Persius/imr-appeals huggingface dataset:
Appeal type: Experimental/Investigational
Decision: Overturned

A 55-year-old female enrollee has requested authorization and coverage for a phase II multi-center study of high dose cyclophosphamide and antithymocyte globulin followed by autologous hematopoietic cell transplantation for treatment of the enrollees diffuse systemic sclerosis with severe lung involvement.  Findings:  Three physician reviewers found that the patient has Raynauds syndrome, and was diagnosed with systemic sclerosis (SSc). She underwent an extensive evaluation including serologic testing, imaging and biopsy. She was treated initially with methotrexate and corticosteroids after developing aching joints and weight loss, as well as proximal weakness in her arms and legs. Pulmonary function testing revealed a significant decrease in forced vital capacities compared to studies done previously. Electromyography demonstrated diffuse myopathic changes involving the lower extremities. Muscle biopsy of the left thigh muscle indicated no vasculitis or inflammation. Because of disease progression, she was the treated with monthly pulsed cyclophosphamide and a slow prednisone taper. She appears to be progressing despite this treatment. Her consultant rheumatologist recommended enrollment in a clinical trial consisting of treatment with high dose immunosuppressive therapy with antithymocyte globulin (ATG) and cyclophosphamide as well as autologous stem cell transplantation. The patients request for authorization and coverage for these services has been denied by the Health Plan as investigational. Systemic sclerosis is an uncommon, heterogeneous connective tissue disorder that affects a number of internal organs in addition to the skin with muscle and joint manifestations. Treatment consists of a combination of immunosuppression with medications such as prednisone and cyclophosphamide, including high dose pulsed therapy for progressive disease. A number of other treatments are available for the different manifestations such as cutaneous, pulmonary hypertension, renal, and arthritic problems. However, there is no satisfactory treatment for progressive disease, especially when this disease progresses while a patient is on aggressive pulsed therapy. Recent trials with autologous transplant and immunosuppression, with or without ATG or mycophenolate (MMF), are promising and pilot studies have led to controlled trials. Currently, long-term follow-up of observational studies and short-term results of controlled trials are promising. Since this patient is progressing with severe complications of SSc on pulsed, high-dose immunosuppressive therapy, entering into a clinical trial is a reasonable alternative. Since there are no better treatments of the disease, the requested clinical trial services should be approved as they are likely to be more beneficial for treatment of this patients medical condition than any available therapy.
Appeal type: Medical Necessity
Decision: Overturned

A 42-year-old female enrollee has requested for a bilateral mastopexy for treatment of her mammary ptosis with intertrigo. Findings:  The physician reviewer found that American Society of Plastic Surgeons, breast reduction surgery is medically necessary for intertrigo unresponsive to medical management. This patient has intertrigo that is unresponsive to medical management.
Appeal type: Experimental/Investigational
Decision: Overturned

A 39-year-old female enrollee requested authorization and coverage of gastric bypass with duodenal switch. The Health Plan denied the request indicating that the requested procedure is considered experimental for treatment of the enrollees morbid obesity.Three physician reviewers performed an experimental/investigational Independent Medical Review. Two physician reviewers concluded that the requested procedure is likely to be more beneficial for the treatment of the enrollee's medical condition than any available standard therapy. One physician reviewer concluded that the requested procedure is not likely to be more beneficial for treatment of the enrollee's medical condition than any available standard therapy. Because two of the three physician reviewers concluded that the requested procedure is likely to be more beneficial for treatment of the enrollee's medical condition than any available standard therapy, the Health Plans denial has been overturned.
Appeal type: Experimental/Investigational
Decision: Upheld

An enrollee has requested reimbursement for a laboratory test. The American College of Obstetricians and Gynecologists (ACOG) supports the utility of additional testing, such as AmniSure, in this clinical setting as a second-line evaluation for premature rupture of membranes. ACOG recommends AmniSure testing in equivocal cases when testing for prelabor rupture of membranes. This patients records do not document that first-line evaluation with ferning, pooling, and nitrazine testing was non-diagnostic. Therefore, the laboratory test was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Findings:  Three of the three physician reviewers found the laboratory test was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.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 is board certified in obstetrics and gynecology and is actively practicing. Physician reviewer 2 is board certified in obstetrics and gynecology and is actively practicing. Physician reviewer 3 is board certified in obstetrics and gynecology with subspecialty certification in maternal and fetal medicine 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: Experimental/Investigational
Decision: Overturned

