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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for hair removal.Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested services.  The primary care provider ordered a serum testosterone level which was normal.  The patients facial hair does not constitute an abnormal structure of the body.  There is no documentation of impaired functioning due to this benign condition.  The requested hair removal is not expected to provide more than a minimal improvement in the patients appearance. Final Result: The reviewer determined that the requested services are not reconstructive in nature and are not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The physician reviewer 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: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Saxenda pen injector 3 mg/0.5 mL (18 mg/3 mL).Obesity is associated with increased risk of multiple comorbidities. Few medications are currently available for the treatment of obesity, and their effectiveness and benefits often fade when the drugs are discontinued. Saxenda (liraglutide) may be prescribed for chronic weight management as an adjunct to a reduced-calorie diet and increased physical activity. Nuffer and Trujillo noted, Data demonstrated that liraglutide can successfully achieve weight-loss benchmarks of 5% or more and 10% or more loss from baseline. In this case, the patient has struggled to lose weight despite a strict diet and regular exercise. Further, the patient is unable to take stimulants because she has tachycardia. Saxenda may assist this patient with losing weight and may have a positive effect in terms of her comorbidities, such as dyslipidemia. Thus, the Saxenda pen injector 3 mg/0.5 mL (18 mg/3 mL) is medically necessary for the treatment of the patients condition.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 endocrinology, diabetes and metabolism, 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 testing performed. Findings:  The physician reviewer found that The patient was diagnosed with a common shoulder strain, and her treatment plan was for symptomatic management with anti-inflammatory medications such as Motrin. There are tests which can specify an individual patients genetic type with respect to the metabolism of different drugs, including opioids and nonsteroidal anti-inflammatory drugs. However, there is no evidence that these tests provide clinical benefit, except in very specific circumstances such as the use of clopidogrel, which was not an issue with this patient. There is a lack of support for the services at issue in the routine management of a musculoskeletal condition.  In sum, the superior effectiveness of panel of gene tests received has not been established. Final Result: The 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 1, 2 and 3 are board certified in internal medicine 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

Nature of Statutory Criteria/Case Summary: An enrollee has requested Sovaldi and Daklinza for treatment of the enrollees hepatitis C virus.  Findings: The physician reviewer found that according to joint guidelines issued by the American Association for the Study of Liver Diseases (AASLD) and the Infectious Diseases Society of America (IDSA), all patients with chronic hepatitis C should be treated except those with life expectancy less than 12 months due to non-liver-related conditions. Per the guidelines, patients with cirrhosis are high priority for treatment. In cirrhotic treatment-naive genotype 3 patients, therapy is recommended with Sovaldi and Daklinza for 24 weeks. This is based partially on the ALLY-3 study, which showed a cure rate of only 58% with 12 weeks of Sovaldi and Daklinza therapy, and the European compassionate use study which showed a cure rate of 86% with 24 weeks of Sovaldi and Daklinza therapy (Nelson, et al; Hezode, et al). Per the guidelines, the Sovaldi, peg-interferon, and ribavirin regimen and the Sovaldi and ribavirin regimen are no longer recommended. Delay in treatment may result in decreased survival (Jezequel, et al). For these reasons, the requested treatment with Sovaldi and Daklinza is medically necessary for 24 weeks for the treatment of this patients hepatitis C infection.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: Experimental/Investigational
Decision: Overturned

A 50-year-old female enrollee has requested for vertical banded gastroplasty for treatment of her obesity. Findings:  Two physician reviewers found that the Lap-Band requires frequent adjustments and support therapy. Additionally, bleeding is possible if band erosions occur. The ghrelin factor is not reduced, anti-inflammatory medicine is not well-tolerated, and marginal ulcers can occur. This is not so with the sleeve gastrectomy. Existing gastroesophageal reflux disease is improved after the first year with this procedure. Furthermore, the peer-reviewed literature shows that revisional surgery is much easier to perform if it becomes necessary. In this patients case, sleeve gastrectomy is likely to be more efficacious than alternative treatment options.
Appeal type: Medical Necessity
Decision: Overturned

