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

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested authorization and coverage for Onexton gel pump. The Health Plan has denied this request indicating that the requested medication is not medically necessary for treatment of the enrollees acne. A review of the record indicates that the enrollee has been diagnosed with acne. The medical records indicated the enrollee had acne present on the face, back, and chest. Papules, pustules, cysts, and erythema were noted. The enrollee was using Onexton gel and Retin-A. The enrollees provider has recommended Onexton gel pump for the enrollee.Acne vulgaris is the most common dermatological disorder in adolescence and young adults. In past decades, systemic antibiotics have had the main role in the treatment of acne patients with inflammatory papules and cysts. In the adult female, acne is a chronic condition with a substantial negative psychological, social and emotional impact. The morphological characteristics of adult female acne are often distinct from adolescent acne. In adults, inflammatory lesions (particularly papules, pustules and nodules) are generally more prominent on the lower chin, jawline and neck, and comedones are more often-closed comedones (micro cysts). Adult acne is mainly mild-to-moderate in severity and may be refractory to treatment. Females with facial acne typically respond more favorably to systemic antibiotic therapies than males. A combination of clindamycin 1% and benzoyl peroxide 5% is indicated for the topical treatment of inflammatory and non-inflammatory lesions of acne vulgaris. Clindamycin/benzoyl peroxide has a rapid onset of action, with acne improvement usually recorded within 24 weeks. Despite widespread use, bacterial resistance is not associated with clindamycin/benzoyl peroxide. This is an effective and well-tolerated option for the management of mild to moderately severe acne. The topical combination of 1% clindamycin and 5% benzoyl peroxide is available in two forms: BenzaClin and Duac. BenzaClin is packaged in a jar and a pump, whereas Duac is packaged in a tube. BenzaClin and Duac show similar propensity to cause moderate irritation. No data is available to suggest that Onexton gel pump may have different efficacy in acne vulgaris than other forms of these agents. Therefore, the requested medication Onexton gel pump is not medically necessary. 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 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: Upheld

Nature of Statutory Criteria/Case Summary:  An enrollee has requested Viekira Pak for eight weeks for treatment of her hepatitis C virus. Findings:  The physician reviewer found that according to the most recent guidelines issued, all patients with chronic hepatitis C, regardless of fibrosis, should be treated except those with limited life expectancy due to non-liver-related comorbid conditions. The guidelines also state that there are benefits in reduction of transmission from women to their children. Per the guidelines, Viekira Pak should be used for 12 weeks rather than eight. Moreover, there is a lack of medical studies for the treatment of Viekira Pak for eight weeks for patients with HCV genotype 1. For these reasons, the requested treatment with Viekira Pak for eight weeks is not supported as medically necessary for the treatment of this patients hepatitis C infection.  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 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 38-year-old male enrollee has requested liposuction in conjunction with gynecomastia surgery for treatment of his gynecomastia. Findings:  Two physician reviewers found that gynecomastia is generally caused by proliferation of fibrous breast tissue and fat. Therefore, treatment should be directed at both components of the breast enlargement. The fibrous component is generally subareolar and can be removed by direct excision or arthroscopic shaving and liposuction. The fatty component is best removed with liposuction. The treatment of gynecomastia with a combination of excision and liposuction is standard of care. In the study by Petty and colleagues, over 25% of the studied patients treated for gynecomastia since 1997 were managed with direct excision and liposuction.  Multiple reports confirm the common use of liposuction as either a primary treatment or adjunct for the management of gynecomastia. In this case, the addition of liposuction will optimize the functional outcome of this patients breast surgery.  All told, the requested liposuction in conjunction with gynecomastia surgery is likely to be superior over other available treatment options.
Appeal type: Experimental/Investigational
Decision: Upheld

A 54-year-old male enrollee has requested for nerve decompression for treatment of his pain due to peripheral neuropathy. Findings:  Three physician reviewers found that a study by Dellon demonstrated that removal of a site of anatomic narrowing of the tibial nerve in an animal study prevented neuropathic walking. Dellon concluded that decompression of superimposed nerve compressions in a patient with symptomatic neuropathy reliably relieves pain, restores sensation, and thereby prevents ulceration and amputation. However, despite this paper, there is a lack of prospective, randomized studies that conclusively demonstrate the efficacy for this procedure. In the absence of such evidence, the superior efficacy of nerve decompression in this clinical situation has not been established.
Appeal type: Experimental/Investigational
Decision: Upheld