A 56-year-old female has requested magnetic resonance imaging (MRI) of the left breast for evaluation of the extent of free silicone in the left breast.   Findings:  Two physician reviewers found that the patient presents with no noted high risk of breast malignancy. She had bilateral silicone augmentation implants with subsequent removal and saline implant replacement four years ago. Free silicone was noted in the medial aspect of the left breast on recent mammogram. There is no clinical finding to suggest malignancy. The provider has requested a bilateral breast magnetic resonance imaging (MRI) to provide a baseline of the degree of free silicone in each breast in this patient. This patient was found at implant revision to have free silicone in the breast parenchyma from previous silicone augmentation implants. Such free silicone makes mammography difficult even under ideal circumstances. Further, the free silicone gel may produce physical findings over time. Overall, MRI is the most sensitive means with which to identify free silicone and with MRI as a baseline subsequent imaging over time will be useful to separate free silicone versus lesions. Ultrasound and mammography are not particularly useful in the detection of free silicone gel within the breast. Over time, the free silicone may coalesce and present as a palpable mass making a differential diagnosis difficult. At this time, there is no clinical indication for biopsy. Consistent with these findings, the requested MRI of the breasts would be more beneficial for this particular patient than any other available exam and should be approved.
Appeal type: Medical Necessity
Decision: Upheld

The patient is a 48-year-old male with a weight of 290 pounds and a body mass index (BMI) of 38. His comorbid conditions include Type II diabetes mellitus, hyperlipidemia, hypertension, obstructive sleep apnea, and gastro-esophageal reflux disease (GERD). He has completed psychological and nutritional evaluations and was deemed an appropriate candidate for weight loss surgery. He has requested authorization and coverage for laparoscopic adjustable gastric banding (Lap Band) which the Health Plan has denied based upon their determination that it is not medically necessary for treatment of the patients morbid obesity.The Lap Band procedure has been promoted as a low risk, easy operation to perform. Patients can however, experience complications after surgery with this procedure. Most complications are not serious but some may require re-hospitalization and/or re-operation. A clinical study with 3-year follow-up conducted in the United States reported that 88% of the 299 patients had one or more mild to severe adverse events. Nausea and vomiting were the most common post-operative complications (51%), as well as GERD (34%), band slippage/pouch dilatation (24%) and stoma obstruction (14%).  In the study, 25% of the patients had their band systems removed, most often following an adverse event.   Additionally, tightening of the band is required to promote weight loss and that process has been shown to worsen GERD, a pre-existing comorbid condition in this patient.I would agree with the Health Plan that the patient should consider other surgical procedures for treatment of his obesity. Therefore, I have determined the requested procedure is not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for genotype testing provided on 8/9/16.Findings:  Two physician reviewers found that the patient has a diagnosis of bipolar disorder. The patient reports to having a severe manic episode in mid-2015. She has received treatment at outpatient, intensive outpatient program (IOP), and partial hospitalization program (PHP) levels of care. She has also received treatment with electroconvulsive therapy (ECT). The provider indicated that the patient was unable to tolerate medications at therapeutic doses due to severe side effects, and she had lack of symptom relief. The patients previous medications included Geodon, Lamictal, Ativan, lithium, Depakote, and Ambien. The patient has requested reimbursement for genotype testing provided on 8/9/16. The Health Plan has denied this request as investigational. The testing at issue was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Genetic testing results show if a patient is a normal responder of certain classes of medications, more or less likely to respond to certain medications, is at low risk of certain adverse events, at higher risk of others, or may have decreased activity of a certain enzyme activity. The fact that one of these results shows up on genetic testing does not indicate that one medication will, definitively, be more or less effective than another. There are other factors that influence medication efficacy such as drug-on-drug interactions and variance in hepatic metabolism of each individual. All of these factors are issues that can be assessed by the provider during follow-up, and adjusted for by changes in medication regimen including increased/decreased dose, augmentation strategies, or discontinuation for a variety of reasons. Studies have shown that clinically useful predictors in genetic testing are scarce for antidepressant therapy, with results being inconsistent and only marginal clinical association between enzyme system variants and drug metabolism, efficacy, and tolerability in the treatment of depression. Final Result: Two 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 psychiatry 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 has requested authorization and coverage for trigeminal nerve injections and greater occipital nerve injections. Current data on occipital nerve blocks remains mixed. Dilli and colleagues concluded that greater occipital nerve blocks did not reduce the frequency of moderate to severe migraine days in patients with episodic or chronic migraine compared to placebo. Inan and colleagues and found that greater occipital nerve blocks were safe and demonstrated greater efficacy than placebo in the treatment of chronic migraine. This patient has a history of chronic migraine since second grade. She has been managed with Botox, but reports incomplete symptomatic relief around the seventh week of the treatment cycle. During pregnancy, treatment with trigeminal and occipital nerve blocks reportedly provided a substantial improvement in pain and ability to function. Oral medications carry a potential risk during breastfeeding. Current literature supports trigeminal and occipital nerve blocks during pregnancy and breastfeeding, for relief of migraines, as interval therapy for Botox. Therefore, trigeminal nerve injections and greater occipital nerve injections (are 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 neurology 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 61-year-old female enrollee has requested for an electric scooter for treatment of her condition. Findings:  The physician reviewer found that there is insufficient documentation to support the use of an electric scooter for this patients condition. In order for the patient to qualify for an electric scooter, there should be sufficient documentation to support that a manual wheelchair would not suffice.