A 39-year-old female enrollee has requested bariatric surgery for the treatment of her obesity. Findings:  The physician reviewer found that with a body mass index of 41.5 and comorbid conditions including diabetes mellitus, this patient meets medical necessity criteria for weight loss surgery. The rationale for requiring psychological evaluation prior to weight loss surgery is to identify a possible eating disorder that may have contributed to the patients obesity.  There is no scientific data to support that patients with bipolar disorder do any better or worse after weight loss surgery than a patient who is not diagnosed with this condition. The patients obesity and its related co-morbidities require surgical treatment; her psychiatric conditions should not prevent her from receiving appropriate treatment for her medical problems.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary:  The parent of an enrollee has requested Saizen for treatment of the enrollees medical condition.   The physician reviewer found that the submitted documentation supports the medical necessity of the requested medication.  The records document short stature and an abnormal growth hormone response test to stimulation tests.  The current medical evidence supports the requested medication in this clinical setting.  All told, the requested Saizen is medically indicated 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 pediatrics with sub-specialty certification in pediatric endocrinology 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 advanced lipoprotein testing. Findings:  Three physician reviewers found that the American College of Cardiology (ACC) guidelines do not support use of advanced lipid testing in this clinical setting. Rather, the ACC guidelines recommend use of standard risk factors and standard lipid profile to make decisions about lipid management. In addition, the guidelines emphasize use of the pooled risk score analysis for decisions regarding statin therapy. The ACC guidelines are formulated based on thorough review of current literature. Given these findings, the advanced lipoprotein testing performed was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Final Results: 2 of 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: All three physician reviewers are board certified in internal medicine with sub-specialty certification in cardiovascular disease 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: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for treatment of rib fracture. Findings:  Three physician reviewers found that this patient has multiple indications for the surgery that was performed. He reported chronic pain from the displaced ribs at multiple levels. The records indicate the severity of the displacement, ranging from 2 to 4 cm overlap between the ribs, anteriorly and posteriorly. Additionally, there was instability of the chest wall noted. The scissoring effect of the overlapped ribs impinged on the intercostal nerves located immediately beneath each rib, leading to his severe chronic pain related to the unstable chest wall fractures. The records demonstrate that surgery was indicated for this patient. The efficacy of rib stabilization by plating has been shown in prior studies. The medical literature has also shown the superiority of this procedure over conservative medical management. For these reasons, treatment of rib fracture received was likely to have been superior to other alternatives for treatment of this patients medical condition. Final Result: 3 of 3 reviewers determined that the services at issue were 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 thoracic and cardiac surgery 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: Upheld

A 58-year-old female enrollee has requested acute inpatient rehabilitation for treatment of status post hip fracture.Findings:  The physician reviewer found that rehabilitation goals were limited to transfers and power-chair mobility. This would not require a three-hour per day acute rehabilitation program and the documentation indicates the patient would not have tolerated this intensity.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a four-year-old male has requested occupational therapy for treatment of his eating disorder.  Findings:  The physician reviewer found that feeding difficulties are common in early life with 25% of children reported to have some form of feeding disorder. Consequences of feeding disorders can be severe, including growth failure and susceptibility to chronic illness. Feeding disorders occur in children who are healthy, who have gastrointestinal disorders, and in those with special needs. Caretto and colleagues evaluated the role of occupational therapists in parent education of infant feeding in the neonatal intensive care unit. The occupational therapists were most frequently identified as responsible for teaching about positioning, infant development, and infant states and cues and were highly involved in educating parents about feeding. Although this study involved neonates, this does prove that occupational therapists have a role in the treatment of feeding problems and are the main providers in the treatment of feeding disorders. Most feeding disorders have underlying organic causes. However, overwhelming evidence indicates that abnormal feeding patterns are not solely due to organic impairment. As such, feeding disorders should be conceptualized on a continuum between psychosocial and organic factors. Disordered feeding in a child is seldom limited to the child alone and is oftentimes a family problem. Assessment and treatment are best conducted by an interdisciplinary team of professionals. At minimum, the team should include a gastroenterologist, nutritionist, behavioral psychologist, and occupational and/or speech therapist. Intervention should be comprehensive and include treatment of the medical condition, behavioral modification to alter the patients inappropriate learned feeding patterns, and parent education and training in appropriate parenting and feeding skills. A majority of feeding problems can be resolved or greatly improved through medical, oromotor, and behavioral therapy. For these reasons, the requested occupational therapy is medically necessary to prevent malnourishment, failure to thrive, and to reduce morbidity in the treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Findings:  The physician reviewer found that The patients parent has requested reimbursement for bilateral mastectomy with chest reconstruction surgery services. Coleman and colleagues noted that chest surgery in female-to-male patients can be performed before age 18 preferably after ample time of living in the desired gender role and after one year of testosterone treatment. The intent of this suggested sequence is to give adolescents sufficient opportunity to experience and socially adjust in a more masculine gender role, before undergoing irreversible surgery. These findings are consistent with Olson-Kennedy and colleagues report that, professional guidelines and clinical practice should consider patients for chest surgery based on individual need rather than chronologic age. There is no requirement or recommendation to wait until 18 to treat gender dysphoria in transmasculine youth with chest surgery. In this case, the medical necessity of the bilateral mastectomy and chest reconstruction has been established by the patients providers. Moreover, the bilateral mastectomy services were in accordance with the generally accepted standards of mental health and substance use disorder care, clinically appropriate in terms of type, frequency, extent, site, and duration, and not primarily for the convenience of the patient or provider. Therefore, the bilateral mastectomy with chest reconstruction surgery services were medically necessary for treatment of this patient. Final Result: The reviewer determined that the services at issue were medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Upheld

