plan has denied this request indicating that the requested medication is not medically necessary for treatment of the enrollees chronic hepatitis C virus (HCV), genotype 1a.According to the most recent joint guidelines issued by the American Association for the Study of Liver Diseases (AASLD) and the Infectious Diseases Society of America (IDSA), all patients with chronic hepatitis C should be treated except those with limited life expectancy due to non-liver-related conditions. The guidelines recommend that all patients should be treated, regardless of fibrosis stage. The guidelines recommend that non-cirrhotic treatment-naive genotype 1a patients should be treated with Mavyret for eight weeks. These recommendations are based on multiple randomized clinical trials, and the medication is U.S. Food and Drug Administration (FDA)-approved for all patients with chronic hepatitis C, genotype 1 regardless of fibrosis stage. A clinical trial showed that only eight weeks of treatment is needed, not 12 weeks. AASLD/IDSA guidelines cite data showing reduced survival with delayed treatment. For these reasons, the requested treatment with Mavyret 100 mg/40 mg three times per day for eight weeks is supported as medically necessary for the treatment of this patients hepatitis C infection.Final Result: The reviewer determined that the requested medication is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in internal medicine with sub-specialty certification in gastroenterology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

The patient is a three-and-a-half-year-old male diagnosed with autism who has had a regression of speech since the age of 18 months. As a function of his autism the patient has significant maladaptive behavior including severe perseverations, tantrums, and sensory-seeking behaviors including pelvic stimulation, spinning in circles, tilting his head, screaming, and jumping up and down. He was admitted to an early childhood partial hospitalization program in November 2004.Upon review of the multi-disciplinary progress reports, the patient has made excellent gains in his behavior. The Health Plan has recommended discontinuing the partial hospitalization program and beginning more traditional services provided by the school and regional center when available.At issue is whether continued partial hospitalization services are medically necessary for treatment of the patients condition.Though there is little scientific literature either in support of or against hospital-based programs for the treatment of autism, such programs are available and considered appropriate in situations in which extreme behavior are present. Such is the case with this patient. The recommendations of the patients treating physician and psychologist are to maintain the program until they complete training and have formalized the outpatient applied behavioral analysis program. Allowing the patient to return to the community without proper services in place is potentially harmful to the patient and would possibly allow the patient to regress. Therefore, the patient should complete the program and should be appropriately transitioned to an applied behavioral analysis program and school setting. Based upon the information set forth above, I have determined the requested services are medically necessary for treatment of the patients medical condition.  Therefore, the Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested gastroenterology consultation and endoscopy for treatment of the enrollees medical condition. Findings: The physician reviewer found that this patient has symptoms consistent with gastroesophageal reflux disease and dyspepsia, but also potentially consistent with esophagitis, gastritis, or ulcer of the esophagus, stomach, or small bowel. Persistent pain or dyspepsia is an indication for gastroenterology consultation. The American College of Physicians guidelines recommend endoscopy for investigation of symptoms when those symptoms are refractory to proton pump inhibitor for four to eight weeks without response.  American Society for Gastrointestinal Endoscopy guidelines for diagnosis of dyspepsia state that endoscopy is an appropriate initial test for dyspepsia.  In this case, there is sufficient support for the requested services for this patient.  All told, the requested gastroenterology consultation and endoscopy are medically indicated 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 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 50-year-old male requested authorization and coverage of a septoplasty for the treatment of deviated nasal septum.  The health plan denied the enrollees request indicating that the requested procedure 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 septoplasty is not medically necessary.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/ Case Summary:  The enrollee has requested authorization and coverage for bilateral breast augmentation. Findings:  The physician reviewer found that the enrollee has gender dysmorphia and is transitioning from male to female. She reports her mental health providers have recommended breast augmentation, laryngoplasty, thyroid cartilage reduction, and facial feminization surgery.  She was seen in consultation for gender related issues and noted that she knew her true gender was female at an early age and she lived as a female often in her life, but had now been living as a female for the past two years. Guidelines from an authority on transgender health issues indicate medically necessary gender affirming/confirming surgical procedures may include breast augmentation for feminization.  The medical procedures related to a gender affirming/confirming surgeries are not cosmetic or elective or for the mere convenience of the enrollee.  These procedures are reconstructive surgeries.  A variety of therapeutic options can be considered for individuals seeking care for gender dysmorphia. These include changes in gender expression and role, hormone therapy to feminize or masculinize the body, surgery to change primary and/or secondary sex characteristics (e.g., breasts/chest, external and/or internal genitalia, facial features, body contouring) and psychotherapy. Although she has not been treated with hormones, the records support the enrollee has been living as a female for years, and desires to have more feminine traits and surgical intervention, inclusive of breast augmentation. Surgical intervention is supported for enrollees with persistent gender dysmorphia.  The enrollee underwent a psychological evaluation and was found to be psychologically sound to have the surgery.  Final Result: The reviewer determined that the requested service is medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The physician reviewer is board certified in psychiatry and child and adolescent 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 similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

