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

A 46-year-old female enrollee has requested bariatric surgery (laparoscopic Roux-en-Y) for treatment of her obesity. Findings:  The physician reviewer found that the submitted clinical information demonstrates the patient meets the National Institutes of Health (NIH) consensus definition of clinically severe obesity. The patient completed a thorough multidisciplinary evaluation that included dietary, behavioral, metabolic and medical clearance. However, while the patient reports participating in Weight Watchers as well as other weight loss programs, there is a lack of objective data documenting the patients weight loss attempts in the records provided. NIH criteria requires adequate documentation of sustained efforts to lose weight prior to consideration of bariatric surgery. In the absence of such evidence, the medical necessity of the requested laparoscopic Roux-en-Y procedure is not established.
Appeal type: Experimental/Investigational
Decision: Upheld

Findings:  The physician reviewer found that An enrollee has requested authorization and coverage for LINX procedure. Overall, there is a lack of randomized controlled trials with long-term follow-up demonstrating that LINX is safer or more effective than standard surgical anti-reflux procedures for the treatment of patients with GERD. One evidence review concluded that the long-term safety and efficacy of LINX - both alone and in comparison to current GERD therapies - remains to be determined (Sheu and Rattner). Another best-evidence review concluded that long-term comparative outcome data past one year are needed in order to further understand the efficacy of magnetic sphincter augmentation (Skubleny, et al.). The current peer-reviewed medical literature does not support the conclusion that LINX is more likely to be beneficial in this case than standard treatment including surgical fundoplication (Sheu, et al.). Further, the American College of Gastroenterology (ACG) guidelines for the management of reflux disease also state that more evidence is needed before LINX can be recommended (Katz, et al.). For these reasons, the requested LINX procedure is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Findings:  Two of the three physician reviewers found the requested LINX procedure is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: The 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.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary:  An enrollee has requested a gene test for evaluation of her medical condition.  Findings:  Three physician reviewers found that while a fine needle aspiration biopsy of a suspicious thyroid nodule is typically an accurate means of assessing whether the nodule is benign or malignant, approximately 15% of fine needle biopsy results are considered to be indeterminate.  Until recently, the only way to establish whether the nodule was thyroid cancer was via surgical excision, even though the majority of the cases turn out to be benign.  A relatively new test, the Afirma Thyroid FNA Analysis, utilizes a gene expression classifier in order to help determine the likelihood of malignancy of nodules with indeterminate cytology on fine needle aspiration biopsy, thereby decreasing the need for unnecessary surgeries.  Because it is very sensitive and has a high negative predictive value, a negative Afirma result is rather suggestive of a benign nodule and can therefore preclude such surgical procedures.  Therefore, gene testing was likely to have been superior over other methods of evaluating this patient.  Final Result:  Three 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 internal medicine with sub-specialty certification in endocrinology, diabetes and metabolism 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 osteochondral allograft transplant surgery. Findings:  The physician reviewer found that the patient presents with recurrent patellar dislocations and bilateral patellar chondral defects. The patients provider has recommended treatment with osteochondral allograft transplantation and tibial tubercle transfer. Osteochondral allograft transplantation is an option in the setting of osteochondral or large chondral defects after failure of other treatment options. The use of fresh allograft for patellar defects as recommended for this patient has been well documented in the current medical literature. Specifically, patient treated with osteochondral allograft transplantation for focal and diffuse chondral defects have experienced positive outcomes. Jungmann and colleagues found that patients undergoing cartilage resurfacing procedures showed less progression of degenerative magnetic resonance imaging (MRI) changes at six-year follow-up than patients with untreated patients with initially identical osteochondral defects. Patients with focal cartilage defects are good candidates for osteochondral allograft transplantation as it promotes healing of the articular defect and prevents progression to osteoarthritis of the knee. In this case, patellar chondral defects are documented based upon arthroscopic evaluation of both knees. This patients provider is planning an osteochondral allograft transplantation procedure in conjunction with tibial tubercle osteotomy for recurrent patellar dislocations and chronic pain. The records document that the patients pain interferes with his ability to perform activities of daily living. Moreover, the patient has reportedly failed conservative treatment with bracing, medications, injections, physical therapy, and arthroscopic chondroplasty. For these reasons, the requested osteochondral allograft transplant surgery is medically necessary for 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: Urgent Care
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for medical services rendered. In this case, the records documented that the patient was actively bleeding, as her initial hemoglobin level was over 8, then 7.2, then 6.6, and was to be transfused as needed for her low hemoglobin levels. Notes documented hypotension. In this patients case, the absence of immediate medical attention could have been reasonably expected to place the patients health in serious jeopardy. Therefore, the services at issue were emergency medical services.Final Result: The reviewer determined that the services at issue were emergency medical services, the absence of which could have been reasonably expected to place the patients health in serious jeopardy. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in emergency medicine 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