A 55-year-old female enrollee has requested for right total ankle replacement surgery for treatment of her advanced post-traumatic osteoarthritis.  Findings:  Two physician reviewers found that this patient is not likely to benefit from total ankle arthroplasty as compared to ankle arthrodesis in management of her post-traumatic degenerative osteoarthritis of the ankle. This decision is based upon review of the literature including the study by Saltzman and colleagues, in which the STAR total ankle replacement was studied versus ankle fusion over a two-year period of time. While ankle fusion affects the heel strike and foot flat portion of the gait, there is no discussion as to the efficacy of orthotics in compensating for the negative functional aspects of an ankle arthrodesis. Overall, the article reports a higher incidence of a number of complications in the STAR group versus the fusion group. In addition, van den Heuvel and colleagues reviewed the history of total ankle arthroplasty with initial high failure rates, and second generation devices with improved outcomes. The authors noted complications of total ankle arthroplasty to include deep infection, loosening, and implant failure. The authors cite the need for longer follow-up to establish the long-term durability and success of total ankle arthroplasty, although they suggest positive outcomes have been reported.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for anterior cervical discectomy and fusion (ACDF) from C4-7 and post-surgery bone growth stimulator therapy. Findings:  The physician reviewer found that this patient is noted to have cervical radiculopathy, but there are no dermatomal symptoms or findings consistent with cervical radiculopathy. She has no evidence of a cervical myelopathy. The records do not include documentation of failed conservative care including therapeutic doses of non-steroidal anti-inflammatory drugs (NSAIDs), physical therapy, home exercise program, and acupuncture. Moreover, other reasonable causes of pain have not been ruled out, since she has not had an examination of her shoulder, vascular, Tinels, or axillae. The patient underwent one medial branch block, but no epidural steroid injection (ESI), or other injections have been performed. The current standard requires findings of cervical radiculopathy with progressive neurological deficit, failure of six weeks of conservative management, and evidence of nerve root compression with correlating clinical examination. These criteria are not met in this patients case. Further, there is no evidence of cervical myelopathy, instability, kyphosis, pseudoarthrosis or deformity. Therefore, the requested ACDF from C4-7, and post-surgery bone growth stimulator therapy are not medically necessary for treatment of this patients neck pain. 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 neurological 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

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for a Hill-Rom Envella Micro Bead Sand Bed. Arnold and colleagues note that multiple case series suggest that air fluidized therapy/continuous low-pressure pressure redistributing beds in long-term acute care hospitals facilitate the healing of advanced wounds in medically complex patients when included as part of a wound care program. However, VanWyhe and Willer note that air-fluidized therapy beds were associated with user dissatisfaction and staff injuries. McInnes and colleagues report that based on the current evidence, it is unclear whether any particular type of low or high tech support surface, such as low air loss beds, air suspension beds, and alternating pressure surfaces, is more effective at healing pressure ulcers than standard support surfaces. In this case, while the patient remains at risk for pressure injuries. The records document intact skin. Given that pressure injury prevention may be accomplished using routine repositioning and one of many different bedding surfaces or overlays, including a gel overlay, a low air loss mattress, or a foam mattress, the requested equipment is not medically indicated. Therefore, a Hill-Rom Envella Micro Bead Sand Bed is not medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested equipment 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 physical medicine and rehabilitation and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld

A 44-year-old female enrollee has requested advanced cardiovascular risk marker testing be performed at the Berkeley Heartlab for an evaluation of her cardiovascular status. Findings:  Three physician reviewers found that this type of testing has not been clearly established in the medical literature. At the present time, there are no clinical trials demonstrating an overall change in health outcomes based on these test results. The American College of Cardiology guidelines have not incorporated advanced cardiovascular risk marker testing as the standard of care for cardiac risk assessment. The basic lipid panel is still the standard for lipid analysis.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for split-night sleep study with continuous positive airway pressure (CPAP) titration (CPT code 95811). This patients history of atrial fibrillation with symptoms of sleep apnea place her at an increased risk for central sleep apnea. A home sleep study is inadequate to detect central sleep apnea in this clinical setting. In addition, home sleep studies can underestimate the severity of sleep apnea. A split-night sleep study is indicated to evaluate the patients OSA, risk for central sleep apnea, and then to treat the patient with the appropriate pressure and mode of CPAP. The patients history of atrial fibrillation and her symptoms with the risk for central sleep apnea support a lab supervised sleep study. Therefore, the requested split-night sleep study with CPAP titration (CPT code 95811) is medically necessary for evaluation and treatment of 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 expertise in sleep 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: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested breast tomosynthesis for evaluation of the enrollees risk for breast cancer. Findings: Three physician reviewers found that Tomosynthesis is a technique that was developed several years ago as a problem solving adjunct to routine mammography. Applying the same basic concept as computed tomography (CT) scanning, by separating the various layers of breast tissue, one can better detect abnormalities. In this particular patient, the patient has breasts that have been described as being extremely dense. While one could make the argument that her mammogram has not changed since the last study, it is specifically patients who have dense breasts that can benefit most from tomosynthesis. The ability to separate out the overlapping structures enables the possibility of demonstrating an otherwise occult tumor. While tomosynthesis is a valuable tool in delineating occult masses in dense breasts, there is still an advantage to sonography in detecting cystic structures. Thus, in this clinical setting, the use of the digital breast tomosynthesis was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Final Result: Three reviewers determined that the diagnostic procedure 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: All three physician reviewers are board certified in diagnostic radiology 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: Upheld

