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

A 52-year-old female enrollee has requested a blepharoplasty for treatment of her dermatochalasis of eyelids.  Findings:  The physician reviewer found that the submitted photographs show bilateral upper eyelid ptosis which constitutes an abnormal structure of the body and lateral hooding on squinting which is not an abnormal structure.  In choosing which treatment is appropriate for an individual patient, the factors contributing to ptosis and the type of ptosis must first be assessed.  In this patients case, the ptosis appears to be aponeurotic, in which case blepharoplasty to remove excess eyelid skin is not medically necessary.  In this setting, surgery would only be medically necessary if the ptosis was severe enough to significantly obstruct the upper visual fields, and there is no documentation of this in the reviewed records.  Furthermore, lateral hooding is due to brow ptosis, not excess upper eyelid skin, and this is addressed by a brow lift, not blepharoplasty. Treatment of lateral hooding by brow lift would only be medically necessary if performed to treat visual field obstruction or skin breakdown/rashes within the hood. There is no documentation of either of these conditions being present in this patient.  The submitted records do not demonstrate that the requested surgery would either improve function or create a normal appearance to the extent possible.  Blepharoplasty would not provide more than a minimal improvement in the appearance of the patient.  All told, the requested blepharoplasty is not reconstructive in nature and is not medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Overturned

The father of a 16-year-old female enrollee requested authorization and coverage of continuing inpatient behavioral health services. The Health Plan denied the request indicating that the requested services are not medically necessary for treatment of the enrollees mental/behavioral disorders.One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer partially overturned the Health Plans denial on the basis that the requested services were medically necessary through 7/11/03 however, continued inpatient behavioral health services are not indicated at this time.
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 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. This applies regardless of fibrosis stage or viral load. The guidelines classify patients with diabetes mellitus as high risk for fast progression. Per the guidelines, treatment-naive genotype 1 patients 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. Per the submitted records, this patient is ineligible for the alternative for genotype 1a due to depression, which can be induced or exacerbated by ribavirin as shown in a trial of ribavirin monotherapy. 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 physician reviewer is board certified in internal medicine with sub-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: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for hydrogel (perirectal spacers). Hydrogel perirectal spacers (SpaceOAR) are considered the standard of care in this patients clinical setting. As noted in the current medical literature, SpaceOAR is supported by randomized prospective studies as improving bowel, urinary, and sexual side effects for prostate radiotherapy patients, as compared with patients not receiving the perirectal spacers. Further, SpaceOAR is supported by the National Comprehensive Cancer Network (NCCN) and American Society for Radiation Oncology (ASTRO) guidelines for management of prostate cancer. Moreover, SpaceOAR hydrogel perirectal spacers have been associated with high quality radiation delivery. Thus, the requested hydrogel (perirectal spacers) is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Findings:  Three physician reviewers found the requested hydrogel (perirectal spacers) is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Final Result: The reviewers determined that requested hydrogel (perirectal spacers) is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. For these reasons, the Health Plans denial should be overturned.Credentials/Qualifications: Physician reviewers 1, 2 and 3 are board certified in radiation oncology and are actively practicing. The 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

The patient is a 48-year-old woman who presented with a palpable abnormality in the right breast. Digital mammogram in February 2006 showed questionable increased density in the upper half of the right breast. Corresponding ultrasound showed a highly suspicious mass at the 10:00 position. Subsequent ultrasound-guided biopsy showed infiltrating ductal carcinoma with associated DCIS. The patient was referred for an MRI of the breasts for surgical planning. At issue is whether the MRI was medically necessary for evaluation of the patients breast cancer.Magnetic resonance imaging of the breast is a newer means of imaging for breast cancer. Peer-reviewed literature (including American College of Radiology guidelines) have shown that MRI of the breast is medically appropriate under certain conditions including determinations of the extent of biopsy proven infiltrating ductal cancer and to evaluate for additional sites of breast malignancy within the ipsilateral and contralateral breast. Magnetic resonance imaging of the breast in these situations allows proper surgical planning including consideration of conservation breast surgery versus mastectomy. For this patient with infiltrating ductal carcinoma, an MRI of the breast was medically necessary for purposes of surgical planning and appropriate treatment of her condition.Based upon the information set forth above, I have determined the MRI at issue was medically necessary for evaluation of the patients medical condition. The Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a two-year-old male enrollee has requested  speech therapy at a frequency of one time per week for one hour for treatment of the enrollees speech delay.  Findings:  The physician reviewer found that this patient has cerebral palsy and both cognitive and language delay. However, with one hour weekly of speech therapy he has made slow but definitive gains. Law, et al. reports that children with speech delay can be readily treated, as confirmed in a meta-analysis of multiple medical journal articles. A study involving both speech-delayed normal and abnormal intellect children, informs us that both groups of children are candidates for successful speech therapy (Goorhuis-Brouwer & Knijff).  Two-year olds, who tested below the 10th percentile for their age in both receptive and expressive language, did benefit from speech therapy in prospective studies (Emanuel, et al. and Buschman, et al.).  The literature is replete with publications supporting the medical necessity of speech therapy in a speech delayed, two-year old population, with either normal or delayed intellect. In summary, it is medically necessary for this patient to receive speech therapy for one hour per week in order to continue the progress he has made.
Appeal type: Experimental/Investigational
Decision: Upheld