A female enrollee requested Harvoni for 12 weeks for medical treatment of her hepatitis C virus.  Findings:  Two physician reviewers found that based on the clinical information provided, the patient does not have evidence of advanced fibrosis of F3 or greater or evidence of extrahepatic manifestations of hepatitis C. The patient is asymptomatic. For this patient, a reasonable medical approach would be to follow the patient longitudinally with periodic assessments for progression using non-invasive testing such as Fibroscan or Fibrosure. As such, Harvoni for 12 weeks is not medically necessary for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient who was diagnosed with osteoarthritis of the right knee. The patient reported right knee pain. Physical examination findings included tenderness over the medial joint line of the right knee. She received a Euflexxa series in September 2018, which provided five months of pain relief. The patient reported right knee pain. The provider noted that cortisone injections somewhat relieved her right knee pain. The patient stated that she would like to postpone a total knee arthroplasty as long as possible. The patient has requested authorization and coverage for Euflexxa injections in the right knee only. The Health Plan denied the request and reported the requested services are not medically necessary for the treatment of this patient. At issue in this case is whether Euflexxa injections in the right knee only are medically necessary for the treatment of the patients medical condition. Review of the current medical literature pertaining to viscosupplementation reveals mixed results.  Although viscosupplementation may relieve knee pain in some patients with osteoarthritis, it is unknown which individuals will benefit. Viscosupplementation can only be recommended in patients with a history of lasting benefit from prior injections and in carefully selected cases where the options are limited. A clinical trial by Campos and colleagues found that viscosupplementation increased functional scores in patients with severe osteoarthritis of the knee, especially within three months of injection. In this case, there is documentation of lasting relief from prior viscosupplementation injections. Furthermore, her options are limited. The patient has tried and failed conservative treatments, with the alternative being a total knee arthroplasty. The medical evidence supports the requested services in this clinical setting. Therefore, Euflexxa injections in the right knee only are medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested services are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in orthopedic 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: Medical Necessity
Decision: Upheld

The patient is a female diagnosed with coronary artery disease, hypertension, hyperlipidemia, mitral stenosis, aortic stenosis, and type 2 diabetes. An echocardiogram showed normal left ventricular function and significant aortic and mitral valve disease. A stress echocardiogram showed evidence of anterior wall ischemia at a low workload (metabolic equivalents of task). The heart rate achieved was beats per minute, which was reported as of target for her age. The patient also showed inability to raise her systolic blood pressure with exertion. The patient reported occasional chest pain with dizziness. The patient had requested coverage for myocardial perfusion imaging. The Health Plan denied the request and reported that the requested service is not medically necessary for the evaluation of this patient. At issue in this case is whether myocardial perfusion imaging is medically necessary for evaluation of this patients medical condition. The patient has angina-like chest pain with multiple risk factors for coronary disease, including type 2 diabetes mellitus, hypertension and hyperlipidemia. An echocardiogram, showed significant valvular heart disease with moderate to severe mitral stenosis and mild to moderate aortic stenosis. The patients valvular heart disease is a contraindication to any stress testing. The stress echocardiogram was notable for poor exercise tolerance and failure to raise her systolic blood pressure with exercise, in both resting and stress wall motion imaging, which indicates significant ischemic heart disease. Evidence of ischemia is produced at less than of heart rate target and at a modest workload. The patients stress echocardiogram results indicate a high risk of future cardiac events. Further non-invasive testing will not clarify the patients cardiovascular risk or change the clinical management and decision making. Medical evidence does not support the requested service in this clinical setting. Therefore, the requested myocardial perfusion imaging is not medically necessary for the evaluation 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 internal medicine with a subspecialty certificate 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: Medical Necessity
Decision: Overturned

A 60-year-old female enrollee has requested skilled level of care services for treatment of her bilateral ankle fracture. Findings:  The physician reviewer found that Medicare and InterQual criteria indicate that for skilled nursing rehabilitation to be medically necessary, the patient should be continuing to make progress in a program of skilled rehabilitation requiring at least one hour per day of such skilled treatment. This patient was non-weightbearing in both lower extremities. The medical records document that the patient continued to work on sliding board transfers, wheelchair activities of daily living, and general conditioning while non-weightbearing in both lower extremities throughout the treatment period. This is consistent with the standard of care and is supported by treatment guidelines. All told, the records support the medical necessity of the skilled level of care services.