The parent of a 5-year-old male enrollee has requested 52 weeks of occupational therapy at a frequency of 2 sessions per week at 1 hour per session (104 sessions) for treatment of the enrollees autistic disorder.  Findings:  The physician reviewer found that review of the submitted evidence demonstrates this patient is significantly impaired, as he still is not toilet-trained and is only minimally effective in dressing and undressing skills. The record indicates that for the past 2 years he has been the recipient of extensive home and clinic occupational therapy.  Therapeutic gains have occurred through these occupational therapy interventions; however, they have been relatively minimal according to the records provided.An extensive meta-analysis of the literature indicates that occupational therapy is effective in reducing many of the sensory processing difficulties associated with autism (Pfeiffer, et al.).  May-Benson and Koomar also performed a meta-analysis of 27 journal articles utilizing sensory integration techniques for autistic children. Their conclusion, based on the meta-analysis, was that occupational therapy was effective, but studies were inconclusive regarding the duration or the amount of occupational therapy necessary for positive effects.  Since this patient has been receiving 2 hours of weekly occupational therapy for 2 years with limited effect, the requested duration of therapy is excessive. His last occupational therapy progress report dated the end of last year recommended 1 hour of occupational therapy weekly. Based on the documentation provided, the Health Plan has authorized 2 hours of weekly occupational therapy for a 12-week period. The services authorized by the Health Plan are medically reasonable and appropriate at this time. The patient should be re-evaluated at the end of the 12-week period to determine if there is a need for additional services based on continuing improvement and progress toward goals.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patients parent has requested reimbursement for transthoracic echocardiogram (CPT 93303). The submitted documentation supports the medical necessity of the services at issue. This patient previously had an echocardiogram in 2015 that showed a small perimembranous VSD. She reportedly had been asymptomatic. Perimembranous VSDs are followed even if hemodynamically insignificant because patients may develop RVOT or LVOT obstruction from overgrowth of aneurysm tissue, aortic insufficiency and double-chambered right ventricle even with no change in the murmur. This is more likely to happen during periods of rapid growth. The published guidelines for children and adults recommend follow-up echocardiogram every three to five years. Therefore, transthoracic echocardiogram (CPT 93303) was medically necessary for the evaluation 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 pediatrics with sub-specialty certification in pediatric cardiology 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 64-year-old male enrollee has requested proton beam radiation therapy for treatment of his  prostate cancer.  Findings:  The physician reviewer found that review of the submitted documentation and relevant literature fails to demonstrate the medical necessity of the requested services. The National Comprehensive Cancer Network (NCCN) guidelines for prostate cancer state: Proton beams can be used as an alternative radiation source. Other treatment approaches such as IMRT are highly effective and well tolerated. There is a lack of compelling data that suggests that PBRT affords a benefit over standard approaches, such as IMRT for prostate cancer. In addition, there is data in the peer-reviewed literature that shows worse outcomes with PBRT therapy. According to a study by Sheets and colleagues, proton therapy has resulted in a greater risk of gastrointestinal toxicity versus intensity-modulated radiation therapy (IMRT). For the reasons provided above, the requested services are not medically necessary for treatment of the patients prostate cancer.
Appeal type: Medical Necessity
Decision: Overturned