A 48-year-old female enrollee has requested authorization and coverage for radiofrequency ablation (RFA) of the lumbar sympathetic chain.Reviewers' Findings:The three physician reviewers found that the safety and efficacy of RFA of the lumbar sympathetic chain for the treatment of CRPS has not been established. The use of RFA in this context is not medically indicated and is not consistent with the community standard of care.
Appeal type: Medical Necessity
Decision: Overturned

A 64-year-old female has requested Actonel 35mg twice weekly for treatment of Pagets disease.  Findings:  The physician reviewer found that Actonel is an appropriate agent for Paget's disease. However, the standard regimen for Actonel treatment of Pagets disease is 30mg every day (not weekly or twice weekly). The patient should continue on daily Actonel 30mg for six months with monitoring of AP levels (in the absence of clinical symptoms). If this regimen fails, it would then be appropriate to switch to a parenteral agent.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested stereotactic body radiotherapy for treatment of her medical condition. Findings: Three physician reviewers found that stereotactic body radiotherapy is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.  Stereotactic body radiotherapy is generally performed when there is a single lesion which needs more curative radiotherapy.  In this case, the patient has multiple lung metastases which have persisted or recurred after chemotherapy. There is a lack of medical literature that supports stereotactic body radiotherapy for the treatment of metastatic choriocarcinoma with multiple lung metastases which are not symptomatic.  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 physician 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: Upheld

A 24-year-old female enrollee has requested authorization and coverage for a myoelectric prosthesis and related accessories for treatment of the enrollees congenital absence of left hand.  Findings:  The physician reviewer found that prostheses that are initiated in the chronic stages post-amputation are frequently abandoned (Biddiss and Chau). In the patients case, however, she does appear motivated to learn and adapt to the use of a functional prosthesis given her recent experience following an injury to her intact distal upper limb. The patient has different prosthetic options, which would include a body-powered prosthesis and a conventional myoelectric prosthesis. A myoelectric prosthesiss advantages are primarily related to cosmesis and a greater grip force per unit of effort. The body-powered devices advantages are primarily related to lighter weight, greater fine tip prehension, greater reliability and greater durability. Given that the patient is in a sedentary occupation, a myoelectric prosthesis is not an unreasonable clinical option. There is no published, high-grade, disinterested clinical literature, however, supporting that a myoelectric prosthesis with a i-LIMB terminal device confers significant, marginal functional benefit in the setting of a distal upper limb amputation due to congenital limb deficiency or otherwise in comparison to a conventional myoelectrical prosthesis (or a non-myoelectrical prosthesis). The majority of patients with congenital distal unilateral upper limb deficiency are independent with all activities of daily living without prosthesis (Buffart, et al; Yigiter, et al). Prostheses assist in some bimanual tasks, but no significant, marginal functional benefit with respect to self-care or activities of daily living has been proven. Thus, the i-LIMB hand prosthesis is not medically indicated in lieu of a conventional myoelectrical or non-myoelectrical prosthesis. Overall, the device is expected to be less functional and less durable than a conventional body-powered or myoelectric prosthesis. Consistent with these findings, the requested equipment is not medically necessary for this patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested authorization and coverage for applied behavioral analysis (ABA) therapy. Findings:  The physician reviewer found that several concepts must be considered when considering the medical necessity of ABA therapy, such as the impairing nature of symptom and the evidence behind the recommended interventions.  In this case, the records indicate the patients behaviors are impairing, given the multiple and varied behaviors which occur during both speech and occupational therapy sessions on a weekly basis. These behaviors hinder the patients progress towards necessary goals in these areas. ABA is a well-documented behavioral approach for individuals with and without autism spectrum disorder. Children with Down syndrome have been shown to benefit from ABA therapy. ABA provides the tools necessary to address the range (in form and function) of behaviors of children with Down syndrome that have, in the past, precluded them from learning opportunities. In addition, research has shown that access to ABA can increase vocal responses in children with developmental disabilities. For this patient, ABA will likely increase his vocal responses, helping make much needed progress towards speech therapy goals while diminishing behaviors and increasing communication skills. Final Result: The reviewer determined that the requested services are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in pediatrics with sub-specialty certification in developmental-behavioral pediatrics 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 25-year-old female enrollee requested occupational therapy of the hand for medical treatment of her myotonic dystrophy.  Findings:  The physician reviewer found that the requested therapy is medically necessary for treatment of the patients medical condition. The medical literature supports the requested therapy in this clinical setting. Aldehag and colleagues (2013) demonstrated that a hand training program had positive effects on strength, self-perception of occupational performance, and of satisfaction with performance. In addition, Brady and colleagues found that patients who participate in regular physical activity for at least one year had greater grip strength than those who were not active. Based on the medical literature and documentation submitted for review, additional occupational therapy of the hand is medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for hospitalization services and prospective authorization and coverage for continued acute rehabilitation services. Based on documentation from the treating providers, the patient was medically approved for transfer to a skilled nursing facility (SNF). There is no documentation of fevers, leukocytosis, wound decline or other symptoms supporting the continued need for the level of care. There were no indications of wound infections, sepsis, pneumonia or bloodstream infection on the last notes provided. For these reasons, the hospitalization services and prospective authorization and coverage for continued acute rehabilitation services were not and are not medically necessary for treatment of this patients medical condition. Final Result: The reviewer determined that the services at issue were not and are not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in family medicine with expertise in wound 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