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested authorization and coverage reduction mammoplasty for treatment of the enrollee's mammary hypertrophy.  Findings:  The physician reviewer found that the request for reduction mammaplasty is medically necessary for treatment of the patients medical condition. According to the guidelines from the American Society of Plastic Surgeon (ASPS), reduction mammaplasty has been proven effective at reducing macromastia related symptoms and improving postoperative quality of life. In this case, the patient presents with well-documented, chronic back, neck and shoulder pain, shoulder grooving and headaches due to the weight of the breasts. This has significantly impacted her activities of daily living. Multiple medical evaluations provide confirmatory evidence of these findings. In addition, based on the overall clinical documentation, the patient has failed reasonable conservative management. Mammary hypertrophy is causing functional problems and would likely benefit significantly from reduction surgery. In sum, breast reduction is medically necessary for this patient and is consistent with standard of care. Moreover, further conservative treatment would not likely improve her functional deficit. Therefore, based on the documentation submitted for review, the request for reduction mammaplasty is medically necessary.Final Result: The reviewer determined that the requested procedure 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 plastic 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: enrollee has requested authorization and coverage for tertiary level of care. Multiple sclerosis is a progressive immune disease affecting the central nervous system, causing neurological dysfunction. Multifocal inflammation of the central nervous system characterizes the disease and causes impaired nerve conduction. Multiple sclerosis care can be provided in many different clinical settings. This patient is currently under care for her multiple sclerosis by a community neurologist. The neurological care as documented by the provider can continue to be provided in the community. The Health Plan has provided a neurologist within a reasonable radius. Therefore, the requested tertiary level of care is not medically necessary for the 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 neurology 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 55-year-old female enrollee requested authorization and coverage of the medication estrace for hormonal therapy.  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 upheld the health plans denial on the basis that the requested medication is not medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient is a 56-year-old male who has a history of asthma, allergic rhinitis and hyperlipidemia. Laboratory testing revealed a vitamin D level of 30 ng/mL. Then patients vitamin D level was 31 ng/mL. There was no documented history of vitamin D deficiency or other risk factors for vitamin D deficiency. The patient has requested reimbursement for vitamin D-3 testing. The Health Plan denied the request and reported the services at issue were not medically necessary for the evaluation of this patient. At issue in this case is whether vitamin D-3 testing was medically necessary for the evaluation of the patients medical condition. The Endocrine Society Clinical Practice Guideline recommends screening for vitamin D deficiency in patients at risk for deficiency. The guidelines do not recommend screening for vitamin D deficiency in patients who are not at risk. In this case, the patient does not have a history of vitamin D deficiency, risk factors for vitamin D deficiency or symptoms suggestive of vitamin D deficiency. None of his documented medical conditions are conditions for which evaluation of vitamin D is recommended. The medical evidence does not support the services at issue in this clinical setting. Therefore, the vitamin D-3 testing was not medically necessary for the evaluation of this patient. Final Result: The reviewer determined that the requested service was 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 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: A transgender enrollee has requested authorization and coverage for facial laser hair removal for treatment of the enrollees gender dysphoria. Findings:  The physician reviewer found that the requested services are medically necessary in this clinical setting. Facial hair removal is within accepted standards of practice and clinically appropriate for treatment of gender dysphoria. Excessive facial hair in a female would be considered abnormal and is referred to hirsutism. Hirsutism is a medical diagnosis where terminal hair grows in female in areas that are normally found in males. This would include the face and parts of the genitalia. A female would be expected to have terminal hair in the scalp, axilla and on the arms and legs. This patients excessive facial hair is more consistent with the male gender. Additionally, hormone therapy has not been effective in improving this patients medical condition. Therefore, facial hair removal is medically necessary for the treatment of this patients gender dysphoria. With regard to whether the requested services are considered reconstructive in nature, excessive facial hair in a female is an abnormal body structure.  Hirsutism is a condition that is congenital in that the hair growth is determined by the genetic and hormonal makeup of the patient. As such, the requested facial hair removal can provide substantial improvement in the appearance of terminal hair and create as normal an appearance as possible in this patient. Moreover, the requested services are going to improve emotional function for this patient. Final Result: The reviewer determined that the requested services are medically necessary and are reconstructive in nature for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. 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: Experimental/Investigational
Decision: Overturned

A 60-year-old female enrollee has requested for a dual energy x-ray absorptiometry (DEXA) scan for evaluation of her osteopenia.  Findings:  Two physician reviewers found that the patient has already sustained two fractures to her extremities since menopause and her 25 hydroxy vitamin D level is low, which is another risk factor for bone demineralization leading to increased risk for fracture. The patients treatment plan will likely be changed based on the findings of the DEXA scan in an attempt to prevent future fractures. Therefore the BMD assessment with the DEXA scan was likely to be more beneficial in this patients treatment than any alternative diagnostic procedure.
Appeal type: Medical Necessity
Decision: Overturned

The parents of a 10-year-old female enrollee requested authorization and coverage of continued speech therapy for the treatment of central hearing loss.  The health plan denied the enrollees request indicating that continued speech therapy 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 speech therapy is medically necessary.