A 61-year-old male enrollee has requested authorization and coverage for MILD (minimally invasive lumbar decompression).  The Health Plan has denied this request indicating that the requested procedure is considered investigational for treatment of the enrollees clinically symptomatic lumbar spinal stenosis.  Findings:  Three physician reviewers found that the patient has clinically symptomatic lumbar spinal stenosis.  The submitted documentation noted that the patient has low back pain. He has not obtained relief with pharmaceutical management, conservative treatments, and physical therapy.  The patient has requested authorization and coverage for MILD (minimally invasive lumbar decompression).  The Health Plan has denied this request and reported that the requested procedure is investigational for the treatment of this patient.  The concept of minimally invasive spinal surgery embodies the goal of achieving clinical outcomes comparable to those of conventional open surgery, while minimizing the risk of iatrogenic injury that may be incurred during the exposure process. The development of microscopy, laser technology, endoscopy, and video and image guidance systems provided the foundation on which minimally invasive spinal surgery is based.  At this time, there is a lack of evidence supporting minimally invasive lumbar decompression in this clinical situation.  The current medical evidence has not demonstrated the superior efficacy of the requested procedure.  All told, the requested procedure is not likely to be more efficacious than other available treatment options.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement, authorization and coverage for inpatient mental health care provided. Most evidence-based treatment guidelines concur that the deciding factor in determining the necessity of inpatient psychiatric care is whether patients appear to be a harm to themselves or others. Medical literatures guidelines agree on this point and additionally cite factors such as overt psychotic ideation; complex biomedical issues; grave disability impairing daily living function; and/or high levels of impulsivity, aggression or mania.In this case, the patient had begun to show response with decrease in psychotic symptoms, thought blocking, and argumentativeness. The patient was not a danger to self or others and was cognitively intact. She demonstrated no self-injurious behavior, no uncontrolled risky behaviors and no uncontrolled destructive behaviors. The patient was compliant with medications and her regimen could safely be managed at a lower level of care. Therefore, the inpatient mental health care provided was not and is not medically necessary.Final Result: The reviewer determined that the requested services were not and are not medically necessary for treatment of the patients mental health conditions. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is board certified in psychiatry and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for the nonsteroidal anti-inflammatory drug medication Flector 1.3% patch for treatment of the enrollees hip pain. Findings:  The physician reviewer found that the medical literature supports the use of the Flector patch for short-term use in the management of acute pain. The true safety profile of topical NSAIDs can only be determined after many years of use in a large patient population. Therefore, long-term, head-to-head trials comparing the efficacy and safety of topical versus oral NSAIDs may be necessary. Future research should also include patients with [osteoarthritis] OA involving multiple joints and comorbid conditions to confirm the safety of topical NSAIDs in patients who may have the highest risk for developing tolerability issues. In this case, the patient has a history of hip pain, osteoarthritis of the left hip and left knee pain. The patient has been treated with the Flector patch with reported relief. Although there is medical literature supporting the Flector patch for short-term use, there is a lack of support for long-term use. Accordingly, the request for NSAID Flector (diclofenac) 1.3% patch has not been established as medically necessary for treatment of the patients medical condition. 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 sub-specialty certification in pain 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

The representative of an 89-year-old male enrollee has requested for skilled nursing rehabilitation services including physical therapy for treatment of the enrollee status post right lower extremity fracture. Findings:  The physician reviewer found that there is no documentation of meaningful participation or potential for meaningful participation with formal therapy services. Further, with regard to medical/nursing care, while the patient has multiple chronic conditions, he has no documented active conditions requiring inpatient hospitalization. Therefore, skilled nursing rehabilitation services/physical therapy are not medically necessary.
Appeal type: Medical Necessity
Decision: Overturned

A 45-year-old male enrollee requested authorization and coverage of the medication viagra for the treatment of erectile dysfunction.  The Health Plan denied the enrollees request indicating that the requested treatment is not medically necessary.One physician reviewer performed a medical necessity Independent Medical Review.  The physician reviewer overturned the health plans denial on the basis that the requested medication is medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld

A 53-year-old female enrollee has requested for removal of sling mesh for treatment of her diagnosed with chronic interstitial cystitis and dysuria frequency syndrome. Findings:  The physician reviewer found that the current medical literature has not demonstrated that surgical excision of residual mesh has a significant impact in this clinical setting.  The complex nature of this patients pelvic pain cannot fully be categorized, as her symptoms have included cystitis and vulvar pain.  In this patients case, additional surgical intervention is not supported by the current medical evidence.  All told, the requested removal of sling mesh is not medically indicated for the treatment of this patients medical condition.