A fifty-seven year-old female diagnosed with colon cancer and early metastatic disease in the liver is requesting authorization of selective internal radiation therapy (SIRT).  The patient underwent surgical excision of the primary tumor and then received chemotherapy. Unfortunately, the metastatic liver disease progressed.Reviewers Findings:  The reviewing physician found that SIRT has been recommended as a promising, therapeutic approach that targets the liver exclusively.  The reviewing physician found that the Health Plan denial should be overturned.
Appeal type: Medical Necessity
Decision: Upheld

A 60-year-old male enrollee has requested a power wheelchair for treatment of his polyneuropathy. Findings:  The physician reviewer found that the records do not establish that the patient would be bed or chair confined without a power mobility device.  The mobility evaluations indicate that he can accomplish his functional activities of daily living independently and that his basic mobility needs would be best met with a manual wheelchair and a gait implement such as a cane.  The patient, moreover, has multiple chronic health conditions that would benefit from increased physical activity and exercise.  Regular use of a power mobility device would decrease his physical activity levels and exercise and could worsen his health conditions.  All told, the requested power wheelchair is not medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement and prospective authorization and coverage for skilled nursing facility (SNF) services. The medical literature indicates that rehabilitation post hospital discharge can be delivered in many settings. When there is concern about the patients inability to return home from the acute setting, SNF care may be indicated. SNF services are supervised by a physician, include physical therapy (PT) and occupational therapy (OT), and nursing is provided 24-hours a day. This patient was discharged from the acute care hospital to the SNF. Prior to admission to the SNF, she was independent living at home. On the date of admission to the SNF, she was completely dependent for standing, sitting, transfers, bathing, and her activities of daily living. She was noted to be participating with PT and required daily professional services for wound care, antibiotics, and monitoring. The treatment she has been provided could not have been administered at a lower level of care. Thus, the SNF services provided were and are medically necessary for treatment of this patients medical condition. Final Result: The reviewer determined that the services at issue were and 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 expertise in skilled nursing facility care 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 34-year-old female enrollee has requested intravenous immunoglobulin (IVIG) therapy for treatment of her multiple sclerosis. Findings:  The physician reviewer found that pregnancy is a relatively protective circumstance for individuals with multiple sclerosis, although the literature shows that relapses are more common during the postpartum period. The relapse rate in multiple sclerosis decreases during the nine months of pregnancy, and it rises significantly during the first trimester postpartum, affecting one-third of patients. Standard medications for disease modification in relapsing remitting multiple sclerosis are contraindicated during breastfeeding. The medical literature shows IVIG to be beneficial in managing relapses of relapsing remitting multiple sclerosis, and to be of adequate safety during breastfeeding. Preventive management of relapses is the cornerstone of treatment for this patients condition.
Appeal type: Medical Necessity
Decision: Upheld

The patient has requested authorization and coverage for hydrocodone (Norco). The Centers for Disease Control and Prevention (CDC) guidelines state that, non-pharmacologic therapy and non-opioid pharmacologic therapy are preferred for chronic pain. Providers should consider opioid therapy only if expected benefits for both pain and function are anticipated to outweigh risks to the patient. If opioids are used, they should be combined with non-pharmacologic therapy and non-opioid pharmacologic therapy, as appropriate. In this case, the patient has physical examination findings suggestive of low back and knee pain. Treatment has included nortriptyline, acetaminophen and Flexeril. The provider referred the patient to physical therapy for non-opioid based treatment as well as participation in a chronic pain clinic, which are consistent with the standard of care. The patient has been intermittently treated with Norco due to multiple emergency department visits. However, she has not fully exhausted non-opioid therapy, including participation in physical therapy, chronic pain clinic, and a weight loss program. Based on the medical records available for review and the current guidelines, the requested hydrocodone (Norco) is not medically necessary for 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 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: Medical Necessity
Decision: Overturned

A 64-year-old female enrollee has requested for Adderall 200 mg for treatment of her narcolepsy.  Findings:  The physician reviewer found that this patients records demonstrate that she has been compliant with her medical regimen for management of her narcolepsy and has been treated by the same provider for many years. It is widely accepted in clinical practice that individual patients will respond to medications and varied doses differently. This patient has benefitted greatly from a medical regimen consisting of Adderall 200 mg per day after failing treatment with lower doses.