Nature of Statutory Criteria/Case Summary: The patients parent has requested authorization and coverage for factor 9 gene testing. This patients provider noted clinical suspicion of a hereditary coagulopathy. There was no family history but the bleeding in the brain was significant enough to require a hematology consultation. The patients activity levels of factor 9 were analyzed after the transfusion of multiple blood products including cryoprecipitate. Thus, the factor 9 activity levels could be falsely elevated. The 44% activity noted in the hospital was at the low end of normal and did not rule out factor 9 deficiency. Moderate or mild symptomatic factor 9 deficiency is characterized by activity levels under 40%. Hence, factor 9 deficiency was not ruled out. The provider thoroughly evaluated the patient and recommended genetic testing as the appropriate next step. The presence of trauma or injury to the brain as the initiating event for the bleed does not obviate the need for genetic testing for factor 9. Given these findings, the requested factor 9 gene testing is medically necessary for this patient. Final Result: The reviewer determined that the requested services are medically necessary for evaluation of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in internal medicine with subspecialty certifications in medical oncology and hematology 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 Harvoni for 24 weeks for medical treatment of the enrollees hepatitis C.  Findings:  Two physician reviewers found that in treatment-naive patients with cirrhosis, therapy is recommended with Harvoni for 12 weeks.  According to the current guidelines, the significance of a positive hepatitis C RNA test result at four, six or eight weeks remains unknown.  There is no recommendation to stop therapy or extend therapy at this time.  Based on published evidence of safety and efficacy in the literature and clinical guidelines, 12 weeks of Harvoni is medically necessary.  However, there is a lack of support for the extension to 24 weeks of Harvoni based upon the provided records.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for a tension-free mesh technique procedure for hernia repair. Researchers note that there is no one standard repair technique for groin hernias. In this case, the patient has right chronic post inguinal herniorrhaphy groin pain. While he has been seen multiple times for right chronic post inguinal herniorrhaphy groin pain, the records do not document an indication for a second surgery, such as a recurrence of right inguinal hernia or signs of mesh infection. Although there is documentation that the patient declined injections due to the short duration of relief provided by cervical injections, it is unclear whether the processes of diagnostic injections and potential nerve ablation have been adequately described to the patient, as the potential for improvement is much different than with the cervical injections. Given that there are more conservative medical treatments for the patients symptoms, such as nerve block or ablation and non-steroidal anti-inflammatory medications, the requested service is not medically indicated. Therefore, a tension-free mesh technique procedure for hernia repair is not medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested service 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 general 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.