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for inpatient acute rehabilitation treatment. The records provided for review do not demonstrate that the complexity of the nursing, medical and rehabilitation needs of this patient require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The patient does not require the intensity of an inpatient rehabilitation facility, in the absence of acute medical issues that require close physician or nursing supervision. The patients vital signs are stable and his laboratory results do not require intensive monitoring. The patients general medical condition was stable for transfer per documentation. The patient may benefit and will likely participate in additional therapy of physical therapy and occupational therapy, but the patients functional status does not require these services in an acute inpatient rehabilitation setting. All told, the requested inpatient acute rehabilitation treatment is not medically necessary for treatment of this patient. Final Result: The reviewer determined that the requested services 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 physical medicine and rehabilitation with subspecialty certification in neuromuscular medicine 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

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for gene testing services (ThyraMIR, and ThyGenX). In this case, the submitted documentation does not support that the services in issue were medically necessary. First, molecular tests do not perform well on Hurthle cells. The patients biopsy of the suspicious right nodule noted that the specimen was sparsely cellular and that most follicular cells seen had Hurthle cell changes. The reading pathologist further commented that the sample in question may not have been representative of the targeted lesion and that the material collected for ThyGenX testing may not be sufficient. Therefore, it was questionable whether the molecular test was done on an adequate sample, thereby raising the question of whether its results can be trusted. Second, NCCN guidelines indicate that a clinician faced with a thyroid nodule without high clinical and/or radiographic risk of malignancy that shows structural abnormalities of undetermined significance, or follicular lesions of undetermined significance on fine needle aspiration, has four available options. These options are repeat FNA, observation, diagnostic lobectomy, or molecular diagnostics. None of these four options has been shown to be superior, since none has shown a difference in outcomes and/or a survival benefit. Molecular diagnostics, however, remains limited by the adequacy of the sample, hence the variability of its sensitivity and specificity for diagnosis. Under the circumstances of this case, where it was questionable whether the molecular test was done on an adequate sample, the treatment option of using molecular diagnostics is less appropriate than other treatment options. Accordingly, the gene testing services (ThyraMIR, and ThyGenX,) were not medically necessary for treatment of the patients medical condition.Final Result: The reviewer determined that the services in issue were 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 subspecialty certification in hematology and medical oncology, 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 Harvoni for treatment of his hepatitis C virus.  Findings:  The physician reviewer found that according to the 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 recommend that treatment-naive genotype 1a 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 (Kowdley, et al; Afdhal, et al). AASLD/IDSA guidelines cite data showing reduced survival with delayed treatment (Jezequel, et al). For these reasons, the requested treatment with Harvoni is 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

Nature of Statutory Criteria/Case Summary:  An enrollee has requested authorization and coverage of Stelara 90 mg/ml subcutaneous solution to inject every 60 days.  Findings:  The physician reviewer found that the current literature suggests that Stelara is safe, effective and may have long term efficacy for patients with moderate to severe arthritis. In this case, the patient has a history of plaque psoriasis and refractory PsA. Systemic therapy would be recommended. The American Academy of Dermatology (AAD) does not recommend a specific agent over another. The AAD recommends ultraviolet A and ultraviolet B, systemic agents and biologic agents. A recent European update to the guidelines states We recommend ustekinumab as second-line medication for the induction and long-term treatment. In this case, the patient has failed phototherapy, conventional systemic agents (methotrexate and cyclosporine) and three TNFi . However, this patients psoriasis and PsA continue to be active. The studies show that Stelara is effective for PsA at the conventional, U.S. Food and Drug Administration approved doses of 45 mg and 90 mg every 12 weeks. In this patients case, the medical records support that Stelara is medically necessary. The patient has failed multiple medications to include three TNFi, methotrexate, and cyclosporine. For treatment of his skin condition, he has tried medications, as well as laser therapy and topical steroids, which have also failed. This patient has well documented failure of multiple therapies and the patient is responding well to Stelara. The patient has had a partial response to conventional dosing. In a review , they showed that dose escalation for ustekinumab (Stelara) to be efficacious and safe. Stelara is being used appropriately for treatment of this patients plaque psoriasis and PsA. As such, its use is consistent with standards of good medical practice. The records support continued damage despite traditional dosing. This patient is requesting a dosage increase of Stelara because conventional dosing produced a partial response. For the reasons noted above, the request for Stelara 90 mg/ml subcutaneous solution to inject every 60 days is medically necessary for the treatment of this patients medical condition. Final Result: The reviewer determined that the requested medication dosage 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 rheumatology 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 35-year-old female enrollee requested authorization and coverage of cognitive therapy. The Health Plan denied the request indicating that the requested therapy is not medically necessary for treatment of the enrollee status post head injury.One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer upheld the Health Plans denial on the basis that the requested therapy is not medically necessary.
Appeal type: Experimental/Investigational
Decision: Overturned

A 48-year-old male enrollee has requested robotic-assisted laparoscopic radical prostatectomy for the treatment of his prostate cancer. Findings:  Two physician reviewers found that this young patient with prostate cancer has requested a robotic-assisted prostatectomy procedure. The literature regarding robotic prostatectomy shows a decreased operative blood loss and decreased risk of transfusion of blood using the robotic approach. It also shows faster convalescence after robotic surgery.
Appeal type: Medical Necessity
Decision: Upheld

A 23-year-old female enrollee has requested residential treatment services for treatment of her depression and suicidal ideation.  Findings:  The physician reviewer found that based on the available medical records, this patient had extensive inpatient psychiatric treatment before admission to residential treatment. While at the residential unit, she was not at risk of harm to herself or others. Her insight and judgment were fair. She was not psychotic or cognitively impaired, and she was cooperative with her program. She was not provided with any treatments that required 24-hour medical or nursing treatment. Consistent with the American Psychiatric Association (APA) guidelines, this patient could have been transitioned to a partial hospitalization program (PHP) that would have provided the appropriate medication management, individual, family and group therapy. All told, the patient could have been safely and adequately treated in a less restrictive environment than residential level of care. Therefore, the residential treatment services provided were not medically necessary for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned

The parents of a 17-year-old female enrollee have requested residential level of care for the treatment of the enrollees eating disorder. Findings:  The physician reviewer found that this patient required close RTC level of supervision throughout her stay. Her past history was of severe anorexia with medication complications and this entire level of service should be covered as medically necessary.
Appeal type: Medical Necessity
Decision: Overturned

A 57-year-old male enrollee has requested for intensity modulated radiation therapy using between 45 Gy and 75 Gy for treatment of his prostate cancer.  Findings:  The physician reviewer found that the combination of IMRT versus conventional radiation with a prostate seed implant will achieve significantly lower doses to the bladder, rectum and bowel, thereby decreasing the incidence of Grade 3 or greater toxicity to these regions.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: an enrollee has requested reimbursement for the gene test performed. Findings:  The physician reviewer found that  the American Thyroid Associations guidelines state that for nodules with FLUS cytology, after consideration of worrisome clinical and sonographic features, investigations such as repeat [fine needle aspiration] FNA or molecular testing may be used to supplement malignancy risk assessment in lieu of proceeding directly with a strategy of either surveillance or diagnostic surgery. If genetic testing is suspicious, the risk of malignancy increases to 40 percent. In this case, the result of the Afirma GEC was suspicious for malignancy. This information was important to determine the decision whether to perform thyroidectomy and the extent of surgery. There are multiple peer-reviewed scientific articles indicating the benefits of the genetic test in thyroid nodules. Final Result: The reviewers determined that the testing at issue was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned.  Credentials/Qualifications: the physician reviewers are board certified in internal medicine with sub-specialty certification in endocrinology, diabetes and metabolism and is 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 parent of a 4-year-old male enrollee requested social skills group with peers for medical treatment of the enrollees autism spectrum disorder.  Findings:  The physician reviewer found that the medical literature supports social skills groups for children with autism as a valuable adjunct to ABA services (Bohlander, et al; Casenhiser, et al). In this case, the patient is high functioning on the autism spectrum and appears to be tolerable to social skills training which should be augmentative to his ABA elopement operant training. Participation in the requested social skills group as part of a comprehensive treatment program including ABA therapy, speech therapy and occupational therapy is medically appropriate and indicated for this patient with social skill deficits. Given the submitted clinical documentation, in addition to the medical literature cited above, the request for social skills group with peers is medically necessary for treatment of the patients medical condition.